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ISLAMIC MEDICAL EDUCATION RESOURCES-03

0208 - MEDICAL MANAGEMENT: ISLAMIC PERSPECTIVES

Paper presented at the Hospital Tengku Azfan, Kuantan on 26th September 2002 by Professor Omar Hasan Kasule, Sr. MB ChB (MUK), MPH, DrPH (Harvard), Deputy Dean for Research and Postgraduate Affairs, Kulliyah of Medicine, International Islamic University, Kuantan, Malaysia. EM: omarkasule@yahoo.com.

1.0 MANAGEMENT FUNCTIONS

1.1 Personnel

The Qur’an enjoins recruitment of capable workers who have strength and honesty[i]. Yusuf was a capable appointee when he was put in charge of the Egyptian Treasury[ii]. Specialization is necessary[iii]. Salary should be according to the work done[iv]. The worker should not be compelled to work beyond capability[v]. The worker must be compensated for services[vi]. Any complaints against workers must be investigated. Omar sent Muhammad b. Musalamah to investigate complaints against Sa’ad in Iraq[vii]. Workers can be dismissed. Omar dismissed Khalid ibn al Waliid[viii], Abu Musa al Ash’ari[ix], Sa’ad Ibn Abi Waqqaas[x], al Mughiira bin Shu’ubat[xi]. Al Mughiirah had been accused of adultery. Omar removed him from office and brought him to Madina for investigations.

 

1.2 Delegation

Delegation is an important management function. Man is a vicegerent on earth. He is delegated to perform certain tasks for which he is accountable. The delegatee must be obeyed as the delegator is[xii]. There are many instances in the siirat when the prophet exercised delegation. He delegated tasks[xiii]. He sent Muadh ibn Jabal to Yaman and checked with him carefully whether he understood the tasks and how he would discharge them[xiv]. Abubakar was delegated to lead the pilgrimage. Abubakar delegated the collection of  the Qur’an to Zayid bin Thabit[xv]. Omar put Abd al-Rahman b. Awf in charge of the pilgrimage in the year in which he began to rule; thus, Abd al-Rahman led the pilgrimage[xvi]. Othman delegated the compilation of the Qur’an to a group of companions that included Zayid bin Thabit[xvii]. The delagatee must be monitored during performance of the delegated tasks. When the prophet put Abu Hurairah in charge of sadaqat al fitr, he checked on him every morning on what happened in the night[xviii].

 

1.3 Decision Making

The Qur’an and sunnat have guidelines on the process of decision making. The decision maker must leave uncertainty for certainty[xix]. The easier decision alternative should be selected[xx]. A decision can be reached by analogy[xxi]. Istikhara is recommended[xxii]. Different but correct perceptions of the same problem exist and must be respected[xxiii]. The Prophet’s decision making can be reviewed in the major decisions that he and his companions made. Discussions were held on solving the problem of how to call Muslims to prayer[xxiv]. At Badr decisions had to be made about whether to fight, on the place of the battle field, and what to do with prisoners of war. Discussions preceded the Muslim decision to fight[xxv] and the Quraish decision to fight[xxvi]. The decision on what to do with prisoners of war was not easy[xxvii] and there were differences of opinion among the leading companions. At Uhud the prophet agreed to the majority decision to fight outside Madina against his better personal judgment[xxviii]. Decisions had to be made with respect to those who refused to fight[xxix]. Digging the trench was the preferred decision at the siege in the battle of the trench. Abubakar made major decisions in his short reign. Three of these major decisions were made against the view of other companions but all agreed later that he was right. He decided to prosecute the wars of apostasy[xxx]. He fought those who refused zakat[xxxi]. He dispatched Usamah’s army[xxxii].

 

