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Dr Omar Hasan Kasule,Sr. MB ChB, MPH, DrPH (Harvard); formerly QA Consultant Physician, SCIP Hospital, Pittsburgh, PA USA (1992-1995); currently Professor, Faculty of Medicine, International Islamic University PO Box 70 Jln Sultan Petaling Jaya Selangor DE 46700 Malaysia
1.0 Definition of Quality Control, Quality Assurance, and Quality Improvement
Concepts of quality have evolved from quality control (QC) which aims at eliminating defects, through quality assurance (QA) which ensures that a certain level of quality once achieved must be maintained, to quality improvement (QI) which requires continous change to achieve even higher levels of perfection. QC does not fit the Islamic paradigm of the practice of medicine whose aim is improving quality of life and not mere elimination of pathology or preventing death (1). Quality assurance, being static maintenance of the status quo, has no future in the era of rapidly advancing medical knowledge and technology; what is today’s quality care will be inadequate care tomorrow. Continuous quality improvement (QI) is a philosophy that is committed to continuous and consistent improvement in quality. It involves training for quality, making the necessary changes in the organizational structure, nurturing a long-term perspective. The aim is not to perform at a pre-set standard but to constantly improve and get better. The Prophet Muhammad called for continous improvement and called a loser any person whose level of performance was the same on two consecutive days (2).
2.0 Quality Improvement in Medicine
Medicine, like all other human endeavors must reflect the Muslim concern for quality. It is even more important because it involves human physical well-being for which the physician is accountable. Quality is a culture and a philosophy of life and not a just certain fixed procedures. Islam in its doctrines and historical expperience has the guidleines that Muslim physicians can use to provide quality medical care. The paper presents the following 4 principles guide a Muslim physician’s approach to QI: ihsaan (excellence), itqaan (quality performance), muhasabat (evaluation), and muraqabat (control). Relevant textual references from hadith and Qur’an are given (3-7)
3.0 Ihsaan
Ihsaan is higher than Islam and iman. In its purest form it involves perfection of worship in the full realization that Allah is ever watchful (8). Lower levels of ihsaan involve attempts to do good and achieve excellence in all human endeavours. The Qur’an uses the word ihsan in connection with good work for neighbors, the poor, the parents (6), and the orphans (9). QI is consistent with the Islamic concept of ihsaan which is restless efforts towards perfection. Improvement must be continuous. Humans can never reach perfection and rest on their laurels. They must always strive to approach it; the nearer the better. Muslims must be leaders of quality because this is the very essence of ihsaan, the highest of the three main tenets of the religion: Islam, iman, and ihsan. Muslims try to achieve excellence in whatever they do.
4.0 Itqaan
The Qur’an uses the concept of itqan to describe Allah’s creation (10). The Prophet in his words (11) and practice (12) taught quality performance. Itqan can only be achieved if there is consistency in the work (13) and when what is done conforms to the declared intention (14). Tasks once started must be completed (15). Quality in medical care is continous and does not come about by accident. The whole culture, leadership, and organizational design must be structured to ensure high quality all the time and in all circumstances.
5.0 Muhasabat
Muhasabat is the very basis for QI. By continous self-criticism and self-evaluation (16-17), the care-giver can identify what is done well and continue or improve and identify what is not done well so that corrective steps can be taken. Muhasabat may sometimes come too late after the damage has been done (18). A control, muraqabat, system is therefore the better approach. The practising physician must be aware that he is personally accountable for all what he does, big or small (19-20), this sense of personal responsibility and accountability produces quality work.
6.0 Muaqabat
Muraqabat is the process of being on the watch-out for any deviations. A human is prone to err and continous vigilance is needed to be able to catch those errors quite early. The physician should be the first to watch performance. Physicians should be aware that all performance or non-performance is observed by Allah (21-23) so they should try their best to keep their conscience at ease. He/she should accept control by others not an invasion but as a welcome assistance in case there are deviations from good care that can be detected early and can be improved.
6.0 Systematic Quality Improvement Programs
It is a moral and professional requirement that institutions that deliver medical care should set up quality assrance and quality improvement programs. The most sincere and committed people can make mistakes (24). Perpetrators of a mistake may not even be aware of what they are doing (25). Quality improvement programs will succeed only when physicians develop the Islamic value of being ready to admit mistakes and change course (26). A quality improvement program must develop objective criteria and measurement instruments. All judgements and improvement plans must be based on evidential facts. Decisions are made according to what is seen externally; the internal intentions are not fathomable to ordinary human beings (27).
REFERENCES
1. Kasule, Omar Hasan: Islamic Perspectives of Medical Education. Paper presented at the Annual General Meeting of the Islamic Medical Association, Khota Bharu july 1996
2. "Man istawa yawumaahu fahuwa maghboon"
3. BUKHARI, Muhammad bin Ismail bin al Mughira. Sahih al Bukhari. Translation of the meanings by Dr Muhammad Muhsin Khan vols 1-9. Kazi Publications, Lahore, Pakistan 1979.
