Indicator 6: Who Is Actually Running This Clinic? The Qualifications Standard Explained

Series: Understanding MSDS | Post 9 of 52
Standard 2 (ROM-2) | Indicator 6 | Category: RED (100% required)

The Manager Who Knew Everything Except Medicine

Chaudhry Nadeem was a businessman, not a doctor. He owned two pharmacies in Faisalabad, and in 2024 he opened a polyclinic on the ground floor of his new plaza. Three consultants rented evening slots. A general practitioner, Dr. Faisal, was hired for mornings.

To run the place day to day, Nadeem appointed his nephew Kamran. Kamran had a BBA, a sharp eye for accounts and an easy manner with patients. Within six months the clinic was busy and profitable.

Then Dr. Faisal resigned. A replacement took three weeks to find.

The clinic did not close in those three weeks. Kamran reasoned that most morning patients needed “routine” things: a repeat prescription, a dressing change, an injection written by the evening consultant. The dispenser handled these, and Kamran signed the register at the end of each day.

The PHC assessor arrived in the second week.

She asked a simple question: “Who manages this clinic, and who is responsible for the clinical services?”

Kamran answered the first part confidently. He hesitated on the second. The morning register showed forty-one patients seen over nine days. None of them had been seen by a doctor.

Indicator 6 was scored as not met.

What Indicator 6 Requires

The indicator reads: The clinic manager has requisite qualifications.

The MSDS Reference Manual is clear that the individual who manages and provides healthcare services at a clinic must be a qualified doctor, currently registered with the PM&DC. In a single-doctor clinic, the doctor is considered the person in charge, owner or manager of the clinic, unless another person has been hired to handle non-technical matters. For polyclinics and larger set-ups, an additional qualification in healthcare facility management is preferable.

When the Owner Is Not a Doctor

Non-doctor ownership is not prohibited. The manual simply draws a firm line between two kinds of responsibility.

The owner or administrator may handle general administrative matters: rent, salaries, supplies, accounts and scheduling. All technical matters related to the provision of healthcare remain the responsibility of the registered medical practitioner, who should not allow anyone else to practice in their absence.

Kamran was entitled to run the accounts. He was not entitled to run a clinic without a doctor.

The Named In-Charge

Where a clinic is owned or run by more than one practitioner, the manual expects the person in charge to be clearly notified. The desirable responsibilities of the person in charge include:

• Services provided according to PM&DC rules and the Code of Ethics, with only allopathic services portrayed and provided
• Maintenance of the building, interior and exterior, with attention to building safety
• General hygiene and courteous handling of patients by support staff
• Dispensing of medicines according to standard procedures
• Records maintained, checked at least quarterly and kept in safe custody
• Facilities and trained staff for emergency care and referral
• A complaint management and redressal system
• Compliance with infection control SOPs

A written notification naming the in-charge, with these responsibilities listed, is simple evidence for the assessor.

How It Is Scored

The assessor reviews the roles and responsibilities of the individuals managing the clinic and providing clinical services, and checks whether their credentials match the services portrayed.

The indicator is scored as fully met unless the survey team identifies significant deficiencies in the credentials. It is a RED indicator. A significant deficiency, such as patients being managed without a registered doctor, cannot be offset elsewhere.

What Nadeem Changed

The corrective action was mostly on paper, and partly in discipline.

A written notification was issued naming the new general practitioner, Dr. Hina, as clinical in-charge, with the eight responsibilities listed and signed. Kamran’s appointment letter was revised to “Administrator, non-clinical matters.” A rule was placed in the staff SOP file: no patient is seen, dressed, injected or dispensed to unless a registered doctor is physically present. If the doctor’s slot falls vacant, the slot is closed.

At reassessment, the credentials matched the services. The indicator was fully met.

“I thought management was management,” Nadeem admitted. “The Commission sees two jobs. I had filled only one.”

A Quick Self-Check

• Is the person responsible for clinical services a doctor currently registered with the PM&DC?
• If the owner or manager is not a doctor, is their role limited in writing to non-technical matters?
• In a shared or polyclinic set-up, is the in-charge clearly notified in writing?
• Do the credentials of each practitioner match the services displayed on your board?
• Has the clinic ever operated a session with no registered doctor present?

Series so far: Post 1, The Inspector | Post 2, 18 Standards, 47 Indicators | Post 3, Red, Yellow and the Score | Post 4, Signboard | Post 5, Easy Access | Post 6, PHC License | Post 7, Door Plate | Post 8, Consultation Hours | Post 9, Qualified Manager

About this series: Educational content on MSDS compliance for clinics under the Punjab Healthcare Commission, based on the PHC MSDS Reference Manual 2017.