1.4 Time Management

Time is so important that Allah swears by it[xxxiii]. Humans will be held accountable over their time use on the Last day. Time passes so it should be used and not allowed to waste[xxxiv]. The best of work is what is regular, khayr al a’amaal adwamuha[xxxv]. The best work is what is manageable and is capably done, khayr al a’amaal ma tutiqunahu[xxxvi]. Time management becomes complicated if there are multiple priorities. The following principles can guide time prioritization. Some tasks are more important than others, fadhl al a’amal[xxxvii]. ‘Ibadat has priority in time allocation[xxxviii]. No time should be wasted. If the Last Day comes and a person has a seedling he should plant it[xxxix]. Some time should be set aside for leisure[xl]. Good time management requires choosing the right priorities[xli]. Biological needs have preference in time allocation[xlii]. Time should be allocated equitably between sleep and work[xliii]. Equilibrium, balance and moderation are required in time management[xliv]. Different activities must be balanced[xlv]. There should be time for the individual and the family[xlvi]. The Prophet gave some of his time to do domestic work in his house[xlvii]. Every person must plan and schedule time but should remember to say inshah Allah[xlviii]. Good management is needed for transition from work to prayer and vice versa[xlix].  A period of rest and calming down before salat can prevent mind pre-occupation in salat, ishtigal al fikr fi al salat[l]. For example if food is served, a hungry worshipper may not concentrate in salat[li]. Retirement to bed should be early[lii]. Appointments must be kept[liii]. Islam inculcates the culture of punctuality. The times of salat are fixed[liv]. There is great reward for arriving early at the mosque[lv]. Punctuality for salat is emphasized[lvi]. Punctuality is emphasized in breaking the fast, ta’ajil al fitr[lvii]. The janazat should be hastened[lviii]. Debt repayment should not be delayed[lix]. Interruptions must be managed carefully to avoid wasting time. Time is saved by brevity and precision[lx]. Habits and routines of life may lead to poor time management. They lead to negligence and forgetting of important duties[lxi]. Omar was against procrastination[lxii]. A Muslim must have the initiative to take action quickly[lxiii].

 

1.5 Diseases of managers and followers

Among diseases of managers are pride, dishonesty, uncompensated weaknesses, ignorance, lack of creativity, seeking excessive veneration by followers, oppression, petty-mindedness, manipulation, seeking false reputation, abandoning followers, and unequal treatment of followers. Leaders are supposed to be humble in dealing with their followers as the prophet was enjoined to be humble to the believers, janaah al dhull li al muuminiin[lxiv]. A dishonest leader will be punished in hell, al waali al ghaash fi al naar[lxv].

The leader who is just has great recompense from Allah, ajr al imaam al aadil[lxvi]. Followers, like leaders, have diseases: hypocrisy, insincerity, bad advice to leader, disloyalty, disobedience, and excessive veneration of the leader. Management failure has several often inter-related causes: (a) refusal to admit mistakes and blaming them on others (b) belief of the leader that he is indispensable and behaving as a dictator (c) fear for position and neglecting training or developing replacements (d) disloyalty to superiors, peers, followers and the organization (e) lack of creativity: hating new ideas, persisting in unproductive but tested ways, and being too bureaucratic (f) lack of common sense, being away from reality and being theoretical (g) Lack of human skills and handling followers well and equitably (h) lack of a sense of bottom-line that you have to produce results (i) failure to lead and following the crowd (j) condoning or tolerating incompetence (k) failure to recognize and reward good work (l) followers hating the leader.

 

1.5 Hatred between managers and followers

The following behaviors of managers lead to hatred by followers: arrogance and feeling indispensable; putting people down; mistrust and disloyalty; inaccessibility; poor human relations (impersonal behavior, not listening to followers; following the crowd; wrong decisions, claiming credit for followers' work, blaming followers for the leader's mistakes, being secretive, withholding information, failure to protect followers from external attacks, public criticism of followers, not consulting followers, and over-working followers.

 

2.0 MOTIVATION

2.1 Concept and Methods Of Motivation In Islam

The 4 components of motivation are commitment, ikhlaas; instincts and innate biological determinants of behavior; drive (an aroused state due to physiological need); and incentives (external stimuli). Motivation is internal whereas manipulation is external. Highly motivated individuals have clarity of vision and objectives, strategic and tactical plans for achieving objectives, high expectancy, energy, drive and self confidence, need for responsibility and control, strong communication skills, taking risks, accepting correction or criticism, want for recognition, doing interesting work, and having authority. These characteristics are not in-born; they can be cultivated and nurtured in any individual. Jannat is a positive motivator. Jahannam is a negative motivator. Motivation can be intrinsic (self motivation), extrinsic (rewards), or reactionary (not real and temporary).

