quality assurance for rh services maharashtra. how we defined quality “ attributes of a service...
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Quality Assurance for RH services Maharashtra
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How we defined quality
“Attributes of a service program that reflects adherence to professional standards, in a congenial service environment and satisfaction on part of the user”
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RCH Quality Framework for Assessment
RCH facility based Services to be assessed
INPUTS PROCESS OUTPUTS
Family Planning Building Infra-structure Equipment Personnel-
training Supplies
Clinic-wide procedures e.g.-Schedules, Hygiene, Asepsis
Technical competence Client Provider
interaction
FP method mix Complications Follow-up
Maternal Health including abortion care and infection prevention
ANC/PNC Norms at Deliveries Complications managed
RTI/STI and HIV
Lab tests Case treatment Follow-up
Child Health/Immunisation
Cold chain maintenance Safe injection practices AD syringe use and disposal
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Coverage under QA• 2006-07 - Pilot project in Ahmednagar• 2009-10 - Six Districts covered (Riagad, Kolahpur,
Aurangabad, Chandrapur, Ahmednagar and Akola)• 2010-11 - Six additional Districts covered (Amrawati, Jalna,
Thane, Satara, Wardha and Nashik)• 2011-12 - Six more districts added (Jalgaon, Buldhana,
Parbhani, Beed, Osmanabad and Bhandara) Operationalized during 2012-13
• 2013-14 - Program expanded to cover entire State with NRHM support.
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Overview of QA program
• Unique internal system of quality assessment and improvement.
• Assessments conducted by DQAG teams ( Officers from district health system)
• Action plans for quality improvement prepared on the day of the visit itself .
• Followed up through meetings , field visits for taking corrective actions.
• Assessors are themselves mentors.
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Quality Assurance Process
Internal and external users
Monitor
Find Gaps
Prioriti
ze an
d
sugge
st so
lutions
Implement
Reassess
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Implementation frame work• Creating structures at state and district level
– State QA cell• PHI and SFWB key implementing partners• Appointment of state QA consultant
– District QA cell• Identification of Nodal Officer for QA• Appointment of QA coordinator
• Processes for QA implementation– Selection of health institutions (Initially 50 in each district expanded to
additional 25 facilities in Phase I and II districts)– Formation of District Quality Assurance Group (DQAG)- CS, DHO,
Specialists– Training of DQAG members– Conducting QA assessment of identified institutions– DQAG meetings
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Institutional structure for Implementation of QA
District level structure• DQAG was created under chairpersonship of Civil
Surgeon/DHO as part of expanded scope of district FP Quality Committee
• Space, Computer, data entry Operator provided to District QA cell
• Identified a Nodal Officer for QA• District Quality Coordinator was appointed• 20-24 members were identified as members of DQAG from
the district level programme managers, clinical specialist, doctors, faculty of DTT/HTT, PHN and staff nurse
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Phase I (6districts)
Phase 2 (6 districts)
Phase 3 (6 districts)
Phase 4 (15 districts)
0
50
100
150
200
250
300
350
400
450
500
280 306 334
177 1340
0
Additional FacilitiesInitial Facilities
Health Facilities covered1231 in 18 Districts
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Type of Health Facilities covered
SDH/RH PHC Sub Center0
100
200
300
400
500
600
700
209
593
429
Number
Number
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QA: The process
Creating an enabling environment• Orientation workshops held for district level Officials
and service providers to explain purpose and processes of QA
• Workshops were held to orient medical officers on purpose and process of QA initiative. (Informed that QA is not fault finding or monitoring exercise)
• QA checklists shared and explained• MOs were told to hold similar orientation for the
facility and field staff during regular monthly meeting
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QA: The process….Contd
Capacity building of DQAG members• DQAG members trained for 4 days on quality assurance,
concepts, assessment and improvement• Training was skill oriented and focused on:
– assessment of quality of RH services using checklists– briefing and debriefing of facility staff– findings gaps in quality of care– Helping the facility staff to think about options for
addressing the gaps for improving quality– helping facility staff to develop a work plan for quality
improvement
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QA: The process….Contd
Live and vibrant checklists• Input indicators• Process assessment• Output indicators• NRHM interventions and state specific schemes Questions in the checklist are designed to make
objective assessment, there is no scope for subjectivity
Separate checklist developed for SDH/CHC, PHC and SC
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Steps in a QA visit
• Briefing in-charge and other staff of the facility• Collecting data using quality checklist• Analysis of data, determining overall quality of RH
services using total scores and finding gaps• Sharing summary findings with facility staff• Discussion with the facility staff on sub-elements with
low scores and assess root causes• Discuss possible and doable solutions• Help facility develop quality improvement action plan
with responsibility of implementation clearly defined
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Facility Grades based on quality assessment
Category Aggregate ScoreCategory A+ 91Percent and aboveCategory A 76 -90 percentCategory B 51-75 percentCategory C 26-50 percentCategory D Up to 25 percent
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Quality Improvement
• Facility In-charge accountable to take action on plan prepared for improvement by DQA team.
