Dear All,
This is an important update for Physiotherapists:
National Council for Clinical Establishments under the Chairmanship of Director General of Health Services, Government of India in consultation with various stakeholders has prepared draft minimum standards for various categories of Clinical Establishments for implementation of the Clinical Establishments Act.
The comments, suggestions, objections, including deletions /additions if required in the draft documents are invited from public at large, including the stakeholders like hospitals and other clinical establishments, consumer groups etc. The comments may kindly be sent to Dr. Anil Kumar, CMO(AK) Room No.506 ‘D’ Wing, 5th Floor, Nirman Bhawan, New Delhi-110018 at his email- id dr.anilkumar@nic.in with in one month of publication of this Notice on the website. A copy of the same may also be endorsed to nsdharmshaktu@yahoo.com
Requesting all Physios to take part in this cause to uplift our Profession.
(This mail contains 3 attachments)
My Draft:
From,
Einstein Jerome,
Physiotherapist,
ESIC Model Hospital(Ministry of Labour and Employment, Govt of India),
Rajaji Nagar, Bangalore-560010
To,
Dr. Anil Kumar, CMO(AK)
Room No.506 ‘D’ Wing,
5th Floor, Nirman Bhawan,
New Delhi-110018
Subject : Comments, Suggestions, Objections and deletion in Clinical Establishment Act Standards for Physiotherapy Centre CEA /Physiotherapy Centre- 023
Objections/Suggestions for Points 1, 2.1 , 6.1 &10.1
1. Definition : A physiotherapy centre is a paraclinical establishment providing , physical therapy services by a physiotherapist to patients with a recent prescription or referral from a licensed medical doctor (physician/surgeon). After three weeks or earlier if indicated a review and re-prescription from the treating medical doctor is required for continuing physical therapy services.
( Objection: This definition, paraclinical word and referral system are not in accordance with any reference , either National or International Standard. Points regarding the definition are mentioned in this draft)
2.1 These set of common minimum standards framed shall be applicable to standalone physiotherapy centre with one or more physiotherapy practioners and physiotherapy sections attached to hospitals or polyclinic.
(Suggestion: Physiotherapy is a Separate Clinical Establishment as per the current Clinical Establishment Act of the Central Government and State Governments. An individual Physiotherapy Clinic/Centre should be included in Clause 2.1. Points regarding the Clinical Establishment of Physiotherapy Clinic/Centre are mentioned in this draft)
6.1 The physiotherapy practitioner as per the scope of the physiotherapy centre shall be registered with State Physiotherapy Council, wherever applicable.
(Suggestion: The State Existing Councils in India, The Maharashtra State OTPT Council & Delhi Council for Physiotherapy & Occupational Therapy have given autonomous and Independent practice status for Physiotherapists with Job nature of Assessment , Diagnosis and Treatment .The same Criteria should be followed in the Clinical Establishment Act)
10.2 Assessment and plan of care: The physiotherapist card/slip of every registered patient must bear the minimum following legibly at every visit: Working diagnosis as provided by the treating medical doctor who has referred the patient, Relevant history and examination findings, Plan of care listing the exercises and physical modalities, Signature and date of the physical therapist, A review and re-prescription from the treating medical doctor after three weeks for continuing plan of care.
( Objection: The treatment is determined by the Physiotherapist who is a qualified Professional according to the current Clinical Establishment Acts and the existing state Councils of India. 3 Weeks is not sufficint duration in case of patients with Paraplegia, hemiplegia, Cerebral palsy etc. Kindly refer the Ministry of Social Justice & Empowerment’s letter No. 9-3/CCD/2007 dated 15/05/2008 , Subject: Handling of Children with disabilities and referral which states that “Most of the doctors are not trained for rehabilitation of Persons with disabilities, they often try to treat their disabilities even when medical or surgical interventions are not required. In the process, most critical period of six years of life is lost which is most important period to train & rehabilitate the child with disability to utilize the residual capacity of the impaired organs. Consequently , it is too late for such children to respond to the rehabilitation therapies even by most qualified & skilled rehabilitation professionals like Physiotherapists etc.