Commitment, ikhlaas, was described in the Qur’an[lxvii]. It is expressed in the intention, Ikhlaas al niyyat. Work is the consequence of the intention. Every work is rewarded according to the intention behind it. Every person is rewarded according to his/her niyyat. The amount of reward is commensurate with the intention. On the day of resurrection people will be resurrected with their intentions. Any work without niyyat is not recognized. The niyyat must be constant and consistent throughout the whole period of performance until completion. Start must be early and serious. Work is best judged by its last stages. The best of work is that which is consistent and continuous. In all performance, the human performs that which he is capable of even if the niyyat envisaged more. Work is a test for the human. Work is responsibility. The Qur’an emphasizes the importance of work[lxviii]. There is reward for work done[lxix]. Humans have freedom to choice in the work that they do[lxx]. Work can be good, ‘amal hasan or bad, ‘amal sayyi. Some people try to decorate bad work to make it appear good[lxxi]. Bad work s condemned and has a bad reward. Good work reflects underlying faith[lxxii]. It is rewarded in the hereafter[lxxiii] and on earth[lxxiv]. Work must be performed with the purest of intentions. Everything including the various organs of the body bear testimony to good work[lxxv]. Allah knows all the work done[lxxvi]. Any form of showing off must be avoided. Riyaa is a type of minor shirk. Working for the purposes of showing off, riyaa, is frowned upon. Turning motivation into performance is a challenge. Performance is affected by the individual's capacity to perform, the willingness to perform, and being given an opportunity to perform. Job satisfaction is how well a worker likes the job. High job satisfaction is directly related to high motivation. The relation between level of motivation and success/achievement is not always linear. Motivation is low at the start of a difficult task when the feeling is 'why waste effort on project likely not to succeed. When the project gets under way and results begin to appear, motivation level is high because of concrete results realized. Motivation is low towards the end of the project when things are moving well. The feeling is 'why bother when all is going so well!’

 

Many of the theories on motivation in the literature reflect the European world-view and would not be applicable to Muslims. Muslims find their motivation in their religion and their cultural heritage. Any approach to motivation that ignores this will not succeed. The Prophet (PBUH) taught that every human endeavor is an act of worship and charity. Thus a Muslim working knows he is worshipping his Lord and this is a powerful motivator in itself irrespective of any material gain. The concept of strife towards excellence, ihsaan, is a great motivator for a Muslim. A Muslim looks at the salary and other material benefits as a means to enable him feed, clothe, and house himself and his family so that he can devote his energy to the work. He does not look at them as a just return for his labor. His labor is worship and only Allah can recompense for it. There are aspects of Muslim character that affect motivation: sharaf (fear of losing face, shame for self and family), thawab (reward in the hereafter), karam (generosity), and wafa (fulfilment).

 

2.2 Methods and Techniques Of Motivation

Positive motivation can be from the leader, peers, working conditions, or the general environment. Motivated leaders clarify goals, set objectives, consult and respect followers, deal with followers kindly, humanely, and with fairness, have good 2-way communication, and make followers feel secure. Motivating work is challenging, meaningful; has opportunities for advancement, learning and personal growth; provides responsibility and independence; and gives job satisfaction. Negative motivation is due to worries, lack of self-confidence, low self-esteem, low self-worth, negative opinions in the work place, poor working conditions, poor leadership, inequity, and injustice. Positive reinforcement (appreciation, reward and praise) is a motivator. Negative reinforcement is reprimand. People work because they believe not because they receive. Intrinsic rewards are task completion, achievement, autonomy, and personal growth. Extrinsic rewards are salary, benefits, and promotions.

 

2.3 Motivation In The Medical Profession

What motivates a student to enter medical or nursing school, will affect his commitment to practice of good medicine. Students are idealistic on entry into the school. They talk about studying medicine and nursing to serve the community. Towards the end of their education, many students talk about benefiting from their education to find a job, enjoy easy life and have a high social status. The future physician is motivated to follow a career in medicine pre-medical school, during medical school, and after medical school. The physician working in a materialistic society is torn between contradictory forces of greed and service. Service should have the higher priority but the material rights and privileges of the physician should not be forgotten because he also wants to live a happy life.

 

2.4 Motivation and Responsibility

The prophet talked a lot about the responsibility of the physician, masuliyat al tabiib[lxxvii]. A physician is a powerful person in the general society. He can use his position to play a leading role in tarbiyyah, amr bi maroof, and nahy al munkar. He can play a leadership role on many burning issues. He can advocate for the poor, the weak, and the deprived. The physician has a duty to undertake research in order to push forward the frontiers of knowledge. Medical practice must be based on new knowledge that is produced by constant research. Research is needed to solve practical medical problems. The physician should publish in order to disseminate knowledge. He should also teach to share his knowledge with others. He also has responsibility to the environment and posterity.

