OPERATIONAL POLICY

FOR AS’AD AL-HAMAD DERMATOLOGY CENTER

Updated  in ‏30 May 2010

For Appendix List, click here

Mission

As’ad Al-Hamad Dermatology center performs two main functions:

a)     Secondary health service to patients seeking general dermatology care through their referral to the center from catchment health areas.

b)    Tertiary health service that provides specialty and subspecialty dermatological care services, whether diagnostic or therapeutic, to all patients in Kuwait.

 To accomplish this, a Referral Policy to As’ad Al-Hamad Dermatology center has been set.

Vision

We plan to provide best dermatological services including diagnostic and therapeutic modalities through upgrading and updating the lab and other diagnostic procedures and also the therapeutic equipments. 

We also plan to set interdepartmental co-operation through clear referral protocols so as to utilize the services available in our center aiming at reaching a true tertiary care dermatological health services.

We also aim at improving the doctors skills and update their knowledge through inviting visiting consultants in different subspecialties in dermatology through the Ministry  of Health and other sponsoring bodies all round the year. This will also permit a better service to the patients by presenting problem cases to these experts.

Functions:

Referral Policy to As’ad Al-Hamad Dermatology Center:

(Please refer to Appendix  1  for a summary table).

       a)     Being a referral specialty, As’ad Al-Hamad Dermatology Center not allow walk-in patients except in  emergencies.  Each patient must have a referral letter from his/ her treating doctor, and should come on appointment basis. Urgent case will be seen without appointments on condition that the patient has a referral letter from the treating doctor mentioning that it is an urgent case. In the latter condition, the patient is given treatment and referred back to his treating doctor according to his residence for follow-up.

       b)    Direct referral from the polyclinics and primary care clinics to specialty units and specialty clinics in the center that provide tertiary care services is not accepted. Such referral is the right of dermatology clinics or units only.

        c)     Regular patients referred through primary care doctors should belong to the catchment health area of As’ad Al-Hamad Dermatology Center (Appendix 2 )

        d)    Cases referred to As’ad Al-Hamad Dermatology Center for Lab investigation or treatment in the various specialty units and specialty clinics are accepted on condition that these cases are referred by a dermatologist from dermatology departments and affiliated dermatology units/clinics only. A referral letter from the dermatologist should be given to the patient with a brief history or summary of the case and the requested procedure to be carried out. Special form for opening a temporary file in the center should be used (Appendix 3).

       e)     Referral from within the center should be through the dermatologist using the special forms designed for each specialty unit (Appendix 4: Dermatopathology, Appendix 5: Immunodermatology, Appendix 6: Mycology, Appendix 7: Medical Photography). Cases that need an immediate action should be discussed in person or by phone with the doctor in charge of these units or clinics. Cases of Mycosis Fungoides or severe Psoriasis that need PUVA therapy should start the treatment in PUVA unit as soon as possible (within one week). 

       f)      Cases referred to the center from one of the hospitals of Al-Sabah Specialty Health Area will be seen as a new case and thereafter evaluated by at least a registrar to decide whether the patient needs:

                                                              i.      An urgent treatment. This is dealt with as an urgent case (see above).

                                                                ii.     A diagnostic procedure in one of the specialty units. The diagnostic procedure will be decided by the dermatologist in the center. Thereafter the patient has to be referred to the treating doctor in the patients’ residence catchments area for follow-up.

                                                             iii.   Treatment and regular follow-up in one of the specially units of the center. The need for this will be decided by the dermatologist in the center. After completion of therapy the same rule for cases referred to a specialty unit will be applied.

                                                             iv.    Treatment and regular follow-up in the specialty outpatient clinics. The treatment in these clinics will be decided by the dermatologist in the center After completion of therapy the same rule for cases referred to a specialty outpatient clinic will be applied.

                                                             v.    Treatment and regular follow-up in the general outpatient clinics. These cases should take an appointment through the polyclinics and only cases belonging to the catchment area of the center will be accepted.

       g)     The referral system for venereal diseases is the same as for the dermatology patients. All new and active cases of venereal diseases are considered urgent.

Internal Policy for As’ad Al-Hamad Dermatology Center

a.      All patients who are receiving regular treatment and follow-up in As’ad Al-Hamad Dermatology Center should have a medical file that is used for the same patient whether he/she is followed up in the outpatient clinics, specialty clinics, or the specialty units.

b.      New patients who will receive treatment in the outpatient clinics in As’ad Al-Hamad Dermatology Center are seen in the first 3 visits on casualty papers (to avoid opening unnecessary files for trivial conditions that do not need regular follow-up). If in this case, the patient needs a procedure to be done on several sittings, a special form should be used during his follow-up sittings (Appendix 8: Treatment Procedure Sheet in Outpatient clinics for Kuwaiti patients, Appendix 9: Treatment Procedure Sheet in Outpatient clinics for Non-Kuwaiti patients, Appendix 10: Phototherapy Treatment Sessions sheet for Non-Kuwaiti patients). Thereafter, the treating doctor should open a file if the patient needs to be followed-up for prolonged periods.

c.     All patients who are referred to As’ad Al-Hamad Dermatology Center and will receive treatment and will be followed-up in the specialty clinics or specialty units should open a file. A special form should be filled out that permits opening a file for a patient referred from outside the catchment areas in which the justification for opening a file should be mentioned (Appendix 3)Also, cases referred for skin biopsy from outside the center should also open a file. However, in the latter case, the file will not be used for treatment but rather for registering the patient in the computer system and to have the patient’s medical information available in the file for future reference. All patients referred for skin biopsies, should receive information about the surgical procedure that will be carried out (Appendix 11). Post-operative instructions should be given to these patients. These include: post-excision biopsy instructions (Appendix  12), post-electrosurgery/ shave biopsy instructions (Appendix13), and post-subcision surgery instructions (Appendix 14). All the information is available in both English and Arabic languages. Patients’ skin lesions must be photographed in the medical photography unit prior to the biopsy after signing the photography consent. If the patient refuses photography, this should be mentioned in his file and the biopsy will be carried out. If the referring doctor sites in the biopsy referral form that the case does not need to be photographed then this would be his own responsibility. Skin surgery appointments has to be done through the technician-in-charge (phone: 24831996/7 ext 246). A special booking notice (English/ Arabic) will be handled to the patient (Appendix 15). A questionnaire about patients past history, medications, allergies, and infectious diseases has to be filled out by the patient before carrying out surgical procedures and  to be kept in his file (Appendix 15b).

