Quality Assurance for RH services Maharashtra

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”

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

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.

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.

Quality Assurance Process

Internal and external users

Monitor

Find Gaps

Prioriti

ze an

d

sugge

st so

lutions

Implement

Reassess

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

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

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

Type of Health Facilities covered

SDH/RH PHC Sub Center0

100

200

300

400

500

600

700

209

593

429

Number

Number

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

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

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

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

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

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.

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.

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

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

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

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

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.

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

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.

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.

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

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

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

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.

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?