 

11.5 Early Muslim Physicians As A Motivator

Ancient were encyclopedic and all-rounded. They would lead prayers in the mosque, go and research on medicine, and may be return to teach Qur’an. They were able to excel while they maintained their Islamic identity. Islam is not incompatible with excellence in science or medicine. Abubakr Muhammad Bin Zakariyyah Al Razi (251-313H/865-923 CE) wrote more than 100 books the most famous being al Hawi al Kabir. He investigated diseases (gynecology, obstetrics, hereditary, eye, small pox, and measles), discovered surgical sutures, used anesthetics, used ammonia to control diarrhea, and considered psychological factors in disease treatment. He was director of hospitals in Baghdad Rayy. Abu Ali Al Hussain Bin Abdillah Bin al Hassan Ibn Sina (370-428 H / 980 – 1037 CE) wrote many books the most famous being al Qanuun fi al Tibb. He recognized that TB was contagious, accurately described the symptoms of diabetes mellitus, and discovered ancylostoma. Besides medicine, Ibn Sina made contributions to science, mathematics, chemistry, and philosophy. Abu Al Qasim Khalaf Bin Abbas Al Zahrawi (b. 912 CE, d. 404 AH/1013 CE) had interest in surgery, pharmacology, and anatomy. He designed over 200 surgical instruments. His book Kitaab al tasriif, became a standard textbook of surgery. He was an expert in cancer surgery and tooth extraction. The family of Ibn Zuhr produced 6 consecutive generations of famous physicians the most famous being Abu Marwan Abdu Al Malik Ibn Zuhr (b. 1091 or 1094 CE d.487H / 1162 CE), who lived in Andalusia and Morocco and authored the book al Taysir translated into Latin and used in Europe. Abu Al Waliid Muhammad Ibn Rushd (B. 1126 CE d.  595 H / 1198 CE) was interested in philosophy and also practiced medicine. He wrote a medical work called al Kulliyat translated in Europe. He made the observation that smallpox infected only once. Alau Al Ddiin Abu Al Hasan Bin Abu Al Hazim Al Qurashi Al Dimashqi Ibn Al Nafees (d. 686H / 1288 CE) described blood circulation before William Harvey but this was not noticed in Europe. He authored Sharh tashriih al qanuun in which he explained pulmonary circulation.

 

3.0 TEAM-WORK

3.1 Principles of Group Work

A group is several persons being interdependent and interacting with one another. The minimum size for a group is three. Muslims are enjoined to mobilize in groups[lxxviii]. Group must be solid[lxxix]. Cooperation in doing good is the basis for group work[lxxx]. There must be openness and trust in the group. Secrecy and concealment destroy groups[lxxxi]. Secret talks between some members of the group are prohibited[lxxxii]. Similarity is the basis for group formation[lxxxiii]. People are attracted to those like themselves[lxxxiv]. Persons who have nothing in common or who do not share common interests can not form a successful group. Members of a group should have empathy for one another being the similitude of one body or one physiological entity[lxxxv]. Members should support one another so that they stand together like a strong wall. They are like a building whose different parts reinforce one another[lxxxvi]. Separation from a group is condemned[lxxxvii]. Islam encourages working in groups but makes it clear that seclusion is better than bad company[lxxxviii]. The excellence of work in a group is illustrated by congregational prayer whose reward is 25 times that of a solitary prayer[lxxxix]. People in a group can share resources especially at times of scarcity[xc]. A group must adhere to and respect some norms. Allowing some members to break the norms will destroy the group[xci]. There are several behaviors that destroy the hegemony and stability of a group. Secretive behavior and concealment of information from some members destroy a group[xcii]. Thus secret talks are prohibited unless they serve a good purpose[xciii]. Members of groups enjoy the benefits of integration, stimulation, motivation, innovation, emotional support, and endurance.

 

Group performance is generally superior to individual performance. By coordinating, channeling, and complementing activities, as well as canceling contradictions an individual's productivity is higher in a team that outside a team. This concept of group-work parallels that of congregational prayer, salat al jamaat. An individual praying in a group gets a 27-fold reward he however still has to perform and take personal responsibility for results. Beside its many advantages group work suffers from some disadvantages: arrogance, suppression of individual initiative, and member mismatch leading to intra-group conflict. There are four stages in group formation. Groups and individuals that compose them go through various stages as they learn to work together. The four stages are: forming (acquaintance and learning to accept one another), storming (emotions and tensions), initial integration (start of normal functioning), total integration (full functioning), and dissolution. Mature groups develop a group identity and have optimized the following characteristics: feedback, decision-making procedures, cohesion, flexibility of organization, resource utilization, communication, clear goals accepted by members, interdependence, participation in leadership functions, and acceptance of minority views. Like everything in life groups are started, they grow and eventually break up. Some groups fail because they are constituted on the wrong basis. The members can not get along together, communicate with or understand one another. There is no commonality of interests, attitudes, and goals. In such a case individual effort will be preferable to a non-performing team. There are behavioral diseases that destroy groups. All of them have been described and have been defined by the Qur'an: hasad, nifaq, namiimah, gaybah, kadhb, riyah, kibriyah, hubb al riyasa, tajassus, and dhun al soo. Seeking personal credit for group work alienates and demotivates. Denying credit where it is due annoys and alienates. An effective group has the following five attributes: following Qur'an and sunnat in all activities, members in the group must feel secure and not suppressed, understanding and sincere practice of group dynamics, all members must be competent and committed to the group, and leadership.