d.     All patients who were referred to As’ad Al-Hamad Dermatology Center from outside the center for treatment in the specialty clinics or specialty units, upon completing their treatment course should be referred back to their treating doctors in the relevant health area according to their residency. A full medical report for these patients should be sent to their treating doctors.

 e.      All patients who open a file in As’ad Al-Hamad Dermatology Center should open also an electronic file at the reception through the computer system by the medical records personnel. All appointments of the patients should be manually recorded on the special yellow card, and should also be registered in the computer system. During future visits of the patients, the patient has to register his show-up in the computer system by the medical records personnel.

 f.       The waiting period for new cases should not exceed one week. Urgent cases will be seen without appointments.

g.     All Dermatology Departments and affiliated Units and Clinics should use special dermatology sheets for the outpatient clinics inside the medical files that have been approved previously by the Council of the Dermatology Departments. These sheets will be added to the patient file for use by the dermatologist (Appendix 16: Outpatient clinic sheet (Derm1), Appendix 17: Investigations sheet (Derm2), Appendix 18: Photo Therapy  sheet (Derm3), Appendix 19: Photo Therapy  sheet (Derm4), Appendix 20: Photo Therapy  PASI sheet (Derm5), Appendix 21: Body Drawing  sheet). A sheet showing the various dermatological diagnoses for each patient with the date of diagnosis should be added as the first page in the file of the patient (Appendix 22). Old single cards that were used in the past should be discouraged and replaced with the files containing the aforementioned dermatology sheets.

h.     Dispensing treatment for the patients from the pharmacy is not allowed except on the formal treatment papers used in the center. If the patient has a file then the treatment sheet inside the file is used. Patients who are treated temporarily on casualty papers will use these papers to dispense the treatment.

i.        Certain medications are only dispensed by the senior registrars or a higher rank. These medications are specified by the Dermatology council and a list of these medications should be available in the pharmacy (Appendix 23). Also, some medications like Roaccutane and Neotigasone need special informed consent to be filled out by the patient (Appendix 24,  Appendix 25 respectively). There should be a Roaccutane follow-up chart (Appendix 26) in patients’ files.

j.        No files should be handled to the patient at any time and under all circumstances. The file transfer from the reception to the outpatients’ clinics or the specialty units should be arranged by the medical records section. 

k.     All the staff of the department will have afternoon duties at the rate of once per week plus a Friday or A Saturday duty every month.  On these days, members of the duty will be present physically in the department for at least 3 hours (from 5:00-8:00 p.m. except in Ramadan from 8:00-10:00 p.m.), and will be on call for the 24 hours on the duty day to cover all emergencies and consultations. Duties will be also carried out during week-ends and holidays where the doctors on duty will be present physically in the department for 3 hours from 9:00 am to 12:00 noon on Saturdays, and in Ramadan from 10:00 am till 12:00 noon. In all cases he/she will be on call for the 24 hours on the duty day to cover all emergencies and urgent consultations. Regulations regarding on-call procedures and system will follow the Job Description set forth by the Council of the Dermatology Departments.

Starting from March 2005, a change of the afternoon duties has been set after it was discussed in the Department Council Meeting in February 2005.

Accordingly, the doctors who are first on call will be responsible for the consultations  (hospital requests) on group basis for the hospitals:

a.      First on-call (A) doctor: responsible for requests from Al-Sabah Hospital Departments including Al-Ettisalat and NBK buildings.

b.     First on-call (B) doctor: responsible for requests from Al-Razi, Maternity, Physiotherapy, and Infectious Diseases hospitals.

c.     First on-call in PUVA (A) doctor: responsible for requests fromIbin-Sina, Babtain, Hamed Al-Essa, KCC, Al-Bahar, Al-Naffisi, and Chemotherapy hospitals.

d.     First on-call in PUVA (B) doctor: responsible for requests from TB-Chest, Cardiology, Allergy, Psychiatry and Addiction hospitals.

In case no First on-call (B) or First on-call in PUVA (B) doctors are available in the afternoon schedule, the First on-call (A) and First on-call in PUVA (A) doctors will be responsible for the requests from the hospitals of the First on-call (B) and First on-call in PUVA (B) doctors  respectively.

An exception to the above-mentioned grouping of hospital rule is when there is only one First on-call doctor (as for example in Fridays), in this condition the underlined doctor in the schedule is responsible for requests from ALL  hospitals on that day. Trainee doctors including those who are enrolled in the Dermatology Board Program should accompany the Second on-call (or Third on-call) doctors during the in-patients round. Also they have to accompany the First on-call doctor during the requests round (for at least one request), and then they have to discuss it with the senior doctor in the afternoon duty.

The second on-call doctor is responsible for any consultation needed by the First on-call doctors during the duty hours (24 hours). The Third on-call is responsible for consultations needed by the Second on-call doctors during the duty hours (24 hours) and also for administrative matters arising during the afternoon duty.

Change of the duties should be on special form (Appendix 27). All minor procedures that can be done in the outpatient clinics are preferably to be carried out during the afternoon duties.

There should be a duty record book in the department, available to any member of staff who wishes to write any comment. Also, all consultations for incoming requests should be recorded in this book mentioning the date, time, name of doctor on-call, location of the patients examined, the diagnosis and any remarks.

l.          Patients who are referred to the center for a medical certificate denoting that he/she is free from sexually transmitted diseases are given this certificate (Appendix 28) after being investigated. The result of the tests is mentioned in the certificate that should be countersigned by the Director of Al-Sabah Hospital.

m.     No medical report should be issued to a patient except after an official application signed by the patients or his legal representative.   The medical report should be prepared and signed by the treating doctor. If the treating doctor is not available for a prolonged time, e.g. on leave, then any doctor assigned by the head of the center should prepare and sign the report on behalf of the treating doctor. The report should be counter signed by the head of the department before being handled to the patient. It does not become official until being countersigned by the Hospital Director.

n.        The medical boards are held on Mondays every week unless the case is urgent. Each board consists of 3 members that should include consultants and senior specialists or specialists. If  a senior registrar to be included  in the board then a consultant, senior specialists or specialists have to be members of the medical board. Patients who are referred for medical boards should get an official letter from the Director of Al-Sabah Hospital before accepting the patient for a medical board. An appointment for the board will be given thereafter. The medical board report should be counter signed by the head of the department and should be sent to Director of Al-Sabah Hospital. In any case it should not be handled to the patient.

o.       Detailed statistics of all activities including the general and specialty outpatient clinics, and specialty units should be daily and regularly carried out by both, the medical records personnel and the nursing staff using a special form (Appendix 29).  Since 2007, the monthly, bi-annual and annual statistics are the direct responsibility of Statistics Department of Sabah Hospital.

p.       The following procedures should be carried out only after an informed conscent has been signed by the patient or his guardian:

1-     Skin biopsy (Appendix 30).