Chief Commissioner has taken notice of the complaints from parents, Rehabilitation professionals , NGO’s etc . and has directed that appropriate instructions may be issued by Medical Council of India and Indian Medical Association through print and electronic media to the effect that the doctors not trained on rehabilitation should restrict their treatment of children with disabilities to their medical illness/disease or else action be initiated against such practices under relevant section of MCI. They should refer such children to the qualified rehabilitation Professionals to ensure that they get appropriate rehabilitation/therapeutic assistance well in time. The court of the Chief Commissioner for persons with disabilities shall be constrained to initiate action under Section 59 of the Persons with Disabilities Act, 1995 against the Doctors who may persist with such practices.
http://www.mciindia.org/circulars/Circular-disabled-children.pdf)
2.2.1 (f) Electrical muscle stimulator (with electro diagnostic facility). (Comments: Electrodiagniosis is mentioned in the equipments. A Physiotherapist performs Strength Duration(SD) Curve to find out the Innervation of a peripheral nerve and this is a supporting evidence of the Diagnosis and examination performed by a Physiotherapist)
Supporting Points for Modifications of Points 1, 2.1 , 6.1 &10.1
1. Delhi Council for Physiotherapy & Occupational Therapy Bill 1997 : “Physiotherapy” means physiotherapeutic system of medicine which includes examination, treatment, advice and instructions to any persons preparatory to or for the purpose of or in connection with movement dysfunction, bodily malfunction, physical disorder, disability, healing and pain from trauma and disease, physical and mental conditions using physical agents including exercise, mobilization, manipulation, mechanical and electrotherapy, activity and devices or diagnosis, treatment and prevention.
(Reference: http://delhiassembly.nic.in/aspfile/billspassed/141997.htm )
2. Maharashtra State OTPT Council: "Physiotherapy" means a branch of modern medical science which includes examination, assessment, interpretation, physical diagnosis, planning and execution of treatment and advice to any person for the purpose of preventing, correcting, alleviating and limiting dysfunction, acute and chronic bodily malfunction including life saving measures via chest physiotherapy in the intensive care units, curing physical disorders or disability, promoting physical fitness, facilitating healing and pain relief and treatment of physical and psychosomatic disorders through modulating physiological and physical response using physical agents, activities and devices including exercise, mobilization, manipulations, therapeutic ultrasound, electrical and thermal agents and electrotherapy for diagnosis , treatment and prevention.
(Reference: http://www.msotptcouncil.com/OTPTActs.aspx )
Maharashtra State has Documented Physiotherapy as an Individual profession and has passed " Maharashtra Council for Paramedical sciences & Technologies" for Paramedics. Physiotherapy and Paramedical councils are two different councils
3. Government of India- Quality Council of India , Survey Report & Recommendations Of Clinical Establishments
4. Various Acts/Rules of the Central Government of India and State Governments of India
'Clinical Establishment' means (i) a hospital, maternity home, nursing home, dispensary, clinic, sanatorium or an institution by whatever name called that offers services, facilities requiring diagnosis, treatment or care for illness, injury, deformity, abnormality or pregnancy in any recognised system of medicine established and administered or maintained by any person or body of persons, whether incorporated or not;
(Reference: http://www.ima-india.org/downloads/Clinical%20Establishment%20Draft%20Rules%20for%20Central%20Govt.pdf
http://clinicalestablishmentstraining.nic.in/WriteReadData/293.pdf)
All the below Acts/Rules (Karnataka Private Medical Establishments Act,2007 /The Karnataka Private Medical Establishments (amendment) act, 2012 , The Andhra Pradesh Private Medical Care Establishments (Registration andRegulation) Act, 2002 ,The Bombay Nursing Homes Registration Act, 1949, The Delhi Nursing Homes Registration Act, 1953,
Manipur Homes and Clinics registration Act, 1992, The Nagaland Health care Establishments Act, 1997, The Arunachal Pradesh Health and Establishment Act, 2002, The Orissa Clinical Establishments (Control and Regulation) Act, 1990, The Punjab State Nursing Home Registration Act, 1991, The Tripura Clinical Establishment Act, 1976, The West Bengal Clinical Establishments Act, 1950, The Jammu and Kashmir Nursing Homes and Clinical Establishments (registration and licensing) act, 1963, Madhya Pradesh Clinical Rules, 1973 / Madhya Pradesh Upcharya Griha Tatha Rajupchar Sanbabdu Sthapama Adhiniyam, 1973 ) state that
“Physio-therapy establishment means an establishment where massaging ,electrotherapy, hydrotherapy, remedial gymnastic or similar processes are usually carried on, for the purpose of treatment of diseases or of infirmity or for improvement of health or for the purpose of relaxation or for any other purpose whatsoever”
For Physical Therapy Establishment, It is under the direct supervision of a properly qualified expert on the particular kind of treatment given in the establishment.