 

3.2 Etiquette of Teaching & Learning In The Health Care Team

The health care team in a teaching hospital is very complex. It is multi-disciplinary and its members play complementary and inter-dependent roles. It consists of both university and hospital personnel all engaged in the care of patients. The academic personnel are the medical faculty as well as the students (under-graduate and post-graduate). The hospital staff is the consultants, nurses, nursing aides, auxiliary medical personnel. All members of the team have the dual function of both teaching and delivering health care. The teaching process is complex. There is programmed and structured teaching. However most of the teaching is passive; there is a lot of learning of attitudes, skills, and facts by being present and watching what is being done to the patient. There is also continuous learning from one another. Students learn from consultants but consultants may also get new insights from students. Teachers should take their task very seriously. The education process, involving giving and receiving knowledge is noble. Teachers should have the humility to know that their knowledge is limited and that they can always learn more. Arrogance because of knowledge is condemned. Teachers must make the learning process interesting and avoid boredom. They should make the atmosphere and circumstances of learning easy for the students.

 

Teachers must be careful in their actions, attitudes, and words at all times because being models and leaders they are seen and are emulated. They must be aware that sometimes they can teach using body language without saying anything; they have to be careful about their public dispositions They should be ready to carry out their function at all times and at any opportunity. They should have an appropriate emotional expression. They can raise the voice to emphasize an important point. They can show anger or displeasure when a mistake is committed. Asking students questions to ascertain their level of knowledge is part of the teaching process and is not in any way a humiliation for them. Teachers should make sure that the students understand by constant repetition. Teachers should strive to pass on to the students as much knowledge as they can. Hiding knowledge is a cause of punishment. The Islamic etiquette of the relation between the student and the teacher should be followed. In general the student should respect the teacher. This is respect to knowledge and not the individual. The prophet taught admiration and emulation of the knowledgeable. Students should be quiet and respectfully listen to the teacher all the time. Students should cooperage such that one who attends a teaching session will inform the others of what was learned. Students can learn a lot from one another. The student who hears a fact from a colleague who attended the lecture may even understand and benefit more. Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience. Taking notes helps understanding and retention of facts. Study of medicine is a full-time occupation; students should endeavor to stay around the hospital and their teachers all the time so that they may learn more and all the time. They should avoid being involved in many other activities outside their studies.

 

 

 

3.3 Etiquette of Care Delivery In The Health Care Team

Each member of the team carries personal responsibility. Leaders of the team carry more responsibility than the others. Leaders must be obeyed to be able to carry out their work well. They however should not be obeyed in committing illegalities, corruption, or oppression, dhulm. The story of Rufaidah is very instructive in the etiquette of medical care for a Muslim. She was kind and empathetic. She was a capable leader and organizer able to mobilize and get others to produce good work. She had clinical skills that she shared with the other nurses whom she trained and worked with. Rafidah did not confine her nursing to the clinical situation. She went out to the community and tried to solve the social problems that lead to disease. She was both a public health nurse and a social worker. She came to the assistance of every Muslim in need: the poor, the orphans, or the handicapped. She looked after the orphans, nursed them, and taught them. The human touch is a very important aspect of nursing that is unfortunately being forgotten as the balance between the human touch and technology in nursing is increasingly tilted in favor of technology.

 

3.4 The Health Care Team: General Group Dynamics

The following are basic rights of brotherhood that all members of the health care team owe to one another: returning greetings, following the funeral procession, accepting invitations, visiting the sick, and responding to sneezer. The following are additional duties: tolerance, forgiveness, helping the oppressed, solving problems, fulfilling needs, compassion and kindness, gratefulness, protecting the honor of others, fulfilling promises and commitments, respect, sincere advice or nasiiha. It is part of the duties of brotherhood to avoid underrating and humiliating others. It is considered part of good behavior to remove any annoyance from the public places. In general, everybody must behave with the best of manners, husn al khulq. Greeting is necessary whenever members meet again even after a short separation. A small group will initiate greeting the larger group. The walking person initiates greeting the one sitting down. Everybody must be greeted whether known or not known. Those in an assembly must make room for any new comer. Two individuals should not engage in secret conversation in the presence of others because that may create an impression of backbiting and suspicion. Standing up when a person enters is a sign of respect. You should not force a sitting person from his seat. When a person goes away for a temporary period, he has the right to reclaim his seat. The following positive behaviors and attributes should be encouraged in the team: mutual love and empathetic caring for one another; leniency in everything; generosity; patience; modesty, haya; cheerful disposition; calling people by their favorite names; recognizing the rights and the position of those older than you; and self control in anger. The following negative attributes should be avoided: harshness in speech, rumor mongering, excessive praise of others in their presence, mutual jealousy and turning away from other, avoiding interaction with a colleague for more than 3 days following a misunderstanding;  spying on the privacy of others. You should avoid repeating the same mistake twice. It is required not to volunteer information about your personal weaknesses unless it involves correcting a mistake related to the general medical work.