2-     Laser therapy (Appendix 31).

3-     Phototherapy (Appendix 32).

4-     Electrolysis (Appendix 33).

5-     Medical photography (Appendix 34).

6-     Patients suffering from Alopecia Areata and will be subjected to topical immune stimulation therapy (Appendix 35).

q.       There are 5 sets of master keys for the center that open all the doors. These sets are kept with the head of the department, his deputy, the administrative secretary, director of Sabah hospital, and the person-in charge of the security. The master keys do not open the pharmacy doors which are opened by a key kept by the chief pharmacist. As of 2008, Emergency Doors Keys are kept in Glass Sealed small boxes adjacent to each Emergency Door in the Center. Glass of the Boxes  to be broken and keys used during emergencies only. Any misuse of the boxes or keys to be reported to the Head of the Department and to be included in the Incidental Reports. All employees were notified about the Emergency Boxes by Internal Circulars.

r.         All doctors should not examine any patient (particularly females) except in the presence of a nurse or assistant nurse that has to be inside the room at time of examination.

s.        All doctors must put on white coats especially during the clinical rounds or clinical examination. Technicians should always put on white coats, and nursing staff must put on their uniform.

 t.          All department staff must put on the official I.D. tag showing clearly their names and rank. 

u.        An emergency kit including all the emergency medications and tools have to be readily available for use. It is the nursing staff responsibility to know the exact location of each kit and to regularly check for expiry dates and for any missing items.

Currently there are 3 emergency kits; one in the outpatients area, the second in the phototherapy area and the third in the theatre.

v.        Anybody scrubbing for any minor procedure should not have any rings, watches or jewellery on the hands or wrists.

w.      Eating, drinking or smoking is not allowed in any part of the department except in the designated areas.

x.        No pharmaceutical representatives to be allowed to visit any doctor in the clinics or units except after 12:30 p.m.

y.        When there is a complaint the following procedure to be followed: The complaint should be submitted in writing to the person in-charge according to the situation. The name of the person who is complaining should be known and the complaint should be signed by him or his legal representative. If it was submitted directly to the head of the department then the person in-charge will be asked to do an investigation and asks all involved persons to write down their views. The head of the department will decide whether the problem to be solved locally or to be referred to the director of Sabah Hospital for further action.

z.        Incident reports should be submitted by the person in-charge according to the situation to the Head of the Department who should discuss these with the members of the department council.

aa.    Any doctor who wants to be excused from work for a certain period of time has to get a written permission from his senior doctor and has to fill a special form (Appendix 36 ). This form will be kept in the file of the doctor for future reference.

bb.  Any doctor who wants to review a patient’s file that is kept at the reception should fill out  a special form (Appendix 37). This form will be kept at the reception to show the location of the file.

cc.   Doctors who want a clinical attachment in the Surgery Unit should follow a certain protocol (Appendix 37b). The doctor has to apply a special form (Appendix 37c), and upon approval of his rotation, the doctor has to use a log book (Appendix 37d). A final report (Appendix 37e) about the performance of the doctor during the attachment will be put by the person-in-charge of the Dermatosurgery Unit.

dd.  Doctors who want a clinical attachment in the Laser Unit should follow a certain protocol (Appendix 37f). The doctor has to apply a special form (Appendix 37g), and upon approval of his rotation, the doctor has to use a log book (Appendix 37h).

 Structure:

 As’ad Al-Hamad Dermatology Center:

This center provides both, secondary dermatology services to the catchment areas and tertiary health care services to all Kuwait. It contains the  following:

I)   Secondary Dermatology Health Care Services to the catchment health areas through the general outpatients clinics:

 All clinics are numbered (1-19) and the patients’ files should show the number of the clinic of the treating doctor rather than the name of the doctor. Appointments of the patients are also referred to by the number of the clinic, whether on the appointment yellow card or in the computer.

These clinics are run by registrars and senior registrars (or higher ranks). The number of personnel is determined according to the norms set by the Dermatology Council; where each dermatology unit is composed of 3 registrars and a senior registrar (or a higher rank) based on the number of patients seen. Each unit should deal with a maximum of 120 patients daily, and accordingly, the number of units in the general outpatients is determined. At present time, there are 2 dermatology units in the general outpatients.

Some of the outpatient clinics work on certain days of the week because the doctor is involved in running either a specialty clinic or invloved in a specialty unit

      For details of the doctors names and their assigned clinics please refer to (Appendix 37i).

II)     Tertiary Dermatology Health Care Services to all Kuwait through The specialty outpatients clinics and specialty units:

a)       The Specialty Outpatients Clinics:

These are specialty clinics that provide advanced care for certain diseases. Each clinic is run by a registrar (or more, according to the number of patients seen in the clinic) who should be under supervision of a senior registrar (or a higher rank).

All specialty clinics should use special forms for the patients that should be inserted in the patients’ files:

-         Appendix   38: Treatment of Alopecia Areata with  DPCP

-         Appendix 39: Sick-Kids Clinic.

-         Appendix 40 : Psoriasis clinic.

-         Appendix 41 : Bullous Diseases clinic.

-         Appendix 42 : Cutaneous T-Cell Lymphoma cases.

Currently the center contains the following specialty  outpatients clinics:

(i)                Pediatric Dermatology clinics: Location: clinics 12 (Dr. Arti Nanda), clinic 14 (Dr Mohammed Kamel), clinic 13 (Dr. Abdalla Al-Arini), clinic 18 (Dr. Rana Al-Noun), and clinic 17 (Dr. Khaled Khamis). The pediatric clinics run at present time on daily basis. These clinics provide dermatology care for all pediatric cases referred by dermatologists or pediatricians. Statistical record of all new pediatric dermatology cases seen since 2000 is maintained. Guidelines of care sheets are given to the parents of children with atopic dermatitis and eczema (Appendix 43 Arabic and English versions).

(ii)              Psoriasis clinic: It is run by one senior specialist  (Dr. Hesham Hanafi, Clinic 2) and one Senior Registrar (Dr Fatima Al-Khawajah, Clinic 9, and one Registrar (Dr. Ibtihal Al-Awadi, Clinic 6). Currently it is working twice per week (Sundays and Wednesdays).