Physiotherapy Clinic is documented in as a Separate type of Establishment as an Out Patent Service under the direct supervision of a properly qualified expert and hence in reference with the above definition of “Clinical establishment”, the Physiotherapist should be able to offer services facilities requiring diagnosis, treatment or care for illness, injury, deformity, abnormality etc in the field of Physiotherapy.
5. Government of India- Quality Council of India , Survey Report & Recommendations Of Clinical Establishments:
Link: http://clinicalestablishments.nic.in/En/1074-reports.aspx
http://clinicalestablishments.nic.in/WriteReadData/384.pdf
A survey was proposed by the Ministry of Health & Family welfare, Govt. of India. It was conducted in collaboration with Quality Council of India (NABH) & Indian Medical Association (HQ). The aim was to carry out survey in all the districts of the 4 states and 7 Union Territories so as to help QCI in defining the minimum requirements for different types of Clinical establishments” for implementation of the Clinical Establishment Act 2010.
Draft Minimum Standards: QCI was given task of developing draft minimum standards for consideration of National Council. Preliminary standards on 15 categories were developed and shared with members and States for feedback. After incorporating survey findings and feedback, draft of minimum standards for 35 categories have now been received from QCI.
(Reference: 4th Meeting of the National Council for Clinical Establishments , Minutes of the Meeting 03/01/2014 and documented by Ministry of Health and family Welfare, Directorate : http://clinicalestablishments.nic.in/WriteReadData/521.pdf Page 2 )
The documentation about Physiotherapy in this survey clearly defines and documents Physiotherapy as an Individual Clinical Establishment. The findings on Physiotherapy are documented below :
(i) Physiotherapy Definition: The treatment of disease, bodily defects, or bodily weaknesses by physical remedies, as massage, special exercises, etc., rather than by drugs.
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 11)
(ii) Physiotherapy Centres/Physiotherapy Clinics are mentioned as a Separate facility
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page No 7 ,11 , 50 and 73)
(v) Registration status of physiotherapist is a Criteria for Physiotherapy Centre
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf page 85)
(vi) Equipments: ElectroTherapy: Traction Unit Cervical Lumbar, Interferential Therapy, Shortwave Diathermy, Cold Packs, Muscle Stimulator with Electro Diagnostic, CPM, Hot Pack Unit, Laser, Wall Ladder, TENS, Parafin Wax Bath, Muscle Testing (Reference:http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 53 & 87)
Exercise Therapy: Wall Ladder, Shoulder Wheel, Dumbbells Weight Cuffs, Thera Bands Thera Tubes, Spirometer, Tilt Board, Swiss ball, Vibrator for Chest Physiotherapy, Treadmill
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 54, 87 & 88)
(vii) Core Group Recommendations:
PHYSIOTHERAPY
(Reference: http://clinicalestablishments.nic.in/WriteReadData/384.pdf Page 68)
Essentials
1. Name of Consultant(s)
2. Fire Extinguisher
3. Display of service provided & Charges
4. Drinking Water facility
5. Registration of the patients
6. Waiting area
7. Backup Electricity
8. Hand wash facility
9. Examination/Treatment tables for patient
10. Torch
11. Bio Medical Waste
12. Thermometer