 

 

 

3.5 The Health Care Team: Special Group Dynamics

The medical team must of necessity include men and women. The interaction between the two genders is close and continuous which creates a special situation. Four basic issues arise: (a) manner of dressing (b) mixing of the 2 genders, ikhtilat (c) seclusion of a male with an unrelated female, khalwat (d) and lowering the gaze, ghadh al basar. Males and females in the team must dress and behave distinctly. Trans-sexual or unisex dressing and behaviour remove the instinctual gender identity. Each gender should maintain its psychological, emotional identity and physical appearance in manners of dress, walking or speaking. Blurring the differences could also make sexual misconduct easier. The medical environment provides many opportunities for male-female interaction at staff meeting or during medical consultation and procedures. The Qur'an forbade free mixing of the genders, ikhtilat, in general[xciv]. Islam fosters a bi-sexual society. This is however not absolute. There are cases when social and professional intercourse between unrelated men and women in necessary and is allowed but with strict precautions to prevent any transgressions. A woman can treat a male patient if there is necessity accompanied by urgency. Non-urgent cases like infertility can wait until a physician of the same gender is available. A bisexual society does not prevent the women from being an active member of society. She can pursue her professional interests even outside the home provided she observes the rules of hijab. Seclusion of a man with an unrelated woman, khalwat,  is a strong temptation for evil. The caregiver should not be with a patient of the opposite gender without a chaperone. This is more severe in cases of psychiatric patients who are prone to being abused. Looking at the opposite sex with desire is prohibited. The Qur'an ordered Muslim men and women to lower their gaze, ghadh al basr[xcv]. Lowering the gaze could be complete or partial. It is partial because of practical necessity. Lowering the gaze doses not mean closing the eyes. It means being careful not to look fixedly or lustfully at the opposite sex. One of the ways of preventing lustful looks is covering what is considered nakedness, awrat. Both men and women must be modest by covering their awrat. Looking at the awrat of another person is forbidden whether that person is of the same or opposite gender. The prohibition includes both looking with or without desire. As part of preventing possible illegal relations, display of adornments that enhance natural beauty is restricted by the Qur'an.[xcvi]

 

4.0 QUALITY

4.1 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 continuous 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[xcvii]. 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 continuous improvement and called a loser any person whose level of performance was the same on two consecutive days[xcviii].

 

4.2 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 experience has the guidelines 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[xcix]

 

4.3 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[c]. Lower levels of ihsaan involve attempts to do good and achieve excellence in all human endeavors. The Qur’an uses the word ihsan in connection with good work for neighbors, the poor, the parents[ci], and the orphans[cii]. 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.

 

4.4 Itqaan

The Qur’an uses the concept of itqan to describe Allah’s creation[ciii]. The Prophet in his words[civ] and practice[cv] taught quality performance. Itqan can only be achieved if there is consistency in the work[cvi] and when what is done conforms to the declared intention[cvii]. Tasks once started must be completed[cviii]. Quality in medical care is continuous 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.

 

4.5 Muhasabat

Muhasabat is the very basis for QI. By continuous self-criticism and self-evaluation[cix], 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[cx]. A control, muraqabat, system is therefore the better approach. The practicing physician must be aware that he is personally accountable for all what he does, big or small[cxi], this sense of personal responsibility and accountability produces quality work.

 

4.6 Muraqabat

Muraqabat is the process of being on the watch-out for any deviations. A human is prone to err and continuous 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[cxii] 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.

 

4.7 Systematic Quality Improvement Programs

It is a moral and professional requirement that institutions that deliver medical care should set up quality assurance and quality improvement programs. The most sincere and committed people can make mistakes[cxiii]. Perpetrators of a mistake may not even be aware of what they are doing[cxiv]. Quality improvement programs will succeed only when physicians develop the Islamic value of being ready to admit mistakes and change course[cxv]. A quality improvement program must develop objective criteria and measurement instruments. All judgments 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[cxvi].