4. MUSLIM, Abul Husain Asakir-ud-Din b Hajjaj bin Muslim al-Qushayri al-Naisaburi Sahih Muslim rendered into English by Abdul Hamid Siddiqi Vols 1-4. Sh Muhammad Ashraf Publishers and Booksellers. Lahore ? year of publication
5. DAUD, Abu Sulaiman Sunan Abu Daud. English translation with explanatory notes by Prof. Ahmad Hasan vol 1-3. Sh. Muhammad Ashraf Publishers and Book sellers Lahore Pakistan, 1984
6. KAHLANDAWI, Maulana Mohammad Yusuf Hayat al Sahaba (3 vols.) English translation by Dr Majid Khan. Idara Isa’at-e-Diniyat (P) Ltd New Delhi 1985
7. Abdullah Yusuf Ali: The Meaning of the Holy Qur’an. Amana Publications, Brentwood, MD 1412 AH/1992
8. 'Umar b. al Khattab transmitted to me a tradition, saying: One day when we were with the Apostle of Allah (may peace be upon him)a man with very white clothing and very black hair came up to us. No mark of was visible on him, and we did not recognize him. Sitting down beside the Apostle of Allah (may peace be upon him), leaning his knees against his and placing his hands on his thighs, he said: Tell me, Muhammad, about Islam..... He said: Now tell me about doing good (ihsan). He replied: It means that you should worship Allah as though you are seeing Him; if you are not seeing Him, He is seeing you...’
Abu Daud 3:13151316, Ch. 1693, Hadith # 4678
9. Nisa: 36
10. Naml: 88
11. "Idha amila ahadukum amalan fa liyutiqnahu"
12. "Narrated Anas : The Prophet ( may peace be upon him ) used to pray a short prayer ( in congregation ) but used to offer it in a perfect manner." Bukhari 1:381, hadith # 674
13. "Aisha reported Allah's Messenger ( may peace be upon him ) as saying: The acts most pleasing to Allah are those which are done continuously, even if they are small, and when Aisha did any act she did it continuously." Muslim 1: 377-378, Chapter 273, Hadith # 1713
14. Do you enjoin right conduct on the people, and forget ( To practice it ) yourself. And yet you study the Scripture ? Will you not understand ? Qur'an 2:44
15. "Aisha reported the Apostle of Allah ( may peace be upon him ) as saying: Choose such actions as you are capable of performing, for Allah does not grow weary till you do. The acts most pleasing to Allah are those which are done most continuously, even if they amount to little, Whenever he began an action, he would do it continuously" Abu Daud 1:358, Chapter 468, Hadith # 1363
16.. " Hadrat Thabit Ibn Jajjaj ( Rad ) says that Umar ( Rad ) said, " Weigh your own selves before you are yourself weighed ( by Allah, concerning your deeds ) If you do so today, then tomorrow, on the Day of Judgment, you will have an easy reckoning. So prepare yourself for the Great Reckoning well in advance before comes the Day whereon you shall be mustered nothing hidden by you shall be hidden Hayat 2:701
17. "Hadrat Anas Ibn Malik ( Rad ) says that one day he was accompanying Umar ( Rad ) and he entered into a garden. There was a small parapet in between us the two and he heard him saying, O the Commander of the Faithfuls! Fear Allah or Allah will surely punish you" ( This he said to his own self. ) Hayat 2: 701
18. "Ali bin Abi Talib said, " The world is going backwards and the Hereafter is coming forwards, and each of the two has its own children; so you should be the children of the Hereafter, and do not be the children of this world, for today there is action ( good or bad deeds ) but no accounts, and tomorrow there will be accounts, but ( there will be ) no deeds to be done". Bukhari 8:285
19. Then shall anyone who has done an atom's weight of good, see it! And anyone who has done an atom's weight of evil, shall see it. Qur'an 99:7-8
20. Namely, that no bearer of burdens can bear the burden of another. That man can have nothing but what he strives for. That ( the fruit of ) his striving will soon come in sight. Then will he be rewarded with a reward complete. Qur'an 53:38-41
21. All that they do is noted in ( their) Books (of deeds ). Every matter small and great is a record.Qur'an 54:52-53
22. Call them by ( the names of ) their fathers: that is juster in the sight of Allah. But if you know not their father's ( names, call them ) your Brothers in faith. or your Mawlas. But there is no blame on you if you make a mistake therein : ( What counts is ) The intention of your hearts: And Allah is oft-Forgiving most Merciful.Qur'an 33:5
23. It was we who Created man and we know what dark suggestions his soul makes to him for we are nearer to him than ( his ) jugular vein. Not a word does he Utter but there is a sentinel by him ready ( to note it ). Qur'an 50:16-18
24. And say " work ( righteousness ) soon will Allah observe your work and his Messenger and the believers: Soon will ye be brought back to the knower of what is Hidden and what is open then will he show you the truth of all that you did. Qur'an 9:105
25. Say: " Shall we tell you of those who lose most in respect of their deeds?. " Those whose efforts have been wasted in this life. While they thought that they were acquiring good by their works?" They are those who deny the signs of their Lord and the fact of their having to meet him ( In the hereafter): vain will be their works, nor shall we, on the Day of Judgement, give them any weight. Qur'an 18:102-105
26. "Narrated Aisha : Abu Bakr As-Siddiq had never broken his oaths till Allah revealed the expiation for the oaths. Then he said, " If I take an oath to do something and later on I find something also better than the first one then I do what is better and make expiation for my oaths." Bukhari 8:404, hadith # 618
27. Judge by what you see; the inside in unknown: "Narrated Umar bin al Khattab : People were ( sometimes ) judged by the revealing of a Divine Inspiration during the lifetime of Allah's Apostle but now there is no longer any more ( new revelation ). Now we judge you by the deeds you practice publicly, so we will trust and favor the one who does good deeds in front of us, and we will not call him to account about what he is really doing in secret, for Allah will judge him for that; but we will not trust or believe the one who presents to us with an evil deed even if he claims that his intentions were good."Bukhari 3:491, hadith # 809