(iii)    Autoimmine Bollous Diseases Clinics: Location: clinics 14, clinic 9  and 15.  It is run by one Consultant (Dr. Arti Nanda), one Senior Registrar (Dr Fatima Al-Khawajah), and  one registrar (Dr. Mousumee Nanda) and currently is working once per week (Tuesdays).

(iv)           Alopecia Areata clinic: Location: in the doctors’ office in the dermatologic surgery unit. It is run by one Consultant (Dr. Arti Nanda) and one Registrar (Dr. Rafaat Madbouli). When needed, another Registrar runs the clinic (Dr Wageeh Waheeb). Currently it is working once per week (Thursdays).

(v)             Contact Dermatitis clinic: Location: in clinic 8. It is run by one Consultant (Dr. Ibrahim Al-Sayad) . The doctor of this clinic is responsible for doing patch testing for patients referred from general dermatology clinics on Mondays after 11 am for the employee referred from the General Medical Council. The results of the latter tests should be recorded on a special form (Appendix 44) that will be handled to the patient. A copy of this report to be kept in the unit.

(vi)           Sick-Kids clinic: In order to provide better quality care to sick pediatric dermatology cases, this clinic is started on Wednesdays. Location:  clinic 12  It is run by one Consultant (Dr. Arti Nanda). This clinic will provide dermatology care services to pediatric patients suffering from:

-            Severe cases of eczema and atopic  dermatitis

-            Lupus Erythematosus.

(vii)         Hair Disorders Clinic:

This is a specialized clinic for diagnosing hair disorders including: Androgenic Alopecia in males and females, Hirsutism (non-endocrine in origin), Primary Hair Disorders, Alopecia Areata patients failed in the standard therapy, and Acute and Chronic Telogen Effluvium.

The clinic has started operation on February 2003 and is run by a Senior Specialist (Dr. Ibrahim AI-Aradi) as a once weekly clinic (on Mondays from 10:30 – 12:30). Referral of the patients should be through a written note in the patient's file and should include brief history, examination and tests done for that patient. Any patient referred without a note will not be accepted. Booking of appointments will be through the nurse-in-charge of this clinic. For the Protocol of this clinic, please refer to Appendix 45.

b)      The Specialty Units:

At present time, these include:

1.       Phototherapy: This is run by 4 registrars (Dr. Ihab Nour El-Dein, Dr. Jihan Raji, Dr Mohammed Taha, and Dr Ali Jamil) supervised by  one Senior Specialist (Dr. Hejab Al-Ajmi) and helped by trained nursing staff. It provides phototesting and phototherapy (Systemic and Topical PUVA, UVB, UVA) for the indicated diseases. Each doctor working in this unit should follow the treatment protocol provided by the center for this unit (Appendix 46).  Topical application of medication for Topical PUVA should be carried out by the nursing staff and not be the patients themselves.

The unit works daily and, at present, accepts new cases on Saturdays, Sundays, Mondays, and Tuesdays. Phototesting is done on Saturdays, Sundays, and Wednesdays for PUVA and daily except Wednesdays for UVB.

The unit also provides afternoon treatment services from 5 to 8 p.m. for the students and teachers only.

The unit also provides Laser therapy for pigmented skin disorders. It works on Saturdays, Mondays, and Wednesdays.

On Mondays it is run by a registrar (on rotational basis) supervised by a Senior Registrar (Dr. Kholoud Qasem). On Wednesdays it is run by a registrar (on rotational basis) These doctors are helped  by a trained nurse. 

Each patient is given information sheet about the photo-therapy and its possible side effects (Appendix 47).

2.       Dermatologic surgery: This is run by one registrar (Dr Nabil Qablawi) and 2 Senior Registrars (Dr. Mohammed Kamel, and Dr Iman El-Masry) and is under supervision of a Senior Specialist (Dr Ibrahim Al-Aradi) helped by a trained nurse. The unit works under supervision of Dr. Ibrahim Al-Aradi. It provides minor surgical procedures done under local anesthesia, including skin biopsies.

The unit works 3 days per week (Sundays, Tuesdays and Thursdays). Three registrars run the clinic according to a fixed time table 3 days per week (Appendix 48). Doctors from the department or from other dermatology departments who are interested to attend the surgical procedures are permitted according to a time schedule that changes every 3 months.

3.       Dermatopathology: This is run by 3 qualified Dermatopathologists: Dr Ghanima Al-Omar, Dr Mohammed Khaled, and Dr. Humoud Al-Sabah) working in 2 units and helped by 2 technicians. The units are responsible for dermatopathological diagnosis of skin biopsies.

Routine, special stains, direct and indirect immunofluorescence, and immuno-histochemical staining are done as indicated. If a procedure is not available in the center, the specimen (or tissue block) is sent to Pathology department at Sabah Hospital, to Kuwait Cancer Center, or to the Faculty of Medicine for processing. 

All patients’ information and pathology report should be entered in the computer system by the secretary working in the pathology unit. A print-out of the pathology report should be signed by the doctor in-charge of the pathology unit.

4. Immunodermatology: This is run by one Consultant (Dr. Richard Dvorak) and helped by 2 technicians. It provides diagnostic facilities essential for certain skin diseases including direct immunofluorescence tests, indirect immuno-fluorescence using monkey esophagus, human split skin, direct smear for Leishmaniasis, Immunoblotting using human skin antigens, human epidermal keratinocytes antigen, circulating immune complexes, and antinuclear antibodies using HEp-2 cells, HeLa cells. If a procedure is not available in the center, the specimen is sent to Hamed Al-Eisa Tissue Transplant Center or to the Faculty of Medicine for processing.

All patients’ information and immunology report should be entered in the computer system. A print-out of the immunology report should be signed by the doctor in-charge of the immunology unit.

5.   Dermatomycology: This unit was was under supervision of a Registrar with very good experience in Dermato-mycology and he is coming from Al-Amiri Dermatology Department once per week (Wednesdays) and is helped by one Registrar from our center (Dr Magdi Fathallah. It provides diagnostic facilities essential for fungal diseases of the skin including direct scrapings and culters. Mycology report should be signed out by the doctor in-charge of the mycology unit.

6.     Corrective dermatology: This is run by one Senior Specialist (Dr. Meshal Al-Ghareeb), two Senior Registrars (Dr Fatima Al-Khawajah and Dr Hanin Al-Raqam), two Registrars (Dr Amr Abdel-Salam and Dr Magdi Fathallah), and one assistant registrar (Dr. Abeer Al-Haifi) and 4 trained nurses. The unit provides different Laser therapies (other than for pigmented lesions)  bedsides some  procedures like removal of milia, skin tags, etc. and also electrolysis for hirsutism.