[i] Qur'an 28:26

[ii]  Qur'an 12:54

[iii]  Qur'an 9:122

[iv] Qur'an 46:19

[v]  Qur'an 2:233, Qur'an 2:286, Qur'an 6:152, Qur'an 23:62

[vi] Bukhari 3:162, hadith # 284

[vii] Tabari 13:190-191, Tabari 13:191-192

[viii] Tabari 11:162-163, Tabari 11:178-179, Tabari 11:180

[ix] Tabari 15:34-35

[x] Tabari 11:176

[xi] Tabari 13:110-114

[xii] Bukhari 9:189, hadith # 251

[xiii] Muslim 2: 943-944, Chapter 706, Hadith # 4294

[xiv] Abu Daud 3:1019, Chapter 1347, Hadith # 3581

[xv] Bukhari 6:163-164, hadith # 201, Bukhari 6:477, hadith # 509

[xvi] Tabari 11:224-225

[xvii] Bukhari 6:475, hadith # 507, Bukhari 6:478-479, hadith # 510

[xviii] Bukhari 3:289-291, hadith # 505

[xix] RS 1:47, hadith #55

[xx] Bukhari 4:491, Hadith #760, Bukhari 5: 473-474, Hadith #668, Muwatta 47:437, Hadith #2

[xxi] Bukhari 9:311-312, Hadith #417

[xxii] Bukhari 2;146-147, Hadith #263, Abu Daud 1:399, Chapter 517, Hadith # 1533, Bukhari 8:257, Hadith #387

[xxiii] Bukhari 5:306-307, Hadith #445

[xxiv] Abu Daud 1:126-127, Hadith # 498

[xxv]  Tabari 7:34-35, Tabari 7:40-42

[xxvi] Tabari 7:45-46, Tabari 7:49, Tabari 7:51-52

[xxvii] Tabari 7:82-83

[xxviii] Tabari 7:107-108, Tabari 7:109-110

[xxix]  Bukhari 6:92, hadith # 113

[xxx]  Tabari 10: 52-60

[xxxi] Muslim 1:15-16, Chapter 9, Bukhari 2;274, Hadith #483, Bukhari 9:286, Hadith #388

[xxxii] Tabari 10:14-15

[xxxiii] Qur'an 103:1-3

[xxxiv] Bukhari 8:284-285, hadith # 425

[xxxv] KS 94, Bukhari Kitaab 2 Baab 32, Muslim Kitaab 77 Baab 43, Abu Daud Kitaab 5 Bab 27, Abu Daud 1: 358, Chapter 408, Hadith # 1365

[xxxvi]  Bukhari Kitaab 19 Bab 18, Muslim Kitaab 6 Hadith 219-223, Abu daud Kitaab 5 Baab 29

[xxxvii] KS93 Muslim Kitaab 33 Hadith 111

[xxxviii] Qur'an: 62:9-10, Qur'an 62:11

[xxxix] Musnad Ahmad

[xl]  Sunan Al Daylami

[xli] Muslim 2:408-409, Chapter 37, Hadith #1877

[xlii] KS315, Bukhari Kitaab 10 Bab 42, Muslim Kitaab 5 Hadith 64-67, Abu Daud Kitaab 1 Bab 43

[xliii] Qur'an 25:47

[xliv] Bukhari 3:107‑108, hadith # 189, Bukhari 3:110-111, hadith # 196

[xlv] Muslim 2: 563, Chapter 436, Hadith #2588

[xlvi] Bukhari 2:140, Abu Daud 1:358, Chapter 468, Hadith # 1364, Bukhari 3:112-113, hadith # 198

[xlvii] KS482, Bukhari Kitaab 69 Baab 38

[xlviii] Qur'an 18:23-24

[xlix]  Qur'an: 62:9-10

[l] Bukhari 1:362, Bukhari 2:175

[li] Bukhari 1:362

[lii] RS 2:838, hadith # 1746

[liii] KS516 Bukhari Kitaab 19 Baab 31

[liv] KS308, Bukhari Kitaab 9 Baab 1, Muslim Kitaab 5 Hadith 166-167

[lv] KS157, Bukhari Kitaab 11, Baab 4, Muslim Kitaab 7 Hadith 10, Abu Daud Kitaab 2, Baab 202

[lvi] KS314, Bukhari Kitaab 9 Baab 5, Muslim Kitaab 4 Hadith 129, Abu Daud Kitaab 2 Baab 9, Muslim 1:50, Chapter 37, Hadith #155, Abu Daud 1:152-153, Hadith # 580, KS314, Bukhari 4:297, hadith # 433

