Compliance & inspection readiness
Licences, Minimum Service Delivery Standards (MSDS) evidence and the daily registers inspectors ask for. Each branch follows its province's regulatory profile.
MSDS readiness · DHA Phase 5
PHC clinic manual · 18 standards / 47 indicators [Verify]85%40 / 47 met
Access, assessment & continuity of care
6/6
Care of patients
7/8
Management of medication
5/6
Patient rights & education
5/5
Infection control
4/6
Facility management & safety
5/7
HR management
5/6
Information management
3/3
Standard groups follow PHC's MSDS areas. Indicator text and wording must be loaded from the official manual for each facility type [Verify].
Gaps to close before inspection
7| Indicator | Gap | Evidence | Owner | Due |
|---|---|---|---|---|
| Sterilisation validated daily | Bowie-Dick not recorded since 06 Oct (autoclave down) | Missing | CSSD tech | 15 Oct |
| Hand-hygiene audit monthly | September audit not uploaded | Missing | Infection control nurse | 16 Oct |
| Fire drill every 6 months | Last drill 02 Mar 2026 | Overdue | Admin | 20 Oct |
| Staff registration valid | 1 nurse PNMC expired | Partial | HR | 18 Oct |
| Emergency tray checklist | 2 drugs near expiry on tray | Partial | Nurse in-charge | 14 Oct |
| Equipment maintenance records | Defibrillator test overdue | Overdue | Biomed | 15 Oct |
| Medication management | Look-alike/sound-alike list not displayed | Missing | Pharmacist | 17 Oct |
Licences & registrations
Reminders 90 / 60 / 30 / 7 days before expiry| Licence | Authority | Facility | Number | Valid until | Document | Status |
|---|---|---|---|---|---|---|
| Healthcare establishment licence | Punjab Healthcare Commission | DHA Phase 5 (clinic) | PHC-LHR-R-04412 | 31 Dec 2027 | licence.pdf | Valid |
| Clinical laboratory licence | Punjab Healthcare Commission | CareWell Diagnostics | PHC-LHR-L-01187 | 30 Nov 2026 | licence.pdf | Renew · 48 d |
| Drug sale licence (Form 8-A, pharmacy) | Provincial Drug Controller | DHA pharmacy | DSL-LHR-26-2281 | 14 Feb 2027 | dsl.pdf | Valid |
| Radiation facility licence | PNRA | DHA imaging (DR X-ray) | PNRA-DX-L-9910 | 22 Jan 2027 | pnra.pdf | Valid |
| Hospital waste authorisation (Rule 28) | EPA Punjab | All Lahore branches | EPA-HWM-LHR-3302 | 05 Oct 2026 | epa.pdf | Expired · renewal filed |
| ISO 15189 accreditation | PNAC | CareWell Diagnostics | ML-0xx (in progress) | — | QMS evidence → | Assessment Jan 2027 |
Hand-hygiene audit · Aug
82% compliance
WHO 5 moments · 60 observations · Sep audit missing
Needle-stick injuries (YTD)
2
Both followed up: HBV/HCV/HIV baseline + PEP decision recorded
Surface / OT swabs
All negative
Last done 01 Oct · day-care OT
Autoclave cycle log
| Date | Cycle # | Load | Temp / time | Chemical indicator | Bowie-Dick | Biological (spore) | Operator |
|---|---|---|---|---|---|---|---|
| 06 Oct | AC-1184 | Dressing sets ×18 | 134 °C / 4 min | Pass | Pass | Negative | CSSD tech |
| 08 Oct | AC-1185 | Minor OT instruments | 134 °C / 4 min | Pass | — | — | CSSD tech |
| 10 Oct | AC-1186 | Dental instruments | Aborted at 118 °C | Fail | — | — | CSSD tech · load reprocessed (tabletop unit), BT-26-031 raised |
Infectious (yellow) [Verify]
14.2 kg
Today · DHA
Sharps (puncture-proof box)
2.1 kg
3 boxes sealed
Pharmaceutical / chemical
0.8 kg
Expired meds returned to supplier where possible
General (black)
26.5 kg
Municipal collection
| Date | Contractor (EPA-authorised) | Manifest no. | Infectious kg | Sharps kg | Vehicle | Signed by |
|---|---|---|---|---|---|---|
| 13 Oct | Lahore Waste Care (example) | MF-LWC-261013-044 | 14.2 | 2.1 | LEB-4471 | Waste officer + driver |
| 12 Oct | Lahore Waste Care (example) | MF-LWC-261012-039 | 16.8 | 1.6 | LEB-4471 | Waste officer + driver |
| 11 Oct | Lahore Waste Care (example) | MF-LWC-261011-035 | 12.9 | 1.9 | LEB-4471 | Waste officer + driver |
Required under the Punjab Hospital Waste Management Rules 2014: a waste management officer, a written waste plan and daily records. Colour codes are configurable per province [Verify].