7.     Medical photography: Being an essential part for dermatology, medical photography of patients is done for follow-up of cases and for teaching purposes. It is run by 2 registrars (Dr. Nabil Qablawi  on Sundays, and Dr. Khaled Khamis on  Tuesdays and Thursdays) helped by a nurse. A special form should be used for each patient to be photographed (Appendix 7) and an informed consent to be signed (Appendix  7).

Information about the photographed patient including name, referring doctor, date, and reference number of photographs is given to the patient in a special sheet (Appendix 49) that should be returned to the treating doctor and kept in patient’s file. For internal use in the unit, a special form is used that will facilitate the filing of the photographs (Appendix 50).

The unit will also help the doctors to keep records of interesting cases and storing them in s presentation format through the use of special forms (Appendix 51 and Appendix 52).

c)       The medical photophysics laboratory

The medical photophysics laboratory is run by 5 physicists. At present time Miss Hanan Bu-Abbass is doing her post-graduate study in UK.  The unit is involved in the following activities:

1- Set up of photo physics lab., Workshop, UVA and UVB treatment rooms, and Laser rooms.

2- Training the nursing staff who are involved in the treatment of patients with PUVA and UVB.

3- Calibration of PUVA and UVB units periodically.

4- Calibration of different instrument and detectors in the lab.

5- Photo-testing of patients of different skin types using Applied Photo physics Photo-irradiator and Multiport solar simulator ( Model XPS 200 )

6- Measurement of the absorbency (or light transmission) of sunglasses for patients treated with photosensitizers, to protect their eyes from UVR.

7- Measurement of erythema and pigmentation in human skin using non-invasive techniques by:

a) Spectrophotometer    ( Minolta CM-200 )

b) Spectrofluorometer   ( FluroMax-2 )

8- Study of changes of optical parameters of human skin with various stimuli, using spectrofluorometer.

9- Training of students of Technical College in the field of applied physics in Dermatology.

III) The Pharmacy:

      This consists of  a dispensing area, lab for preparation of some formulas, and a store. It is under supervision of Main pharmacy at Al-Sabah Hospital, and the chief pharmacist is in-charge of the pharmacy of the. Several pharmacists or assistant pharmacists (number is not fixed) are daily working in the pharmacy.

The pharmacy works in morning hours only. Patients seen in the afternoon duty and need urgent treatment are referred to the casualty medical  pharmacy to dispense medication. Otherwise, the patient can dispense the prescribed medication next day.

The pharmacy keys are separate and different from the master keys of the center. These are kept with the chief pharmacist.

 Equipments:

 1.     Phototherapy Unit (The Treatment Rooms and the Photophysics Lab):

                   A.   Two Ultraviolet machines (UVA + UVB) for treatment of patients.

                   B.    Five Ultraviolet machines (UVA Standing Cabinet) for treatment of patients.

                   C.    One Ultraviolet machine (UVA Lying-down Cabinet) for treatment of patients.

                   D.    One Ultraviolet machines (UVB) for treatment of patients.

                   E.    Two Ultraviolet machines of the Narrow-Band (NB-UVB) for treatment of patients

                   F.    One Ultraviolet machines of the UVA1 Band for treatment of patients

                   G.   Seven Ultraviolet machines (UVA) for treatment of lesions on extremities.

                   H.   Two B-Clear Machines.

                   I.     Spectroradiometer for calibration of the Ultraviolet machines and for measuring the ultraviolet light emitted from the sun.

                   J.     Spectrofluorometer for measuring the fluorescence in different transparent liquids and changes in the skin.

                   K.    UV Biometer for measuring the amount of Ultraviolet rays reaching the earth round the clock, all round the year.

                   L.    One Solar Simulator machine.

                   M.   UV test machines: one UVA, one UVB, and two NB-UVB machines.

2.     Dermatopathology Unit (The Lab and Doctor’s office):

                   a.   Microtome for cutting paraffin blocks.

                   b.    Embedding machine for embedding the processed biopsy specimen in paraffin.

                    c.   Tissue processor for fixing the biopsy specimen in different steps.

                    d.   Incubator for fixing the slides and incubation (staining).

                     e. Water bath for stretching the cut sections and to take it on slides.

                     f.        Multihead Microscopes.

                      g.     One light microscope for examining the quality of the sections.

                     h. Three microscopes in doctor’s office, used for examining and reporting the slides and also photography of the slides when needed plus for teaching purposes.

                     i. Hot Plate for heat fixing the slides.

                     j.  Oven for incubation at high temperature.

                     k.   Fume Hood for absorbing toxic gases.

                     l.    Microwave processor for immunostaining and immediate processing.

                     m. Weighing machine for preparation of various reagents and solutions.

                     n.   Elisa equipments for doing several tests including circulating immune complexes, SS-A and SS-B antibodies, Desmoglein Ab (1 and  3), anti-gliadin Abs, and BP 180

3.     Immunodermatology Unit:

                       a. Equipments for electrophoresis and immunoblotting.

                       b. Co2 incubator for tissue cultures.

                       c. Microbiological cabinet for sterile preparation of cells and tissues.

                       d.Inverted microscope for cell microscopy.

                       e. Refrigerated Centrifuge.

                       f. Ordinary Centrifuge

                      g. Cryostat for cutting sections for DIF and IIF tests, and Moh’s surgery.

                       h. Fluorescent microscope for reading and reporting DIF and IIF tests, and Moh’s surgery.

                       i. Ordinary microscope.

                       j.  Deep Freezer (-80 C) for long time storing of valuable samples.

                       k. Freezer (-25 C) for short time storing of samples.

                       l. Refrigerator (-15 C  -4 C)

                       m. Analytical Balances

                        n. Autoclave

                        o. Two sets of computers with printers

                        p. Digital Camera DP-70 for recording immunofluorescence and histopathology microscope samples.

4.     Corrective (cosmetic) Dermatology Unit:

                        a.   Five Nemectron equipments for electrolysis.

                        b.  One Birtcher-Hyfrecator for removal of skin tags, syringomas, dermatitis papulosa nigra ...etc

                        c.  Ellman Surgitrone Machine

                        d.  Quantum SR/DL (Lumenis) Machines

                        e.  Relume (Lumenis) Machine

                        f.  Photoclearing Acne Machines

                        g.  Iontophoresis Machine

                        h.  B-Clear (Lumenis) Machine

 5.     Dermatologic Surgery Unit:

                        a.  Elman Surgitron equipments (3)

                        b. Diathermy equipments (Hyfrecators 2000) 2 machines.