[lvii] KS330, Bukhari Kitaab 30 Baab 45, Muslim Kitaab 13 Hadith 47-51, Abu Daud Kitaab 14 Baab 21

[lviii] KS161, Bukhari Kitaab 23 Baab 51, Muslim Kitaab 11 Hadith 51-59, Abu Daud Kitaab 20 Baab 33 & 45

[lix] KS239, Bukhari Kitaab 38 Baab 12, Muslim Kitaab 22 Hadith 33

[lx] KS p. 492, Bukhari Kitaab 7 Baab 1, Muslim Kitaab 5 Hadith 3, Abu Daud Kitaab 2 Baab 174

[lxi] Qur'an 102, KS p. 315, Bukhari Kitaab 9 Baab 37, Muslim Kitaab 5 Hadith 309-316, Abu Daud Kitaab 2 Baan 11

[lxii] Tabari 14:120

[lxiii] KS83, Muslim 1:141-142, Chapter 91, Hadith #625

[lxiv] 26:215

[lxv] KS101 Muslim K1 H229, Ahmad 2:425, Ahmad 2:431, Ahmad 2:479, Ahmad 2:521, Ahmad 3:441, Ahmad 3:480, Ahmad 4:231, Ahmad 5:25, Ahmad 5:27, Ahmad 5:238, Ahmad 5:329, Ahmad 5:362, Ahmad 5:366

[lxvi]  KS46 Muslim K33 H18, Muslim K33 H19, Muslim K33 H43, Tirmidhi K13 B4, Nisai K49 B2, Ahmad 2:26, Ahmad 2:523, Ahmad 3:22, Ahmad 3:55, Ahmad 6:70, Ahmad 6:93

[lxvii]  2:139 & 98:5

[lxviii]  6:135 & 67:15

[lxix]  2:85

[lxx]  4:66

[lxxi]  6:108 & 47:14

[lxxii]  38:24 & 103:2-3

[lxxiii]  2:25 &  99:7

[lxxiv]  16:97 & 24:55

[lxxv] 24:24 & 41:20

[lxxvi] 2:74 & 99:6

[lxxvii] KS338 Abudaud K38 B23, Ibn Majah K31 B16

[lxxviii] Qur'an 4: 71

[lxxix]  Qur'an 61:4

[lxxx] Qur'an 5:2

[lxxxi] Qur'an 58:9-10

[lxxxii] Qur'an 4: 114

[lxxxiii] Bukhari 4:348

[lxxxiv] Bukhari 8:122-123, hadith # 196

[lxxxv] Muslim 3: 1368, Chapter 1067, Hadith # 6258

[lxxxvi] Bukhari 8:34, hadith #55

[lxxxvii] Abu Daud 3:1332, Chapter 1706, Hadith # 4740

[lxxxviii] Bukhari 8:332, hadith # 502

[lxxxix] Hadith No. 620" Bukhari 1:277, hadith # 466, Muslim 1:314, Chapter 234, Hadith #1360, Bukhari 1:351, hadith # 618

[xc] Bukhari 3:402, hadith # 666, Bukhari 3:400-401, hadith # 663

[xci] Bukhari 3:406, hadith # 673

[xcii] Qur'an 58:9-10

[xciii] Qur'an 4:114

[xciv] Qur’an 33:53

[xcv]  24:30-31

[xcvi] 24:31, 33:59

[xcvii] Kasule, Omar Hasan: Islamic Perspectives of Medical Education. Paper presented at the Annual General Meeting of the Islamic Medical Association, Khota Bharu july 1996

[xcviii]  "Man istawa yawumaahu fahuwa maghboon"

[xcix] 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.; 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;  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;  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; Abdullah Yusuf Ali: The Meaning of the Holy Qur’an. Amana Publications, Brentwood, MD 1412 AH/1992

 

[c] 'Umar b. al Khattab transmitted to me a tradition, saying: One day when we were with the Apostle of Allah may peace be upon hima 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

[ci]  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;

[cii]  Nisa: 36

[ciii]  Naml: 88

[civ]  "Idha amila ahadukum amalan fa liyutiqnahu"

[cv]  "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

[cvi]  "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

[cvii]  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

[cviii]  "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

[cix]  " 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;.  "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

[cx]  "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

[cxi]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 99:7-820. “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

[cxii]  All that they do is noted in  their Books of deeds . Every matter small and great is a record”Qur'an 54:52-5322. “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 Mercifu:l.Qur'an 33:5; “ 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

[cxiii]  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

[cxiv]  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

[cxv]"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

[cxvi]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

Omar Hasan Kasule, Sr. August 2002