13. Weighing machine
14. BP Apparatus
15. Electrotherapy Equipments/ Modalities
a) Short Wave Diathermy
b) Ultrasonic Therapy
c) Interferential Therapy
d) Hot Packs
e) Wax Bath
f) TENS
g) Traction Unit (Cervical / Lumbar)
h) Muscle Stimulator
16. Exercise therapy Equipments/ Modalities
a) Cold Packs
b) Shoulder Wheel
c) Over Head Pulley
d) Wall Ladder /Abduction Ladder
e) Weight Cuffs / Weights
Optional
1. Electrotherapy Equipments/ Modalities
a) Micro Wave Diathermy
b) LASER Therapy
c) Muscle Stimulator Electrodiagnostic
2. Exercisetherapy Equipments/ Modalities
a) Cryo Cuff Unit
b) Continuous Passive Motion Exerciser
c) Supinator Pronator Exerciser
d) Heel / Ankle Exerciser
e) Tilt Board
f) Parallel Bar
g) Mat Exercise Facility
h) Suspension Therapy Unit
i) Stationary Bicycle
j) Treadmill
k) Vibrator
l) Swiss Ball
m) Rowing Frame Exerciser
n) Gripper / Gel Balls
o) Graded Elastic Exercise Bands
p) Quadriceps Table
Toilets
Noise Pollution Certificate
Air pollution certification
6. Ministry of Social Justice & Empowerment’s letter No. 9-3/CCD/2007 dated 15/05/2008 Subject: Handling of Children with disabilities and referral
“Most of the doctors are not trained for rehabilitation of Persons with disabilities, they often try to treat their disabilities even when medical or surgical interventions are not required. In the process, most critical period of six years of life is lost which is most important period to train & rehabilitate the child with disability to utilize the residual capacity of the impaired organs. Consequently , it is too late for such children to respond to the rehabilitation therapies even by most qualified & skilled rehabilitation professionals like Physiotherapists etc.
Chief Commissioner has taken notice of the complaints from parents, Rehabilitation professionals , NGO’s etc . and has directed that appropriate instructions may be issued by Medical Council of India and Indian Medical Association through print and electronic media to the effect that the doctors not trained on rehabilitation should restrict their treatment of children with disabilities to their medical illness/disease or else action be initiated against such practices under relevant section of MCI. They should refer such children to the qualified rehabilitation Professionals to ensure that they get appropriate rehabilitation/therapeutic assistance well in time. The court of the Chief Commissioner for persons with disabilities shall be constrained to initiate action under Section 59 of the Persons with Disabilities Act, 1995 against the Doctors who may persist with such practices”.
(Reference: http://www.mciindia.org/circulars/Circular-disabled-children.pdf)
7. Public Notice by Government of NCT of Delhi:
Directorate of Health Services , Department of Health and Family Welfare, Government of NCT of Delhi had issued a public notice in March 2014 stating Physiotherapy as a System of Medicine in along with Allopathic, Ayurveda and Unani, Homeopathy and Dental
8. Findings of the Planning Commission of India (2007-2012):
Point number 3.1.104 states that “In the field of paramedical education, priority will be given for establishment of National Para Medical Council as an apex body to determine standards and to ensure uniform enforcement throughout the country. On similar lines, councils for physiotherapy and occupational therapy should also be established”
This differentiates Physiotherapists from paaramedcals.