                        c. Surgical tools for minor surgeries done under local anesthesia.

                        d CryoLab Container and Gun (1)

                        e. Bell’s Hard Engine for Dermabrasion (1)

                        f. Electrosurgery Vacuum Machines (2)

                         g. E.C.G. Machine (1)

                         h. Examination (Operation) Tables (3)

                         i. Examination (Table) Lights (3)

6.     Dermatomycology Unit:

                          a. Two incubators for cultures of mycology specimens.

                           b. Ordinary microscope for examining the direct smears for evidence of fungal infection.

7.     Outpatient Clinics:

                           a. Birtcher-Hyfrecator in each clinic for removal of warts, skin tags ..etc.

                            b. Liquid Nitrogen drums are used to distribute liquid nitrogen in small containers to be used by the doctor in his clinic for treatment of warts ..etc.

                           c. Hand-held Liquid Nitrogen cylinders

8. Laser Rooms:

Two Q-Switched Alexandrite Lasers (Candela)

Function of the Department Council:

1. The Department Council is chaired by the Chairperson of Department (or his deputy) and will have a monthly meeting.

2. Membership of the Department Council:

Setup of the council included all Consultants, Senior Specialists, Specialists, and one Registrar representative for all junior doctors. The latter to be changed on rotational basis yearly. Also, persons in-charge of the Labs, Pharmacist in-charge, person in-charge of the Medical Records, and one representing Nursing staff.

It is held on last Tuesday of every 2 month at 12:30 pm. 

3. The Department Council will determine the size of the adequate team to run the different units in the department according to the norms set by the Dermatology Council for the dermatology service; where each outpatient-unit normally consists of one senior registrar or higher plus 3 registrars.

4. The council will ensure implementation of the Job Description set forth by the Council of the Dermatology Departments and in accordance with the general rules laid by the Ministry of Health.

5. The council will be responsible for implementation, maintaining, and reviewing compliance with the clinical guidelines of care set by the Council of the Dermatology Departments.

6. The Council will identify, initiate and maintain Bylaws, Rules and Regulations for the proper functioning of the department staff.

7. The Council will identify the problems that might be met with during running of the department and units and should put forward suggestions to solve such problems.

8. The Department Council will suggest to the Chairperson of the department, the needed medical equipments and tools, scientific books and periodicals, and names of consultant visitors. The Chairperson in turn will discuss these matters with his colleagues in the Council of the Dermatology Departments.

9. The Council during its monthly meeting should discuss the detailed statistics carried out by the Person in-charge of the Medical Records regarding various activities of the department and its units, and find out any indicators of deviation from normal and expected findings. Abnormal findings should be discussed and investigated by members of the council and proper solutions to be suggested.

10. The Council should contribute in planning of the Annual Vacations of the department and units.

11. The Department Council should be aware of the steps and principals of the Emergency Plans set by the Council Board of the Hospital and should be able to implement these plans whenever needed (Appendix 62 ).

A departmental Emergency Plan has been set that includes an Emergency Team during morning working hours and during afternoon duties. The details of this plan is available through 12 Emergency Circulars (Appendix 54 ).

12. Promotions, shortages, proposed plans, change of structure will be discussed in the Council’s meeting.

13. The Council will review and evaluate on continuing basis the clinical privileges of the staff, to ensure a high level of professional performance by all persons authorized to practice in the department.  Senior members of the Council in a closed meeting will decide on the appropriateness of the professional performance and ethical conduct of members of the department.

14. The Council will support the appropriate utilization of the department resources, and support all clinical and non-clinical activities that serve to promote and maintain accreditation of the department locally and internationally.

15. The Council will discuss the duties of running the day to day business e.g., minor operation theatre, phototherapy, post-graduate and in-service training, the morbidity/mortality, research, the medical records..etc.

16. The Department Council will decide on the appropriate educational setting which will maintain scientific standards and continuous advancement of professional knowledge and skills through the following:

a) The department weekly clinical meeting (for details, please. Refer to the Department Teaching and Training Activities section).

b) The Department Council will encourage the contribution of the staff members of the department in the Grand Clinical Meetings that are held in collaboration with other Dermatology Departments of the Ministry of Health several times a year.

c) The Department Council should encourage active participation of the staff members of the in various scientific meetings inside and outside the country, and should put forward a plan and policy for nomination of the participants in the conferences.

d) The Chairperson will advertise all academic and clinical meetings.

17.  The Department Council should review the accumulated CME/CPD points of staff, and evaluate the CME/CPD activities of the department (for details please refer to the Teaching, Training and Continuous Professional Development CPD/CME section).

18. The Department Council will discuss the outcome of the Medical Records Chart Review (for details, please refer to the       Department Medical Records Chart Review section), and will take the necessary actions

19. Discussion of Incident reports.

20. Evaluation of the operational policy, at least twice per year, and to be updated and re-printed at least once per year. The evaluation should include: Strength, Weaknesses, Opportunities, and Threats.

21. Discussing the Dermatology Audit (refer to The Dermatology Audit section for details).

Role of the Chairperson of the Department:

The Chairperson of the department is responsible for   the following activities:

a) All clinically related activities of the department, unless otherwise specially delegated to heads of units in writing.

 b) All administratively related activities of the department other than those specifically delegated to heads of units in writing including the supervision of the performance of the nursing staff, the technicians, and the pharmacists in liaison with the concerned supervisors.

 c) The integration of the department into the primary functions of the hospital and other services of the Ministry of Health. 

 d) The development and implementation of Operational Policies and Procedures in accordance with the updating and reviewing them in the departmental council.

 e) The recommendations for the appointment of adequate number of qualified and competent persons to provide quality care.

 f) Continuing surveillance of the professional performance of all individuals who have clinical responsibilities in the department

 g) Recommending to the Departmental Council the clinical privileges of the members of the department.

h)    The continuous review and improvement of the quality of care and services provided through nomination of Quality Assurance coordinators, and the maintenance of Quality Assurance program in the department. This will be maintained through nomination of a Medical Record Chart Review Committee in the department.  The committee will ensure that all Medical Records are documented accurately and are readily accessible and provide prompt retrieval of information  (for details, please refer to the Department Medical Records Chart Review section).

 i)  The orientation and continuing education of all persons in the department.

 j)   Recommendations for space and other facilities needed by the department.

 k)  Nominating names of the members of  Medical Boards.

 l)   Participating in the function of the Council of Dermatology.

 m) Investigating the complaints submitted to the head of the department, following the procedure mentioned in the Internal Policy section.

The Department Medical Records Chart Review Committee and Function:

This should be announced by the Chairperson and includes some of the Senior Registrars, Specialists, Senior Specialists and Consultants.  At present, this committee includes: Dr. Qasem Alsaleh (Chairman), Dr. Arti Nanda (Consultant Dr. Hesham Hanafi (Senior Specialist), DR. Ibrahim Al-Aradi (Senior Specialist),  Dr. Meshal Al-Ghareeb (Senior Specialist), and Dr. Kholoud Qasem (Senior Specialist) (Appendix 55).

The committee will report to the Department Council at least once per month.

It will assure that all patients who are being followed-up at As’ad Al-Hamad   Dermatology Center must have a medical record according to the Referral Policy mentioned previously.

The content of the medical record should be sufficiently detailed to enable any other on-duty or consulted doctor to provide continuing care to the patient. The committee will use a standard form to evaluate the charts (Appendix 55b).

Minimum information should include: identification data, medical  history of the patient, detailed physical examination of all body systems, presenting problems and other associated problems, diagnostic and therapeutic plan, progress notes (in measurable terms relevant to patient's condition).

Members of the committee will conduct weekly Chart Review of the Medical Records and identify medical record deficiencies accordingly to medical record deficiency check-list (Appendix 56). They will decide on the non-compliance and refer these cases to the Department Council.

The committee will make sure that the medical records contain sufficient information to assure the continuity of care. The following standards of review, together with those of the Medical Records Department Review Chart (Appendix 57), shall be utilised making their decision:

1. The record contains the scope and details of information appropriate to the diagnosis.

2. The record substantiates the final diagnosis.

3. The record refers to important abnormalities, laboratory or     other special examinations.

4. The record identifies important risk factors that have a bearing on choice and application of treatment.

5. If admitted, the record should include a concise summary of the reason for admission, listing of problems in chronological order, findings, treatment given or procedures performed condition of the patient on discharge and any pertinent discharge instructions.

6.The record should be signed clearly and stamped by the treating doctor.

            Therefore, the record will consist of:

a.      History: past, present.

b.     Provisional diagnosis.

c.     Problems:  Problem 1,   Problem 2 ,  Problem 3, Problem…etc

d.     Investigation plan.

e.      Therapeutic plan.

f.       Progress Note (relevant to patient's problem in measurable terms).

g.     Consultations:

                   - Change of management plan.

                   - Change of therapeutic plan.

                   - Discharge summary.

                   - Follow-up appointments.

                   - Discharge Rx and dietary plan ^(*)

                   - Re-admission plan.

                   - Operative report.

                   - Consultation Report.

^(*) Applicable for in-patients and also outpatients who finished treatment in specialty clinics or units and will be referred to their treating dermatologists.

Risk management activites (Patient/ Staff Safety and Incident Report):

1-       It is the responsibility of the person-in charge of each unit in the department to inform the head of the department or the administrative secretary about any problem in the equipments in his unit so as to call the workshop people to repair the equipment so as to ensure the continuity of the service and the safety of the personnel and the patients.

The Infection Control Measures against transmission of HIV and other Blood-borne infections for safety of health-care workers distributed by the Quality Assurance and Infection Control Department, Al-Sabah Hospital (Appendix 58) should be followed-up.

 2-     In the event of a pin-prick or other blood/body fluids exposure, the policy for Incident Report for Exposure to Blood/Body Fluids that was distributed by the Quality Assurance and Infection Control Department, Al-Sabah Hospital (Appendix 59) will be followed.

3-    Any incident that happens in the department during a treatment procedure should be recorded and forwarded to the head of the department who should discuss all incidents in the department council meetings. Measures should be taken to avoid such incidents in the future, if possible.

Admission and Discharge Policies:

          (a) Admission Policy:

As there are no wards for dermatology, the patients are admitted usually to the medical department or pediatric department of the hospital to which the dermatology department is affiliated. For As’ad Al-Hamad Dermatology Center, admission is done to the medical department or pediatric department of Al-Sabah Hospital.

The Consultants, specialists, or Senior Registrars should approve the admission of patients. The treating doctor (or the doctor on-duty if the treating doctor is not available) will admit the case and is responsible for writing the in-patient sheet including full history and examination notes, together with the investigations to be requested. The Consultants or Senior Registrars/specialists on duty should examine the patient after being admitted on the same day of admission, review the admission chart including the investigations requested, and to write down the treatment plan. After being admitted, the patient must be followed up by the Consultants or Senior Registrars/specialists on call on daily basis. During week-ends and holidays the doctor on duty is responsible for following up the admitted patients and should report to the Consultants or Senior Registrars/specialists on call.

Review of the in-patients’ condition including various investigative procedures and management should be carried out during the weekly clinical meeting held on Tuesdays.

           (b) Discharge Policy:

It is the responsibility of the Consultants or Senior Registrars/specialists on-call to discharge the in-patients when they are fit for discharge. A discharge summary should be written and a referral letter to the treating dermatologist should be given to the patient for follow-up.

According to the diagnosis, the patient is referred to either the general outpatient clinics, the specialty outpatient clinics, or the specialty units for follow-up.

Evaluation of the Departmental Policy: strengths, weaknesses, opportunities, and threats.

Evaluation of the operational policy should be done at least twice each year by the department council. Revision of the policy will be done and suggestions discussed. Input from all the doctors of the department should be encouraged.

Strengths:

1.   As’ad Al-Hamad Dermatology center providing a tertiary care service makes it a unique department of dermatology in Kuwait.

The center provides specialty and subspecialty dermatological care services to the patients allover Kuwait through the available equipments and personnel  in the specialized clinics and units.

2.   The center is recognized as a teaching and training center for candidates enrolled for the Kuwait Board of Dermatology program.

3.   International collaboration for problem cases has been established recently with many centers through the following:

a. Problem pathology slides are sent through the ministry to Dr. Eduardo Calonje in St. Johns Institute of Dermatology in London University in U.K.  for diagnostic consultations and reporting.

b. Consultations on genodermatoses are sent to Dr.  Ahmed Teebi, professor  and Head of Genetic Department in University of Toronto in Canada, and to Dr. John McGrath in St. Johns Institute of Dermatology in London University in U.K.

4.   An electronic calling system is available for calling the patients in the out-patients area and the Phototherapy area.

5.   The available computer network permits a modern service through registering patients’ information and appointments, follow-up of patients by their electronic medical files, and writing the patients reports retrieved from their electronic medical records. Various statistics including the diagnoses of patients based on the ICD 10 protocol became available through the computer system. At present there are several software modules available for the following applications:

a.      Patient registration (at Reception).

b.     Patient electronic medical files (available for all the doctors in the general and specialty clinics).

c.     Photo therapy program (available for the photo therapy unit).

d.     Pathology program for pathology reports.

e.      Mycology program for mycology results and reports.

f.       Biopsy Appointments.

6.   The computer network also permits access for all dermatologists in the center to specialized dermatology software applications on compact disks (CDs) available on CD server.

 7.   Advanced audiovisual facilities are available in the center including digital cameras and data show that, together with the computer network, enable presentations of clinical cases and  pathology slides in the weekly and grand meetings. Also these facilities are used to present  problem cases seen by visiting professors and consultants in seminars held for all dermatologists to attend the comments of these visitors regarding these cases. In addition, there are facilities for conference slides processing and for publications.

 8.   Internet connection in the center is available all the day for all the doctors to facilitate scientific and medical search of literature and internet services in the medical field.

 9.   There is a web site for the center on the internet (www.dermakuwait.com) that provides  link to vast dermatology services worldwide. Also, this operational policy and the treatment guidelines for the ten most common skin diseases are available in the site for viewing and for downloading.

10.  Appointments schedule by internet is now available through the center website for the patients to request their appointments.

11.  The health issue magazine is produced 3 times per year and is addressing mainly the patients about various dermatology diseases.

Weaknesses:

1.   As’ad Al-Hamad Dermatology center is a secondary and tertiary care service center and should not allow walk-in of non-emergency cases. Also, all referred patients should come on an appointment bases. This is not always the case, and in many instances we are obliged to treat such patients because of lack of ministry support.

2.   In spite of the spacious nature of the center, recently and because of expansion of the services in the center, we are in need for extra rooms to be used as stores and rooms for sorting the non-clean laundry. We have suggested building extra rooms in a space that is available outside the building of the center near the employee parking.

3.  There is discrepancy between the catchment areas of As’ad Al-Hamad Dermatology center and those of Al-Sabah Hospital. This leads to problems in interdepartmental co-operation and interdepartmental policies. Unifying the catchment areas for both should be considered.

Continuous Professional Development CPD/ CME

Teaching, Training and Continuous Professional Development CPD/CME:

1.   Department teaching and training activities:

 a) The center will have a clinical meeting at least once per week. The weekly clinical meeting will be a minimum of 2 hours session that is held currently on Tuesdays, starting at 12:00 noon. All the doctors of the department will participate. Active participation of the Registrars and Assistant Registrars must be encouraged. The activities will include presentation of problem cases, lectures and journal club. Problem cases are seen physically in the outpatients. Special form for each patient should be filled out by the presenting doctor (Appendix 60).  All patients should be photographed by the doctor in charge of the photography unit using the special photography form (Appendix 7). The cases are then reviewed and discussed in the clinical meeting room through retrieval of the patients photographs using the computer network in the center. This meeting has been accredited by the KIMS as Category II CME program. During this weekly clinical meeting, discussion of the in- patients admitted to the medical wards will be carried out regarding various investigative procedures and management of these cases.

b) The staff members of the center participate in the Grand Clinical Meetings that are held in collaboration with other Dermatology Departments of  the Ministry of Health 4 times a year.

 c) The staff members of the center should have active participation in various scientific meetings inside and outside the country.

 d)   The center is involved in teaching a pediatric dermatology course for the 6th undergraduate students, and a general dermatology course for the 7th year medical students through the clinical tutors approved by the ministry.

 e)    The center, through the senior registrars and higher ranks, are also involved in medical training and teaching of the family doctors and trainees of Kuwaiti board of Medicine and Pediatrics sent for this purpose by the KIMS. Also, they are responsible for postgraduate doctors sent for Canadian board in Dermatology, in General Medicine, or in Pediatrics who spend an elective course in dermatology in the Center whenever assigned by the KIMS.

After the daily round with the senior staff, the candidates might be distributed to the outpatient clinics (general or specialty clinics) or the specialty units to build up clinical experience in dermatology.

 f)   Since 2003 the center is involved in teaching and training the Candidates of Kuwait Board of Dermatology. Details of the teaching schedule of these doctors are available in Appendix ( )

2.       Continuous Professional Development CPD/CME:

The department council will organize and maintain the following:

                1.  The annual CPD/CMEs of the department.

                 2.     The minimum score of CPD/CME points for each member of staff.

                 3.     Evaluation of the efficacy of the CPD/CME programmers, and the quality of different components (Departmental lectures, seminars, workshops, clinical rounds, teaching rounds, clinical review meetings..etc).

The Dermatology Audit:

This can be achieved through the following:

I.    Clinical Auditing. This can be a function of The Department Medical Records Chart Review. It should include the following:

                          1.     Number of readmissions within one month.

                          2.     Number of incidents of unauthorized drug use.

                          3.     Number of medication errors.

                          4.     Accuracy of diagnosis.

                          5.     Number of patient/family complaints regarding drug therapy.

                          6.     Length of stay of in-patients more than 30 days.

                          7.    Patient satisfaction questionnaire result.

                          8.     Number of requests where the response was delayed more than 24 hours and the reason for that delay.

                          9.     Number of treatment refusals by the patient.

                          10.   The appropriateness of investigations.

II.     The Department Mortality and Morbidity Committee. Is responsible for discussing mortality and morbidity of in-patients whenever applicable.

III.  The Lymphoma Review  Committee. Consists of Dr. Qasem Alsaleh, Dr. Hejab Al-Ajmi, Arti  Nanda, Dr. Humoud Al-Sabah,  . Dr. Ehab Noreldin, Dr Jihan Raji, Dr Mohammed Taha, and Dr Ali Jamil. (Appendix 60 b). It is responsible for reviewing all cases of cutaneous lymphomas especialy the Cutaneous T-Cell Lymphomas (Mycosis Fungoides) that are referred to the center. According to a circular from the Under-Secretary of the Ministry, all cases of Mycosis Fungoides to be referred to the center for diagnosis, management, and followup (Appendix 61).

The reports of these committees should be finally discussed and reviewed by the Department Council during its regular meetings.

CHART ROUND -DEFICIENCY LIST

  Additional comments: _________________________________________________________

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