| Equipment | Location | Range | Today AM | Today PM | Excursions (30 d) | Logged by |
|---|---|---|---|---|---|---|
| Vaccine fridge | DHA pharmacy | 2–8 °C | 5.1 | due 17:00 | 1 (power cut) | Noman Ali |
| Reagent fridge 1 | Lab · chemistry | 2–8 °C | 4.2 | due 17:00 | 0 | Asad Mehmood |
| Blood culture incubator | Lab · micro | 35–37 °C | 35.8 | due 17:00 | 0 | Micro tech |
| Freezer −20 | Lab · serum archive | ≤ −18 °C | −21.0 | due 17:00 | 0 | Asad Mehmood |
| Room temperature | Pharmacy store | ≤ 25 °C | 27.4 | due 17:00 | 6 | Noman Ali |
Readings come from MedX Bridge data loggers where available, or are entered manually twice a day. An out-of-range reading opens a non-conformance automatically.
| Check | Frequency | Last done | Next due | Result |
|---|---|---|---|---|
| Fire evacuation drill | 6-monthly | 02 Mar 2026 | 02 Sep 2026 | Overdue |
| Fire extinguishers (8) pressure & tag | Monthly | 01 Oct 2026 | 01 Nov 2026 | OK |
| Emergency exit signage & lights | Monthly | 01 Oct 2026 | 01 Nov 2026 | OK |
| Generator load test | Weekly | 12 Oct 2026 | 19 Oct 2026 | OK |
Open
4
Closed (Sep)
17
Within SLA
88%
Escalated to PHC
0
| Ref | Category | Summary | Status | SLA |
|---|---|---|---|---|
| CMP-26-0088 | Waiting time | Waited 70 min for Dr. Sana (late session) | Investigating | Due 15 Oct |
| CMP-26-0087 | Billing | Charged consultation within free follow-up window | Resolved · refunded | Met |
| CMP-26-0085 | Lab report | Report delayed (analyser down) | Acknowledged | Due 16 Oct |
Complaints come from the front desk, the patient app, NPS scores of 6 or below, and WhatsApp. Lifecycle: Logged → Acknowledged → Assigned → Investigating → Resolved → Closed / Reopened. The patient rights charter and the PHC complaint channel are displayed in each branch.
No single statutory retention period was found for Pakistan
These defaults are a conservative policy set by the clinic. Records are never deleted automatically; the system flags them for review once retention ends.
| Record type | Retention (default) | After retention | |
|---|---|---|---|
| Adult clinical records (EMR, Rx) | 7 years after last visit | Review → archive / anonymise | Edit |
| Minors' records | Until age 25, or 7 years after last visit (whichever is later) | Review | Edit |
| Consent forms for procedures | 10 years | Review | Edit |
| Lab reports | 7 years · histopathology blocks/slides per lab policy | Review | Edit |
| Radiology images & reports | 7 years (mammography 10) | Move to cold storage | Edit |
| Medico-legal cases | Indefinite until case closed + 10 years | Manual only | Edit |
| Financial records & tax invoices | 6 years (FBR e-invoice draft) [Verify] | Archive | Edit |