(Reference: Page 84 and 85 –Eleventh Five year Plan (2007-2012)_ Vol 2 –Social Sector Eleventh Five Year Plan(2007–2012)Social Sector Volume II-Planning Commission of India)
9. Expert Opinion:
Committee also took note of the views expressed by Dr. M.K. Bhan, Professor of Pediatrics, AIIMS and presently on deputation as Secretary, Department of Biotechnology who pointed out that currently, access to high quality rehabilitation was very limited in our country and physiotherapy deserved to be supported and promoted in a decisive manner, in terms of education and training. While accepting the fact that in planning physical rehabilitation, assessment by medical and surgical disciplines was important, it was also mentioned that only a small number of physicians had a reasonable understanding of physical rehabilitation. In general it has been seen that the medical profession does not always enable thriving of the support services and generally reluctant to grant them proper professional status. This indirectly leads to much needed professions such as physiotherapy becoming unattractive and in the process keeping good quality students away. It was, accordingly, emphasized that adequate recognition should be granted to physiotherapy through legislation and for ensuring adequate access to physiotherapy services in the country, physiotherapists be allowed to open independent service centres. The education of physiotherapists should in itself provide ample understanding of when physical therapy is required
( Reference: Clause 9.39Thirty-First report on Paramedical and Physiotherapy Central Councils Bill-2007)
10. Clinical Establishment Act 2010- Court Notification:
The Patna high court directed the state government to frame rules to implement the Clinical Establishment (Registration and Regulation) Act, 2010, in the state. Hearing a PIL filed by Veteran's Forum for Transparency in Public Life, a division bench of Justice Navin Sinha and Justice Shailesh Kumar Sinha directed the government to frame the rules by January 31, 2014. "If it is not so done, principal secretary, health department, shall be present in person and show cause," the court ordered. The Act was enacted for registration and regulation of the clinical establishments with a view to ensuring minimum standards of facilities and services. Bihar adopted the Act in July, 2011, but the rules to implement it have not been framed yet, petitioner's counsel Dinu Kumar submitted. According to the Act provisions, a clinical establishment is supposed to maintain records of outpatient, inpatient, operation theatre, labour room, MTP, case-sheets, laboratory register, discharge summary, complaint register, number of beds, system-wise and speciality-wise in the establishment, rates of different services, et cetera. Additional advocate general 14 P N Shahi informed the court through a counter affidavit that the rules are being drafted and the State Council and District Regulation Authority will be constituted soon. However, the court termed it "evasive" for not having proper dates and ordered the state to frame the rules, to constitute a state council for clinical establishments and district registration authority by January 31 and submit a report before it by February 3, 2014.
11. Ministry of Law:
Ministry of Law was of the opinion that the profession of physiotherapy should not be covered within the meaning of the term ‘paramedical’
(Reference: Thirty-First report on Paramedical and Physiotherapy Central Councils Bill-2007)
12. Documentation about Physiotherapy in the Thirty-First report on Paramedical and Physiotherapy Central Councils Bill-2007 (Presented to the Rajya Sabha on 21st October,2008 and laid on the table of Lok Sabha on 21st October,2008):
Clause 8.2 “Physiotherapy being considered a discipline distinct from paramedical disciplines finds a specific mention in the title (Paramedical and Physiotherapy Central Councils Act, 2007)”
Clause 9.36 Committee’s attention was also drawn to the parallel position of Naturopathy and Yoga when compared with physiotherapy as both were based on physical and psycho-somatic methods of diagnosis and treatment, with both claiming benefit to the patients in a drugless manner. It was argued that both Naturopathy and Yoga are granted equal status along with Ayurveda under AYUSH. Thus, physiotherapy also deserved to be granted an independent status.
Clause 9.46 “The fact that physiotherapy education over the years has made significant advancements and has evolved as a distinct profession seems to be well established. This is strengthened by the considered opinion of Ministry of Law that physiotherapy profession should not be equated with the paramedical professions”
Clause 9.47 “The Committee also takes note of the fact as mentioned by the representative of the Ministry that in USA, physiotherapy profession has reached a stage where these professionals can practise independently. Not only this, in some of the international Acts, it has been specifically provided that physiotherapists having the required experience can give physiotherapy treatment without a referral. These Acts also confer upon a physiotherapist the right to practise with or without referral governed by the circumstances of the case.”
Clause 9.49 “The Committee also takes notes of well-founded objection raised with regard to the definition of physiotherapy as given in the Delhi Act. The Committee, accordingly, recommends that this definition may be included with the replacement of the words ‘physiotherapeutic system of medicine’ by the word ‘therapy’ or ‘health care profession’. Secondly, to set at rest the apprehensions expressed by all concerned about physiotherapists assuming the role of a doctor, following provision may be added at the appropriate place in the Bill,.”
13. World Health Organization (WHO) and International Labor Organization (ILO)
1. Definition of Physiotherapist by World Health Organization which emphasizes on assessment and formulating a treatment plan independently by Physiotherapists.