• 60-70 percent gaps in quality need local action, which facility In-charge can take using NRHM/RCH untied funds and involving RKS.
• In cases of 20-25 % gaps, district level actions are required. State level interventions are needed to address 10-15% gaps.
• Quality assessment provides an opportunity to identify gaps in infrastructure and other inputs for which the facility or district could plan in next year’s district PIP especially when these inputs needs more resources than what is available as flexible or untied funds.
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Key Achievements
• Overall improvement in quality of indicators at majority of facilities.
• Improvements in key issues like BMWM, physical amenities, cleanliness, availability of equipments, medicines etc.
• Increase in output indicators and utilization of services in some facilities.
• Increased awareness of MOs and staff on issues related to quality and client satisfaction.
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Quality Improvement in facilities- Phase I districts. Percentage of facilities in category A and A +
Ahmednagar
Auranga
badAko
la
Kolhapur
Chandrap
ur
Raigad
0
20
40
60
80
100
120
28 24
6
26 2210
54 5871
98
78 77
First VisitLast Visit
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Quality Improvement in additional facilities- Phase I districts. Percentage of facilities in category A and A +
Ahmednagar
Auranga
badAko
la
Kolhapur
Chandrap
ur
Raigad
0
20
40
60
80
100
120
28
6
20
52
612
5261
48
10091
36 First visitLast visit
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Quality Improvement in facilities- Phase II districts. Percentage of facilities in category A and A +
Amravati Jalna Nashik Satara Thane Wardha0
20
40
60
80
100
120
20
0
15
3022 22
90
70 73
8694 98
First VisitLast Visit
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Quality Improvement in additional facilities Phase II districts. Percentage of facilities in category A and A +
Amravati Jalna Nashik Satara Thane Wardha0
20
40
60
80
100
120
36
0
124 0 0
36
17
3828
62
100
First VisitLast Visit
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Findings of Evaluation of QA project
• knowledge and awareness about Quality processes and indicators among facility in-charge and staff better in QA facilities than non-QA facilities.
• Significant increased consciousness amongst staff about ‘Quality’ of RCH services
• Major responsibility to improve quality taken up by persons from within the system. Minimal additional HR involved.
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Key recommendations of the evaluation
The QA action plans have met grand success in resolving issues at the facility level, moderate success at the district level issues; however, almost no efforts were made for resolution of issues at the state level.
Issues not resolved at State level• Availability of skill mix at SDH/RH• Availability of trained MOs in Minilap, MTP, NSV at PHC• Training in RTI/STI- Mos, Staff Nurses, LHVs, Lab.Tech• Training in SBA for ANMS• Training in BEmOC for MOs• Availability of Protocols and guidelines
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Gaps not addressed at District/ facility level
• Cleanliness and Infection Prevention Practices (segregation and disposal)
• Empanelment of trained MOs.• Availability of referral Register.• Availability of sterilization case cards and consent
forms.• Availability of equipment such as emergency tray,
oxygen cylinder, suction apparatus, etc. as per prescribed standards.
• Registration of ARI/diarrohea for under 5 yrs.
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How gaps were addressed
• DQAG members act as mentors and help facility staff bridge identified gaps.
• Monthly meetings of DQAG with CS/ DHO to discuss action taken report on gaps identified.
• Participation of State QA consultant in District meetings.
• Quarterly review meetings at State level.
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Challenges- Systemic issues• Vacancies and high turn over of staff• Lack of ownership and interest especially by
clinical members of DQAG leading to cancellation or rescheduling of some visits
• Lack of willingness to involve civil society• Ensuring commitment from district level program
mangers for Quality assessment and improvement through monthly review meetings, sparing members for QA visits and timely action on district level actions identified for improvement
• Constitution of DQAG and keeping it together as a cohesive group
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Other Challenges
• Changing strategy to address differential needs of persistently better and laggard health institutions on quality indicators
• Developing strategies for universal coverage in context of local realities
• Maintaining motivation level of health facility staff and DQAG members
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Learnings• It is a feasible and effective intervention• Majority of gaps in quality of care can be addressed at local
level, some at district level and only few at state level• It provides many collateral benefits such as team building and
on job improvement in knowledge and skills • Local capacities can be developed to reduce dependency on
external support for implementation and up-scaling • With community involvement it becomes more effective• It is a cost effective intervention
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Forging Ahead
• Initiated a pilot for synergy between CBM and QA in Beed District.
After QA Assessment and preparation of action plan a meeting of DQAG team members , MS/MO & staff and CBM NGO members as well as RKS members is organized at the facility to discuss the action plans prepared under QA and under CBM. The QA action points are followed up by CBM NGO members when they visit the facilities for CBM work.
• Process for incorporating a gender index as part of the checklists underway.
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Synergy between RMNCH+A and QA
• Main objective common- Addressing identified gaps for client satisfaction.
• Checklists- QA checklists comprehensive covering input, process and output indicators and could be used for monitoring.
• Visits- In RMNCH+A, One District monitor visits two-three facilities a day. In QA a four member DQAT visits 10-15 facilities a month. Visits more meaningful.
Could the two be clubbed and District Monitors become part of DQA Group?