"Physiotherapists assess, plan and implement rehabilitative programs that improve or restore human motor functions, maximize movement ability, relieve pain syndromes, and treat or prevent physical challenges associated with injuries, diseases and other impairments. They apply a broad range of physical therapies and techniques such as movement, ultrasound, heating, laser and other techniques. They may develop and implement programmes for screening and prevention of common physical ailments and disorders"
Link: http://www.who.int/hrh/statistics/Health_workers_classification.pdf
2. International Standard Classification of Occupations (ISCO) is a tool for organizing jobs into a clearly defined set of groups according to the tasks and duties undertaken in the job.
The World Health Organization (WHO) has classified physiotherapists in professional group (ISCO Code 2264) and paramedical professionals have been classified in a separate entity ( ISCO code 2240).
WHO Link: http://www.who.int/hrh/statistics/Health_ workers_classification.pdf)
3. Physiotherapists and related associate professionals treat disorders of bones, muscles and parts of the circulatory or the nervous system by manipulative methods, and ultrasound, heating, laser or similar techniques, or apply physiotherapy and related therapies as part of the treatment for the physically disabled, mentally ill or unbalanced.
The International Labour Organization (ILO) is the international organization responsible for drawing up and overseeing international labour standards. It is the only 'tripartite' United Nations agency that brings together representatives of governments, employers and workers to jointly shape policies and programmes promoting Decent Work for all. Link : http://www.ilo.org/public/english/bureau/stat/isco/isco88/3226.htm
The International Labour Organization (ILO) is the international organization responsible for drawing up and overseeing international labour standards. It is the only 'tripartite' United Nations agency that brings together representatives of governments, employers and workers to jointly shape policies and programmes promoting Decent Work for all.
International Standard Classification of Occupations (ISCO) is a tool for organizing jobs into a clearly defined set of groups according to the tasks and duties undertaken in the job.
ISCO’s main aims are to provide:
-a basis for the international reporting, comparison and exchange of statistical and administrative data about occupations;
-a model for the development of national and regional classifications of occupations; and
-a system that can be used directly in countries that have not developed their own national classifications.
Physiotherapists and related associate professionals treat disorders of bones, muscles and parts of the circulatory or the nervous system by manipulative methods, and ultrasound, heating, laser or similar techniques, or apply physiotherapy and related therapies as part of the treatment for the physically disabled, mentally ill or unbalanced.
Tasks include -
(a) advising communities and individuals on correct body postures, for work or otherwise, to avoid injuries and strain and to strengthen muscles;
(b) conducting examinations to make diagnoses of disorders of bones, muscles and parts of the circulatory or the nervous system to determine proper treatment or refer to Medical doctors, if necessary;
(c) treating disorders of bones, muscles and parts of the circulatory or the nervous system by manipulative methods, and the use of ultrasound, heating, laser or similar techniques;
(d) massaging client or patient to improve circulation, soothe or stimulate nerves, facilitate elimination of waste matter, stretch contracted tendons and produce other therapeutic effects;
(e) examining body deformities and disorders to determine and write specifications for artificial limbs or other appliances, helping to fit them and explaining their use;
(f) applying physiotherapy and related techniques as part of the treatment of the mentally ill or unbalanced;
(g) performing related tasks;
(h) supervising other workers.
14. World Confederation of Physical Therapy (WCPT)
Physical therapists are qualified and professionally required to:
-undertake a comprehensive examination/assessment of the patient/client or needs of a client group
-evaluate the findings from the examination/assessment to make clinical judgments regarding patients/clients
-formulate a diagnosis, prognosis and plan
-provide consultation within their expertise and determine when patients/clients need to be referred to another healthcare professional
-implement a physical therapist intervention/treatment programme
-determine the outcomes of any interventions/treatments
-make recommendations for self-management.
(Reference: http://www.wcpt.org/what-is-physical-therapy)
Kindly take note of the Points mentioned in the draft and modify the Definitionm, Referral System and Scope of Scope of Physiotherapy in the Clinical Establishment Act to have a international Standard rehabilitation and habilitation services in our Country.
Thanking you in advance.
Sincerely,
Einstein Jerome,
Physiotherapist,
ESIC Model Hospital(Ministry of Labour and Employment, Govt of India),
Rajaji Nagar, Bangalore-560010
Contact details:
