Overview of Quality at

PHCs – HWCs

Transforming Comprehensive Healthcare in India

 Journey of Quality
• Quality in healthcare in India came with the introduction of RCH in 1997.
• 12th Five Year Plan ( 2012- 17 ) observed that “ Quality of Healthcare” services
varies considerably in both the public and private sector.
• National Health Mission was launched in the year 2005 with the mission of
improving the availability of and access to quality healthcare by people ,
especially the people residing in the rural areas , women and children.
• The Watershed moment in the quality improvement initiative came in March 2005
, when the honorable supreme court , in Ramakant Rai and Health Watch UP and
Bihar Vs Union of India directed all states to set up quality assurance committee
( QAC ) for Family Planning Services at State and District Level .

Transforming Comprehensive Healthcare in India

 Quality in General
• Quality is the degree of adherence to pre-determined standards.

• Quality is Minimizing variations.

• Quality is Standardization.

• Quality is Meeting and Surpassing the Customer Expectations

• Quality is Doing Right Things, in Right Way, First Time & Every
time.

Transforming Comprehensive Healthcare in India

 Quality in Healthcare
EFFECTIVENESS Achieving outcomes as desired by doing right things.

EFFICIENCY Relates to maximizing the quality of health care delivered or health

benefit achieved for a given unit of health care resources used.

EQUITY Relates to providing health care of equal quality to those who may differ
in personal characteristics

PATIENT CENTEREDNESS Relates to meeting patients' needs and preferences.

SAFETY Avoiding harm to patients from care that is intended to help them

TIMELINESS Relates to obtaining needed care while minimizing delays.

Transforming Comprehensive Healthcare in India

Why

Transforming Comprehensive Healthcare in India

Dimensions of Quality
Dr Avedis Donabedian (1919-2000)

Structure

QUALITY

Process Outcomes

Transforming Comprehensive Healthcare in India

 Measurement System Under NQAS

Broad themes for assessing aspects of

Area of Concern Quality
Statement of Requirement
Standards
Statement of requirement for Standard
Measurable Elements

Checkpoints Specific requirement of Standard & ME

Checklists Tangible measurable checkpoints

Transforming Comprehensive Healthcare in India

 For Primary Health Centers
 8 Area of Concern
 50 Standards
 247 Measurable Elements
 Check Points divided into 6 Checklist
• OPD
• IPD
• Labor Room
• Laboratory
• National Health Programs
• General Administration

Transforming Comprehensive Healthcare in India

Relationship Between Different
Components

Departmental
Checklists

Checkpoint
Measurable
Elements
Score
Standard
Checkpoint card
Departmental &
Area of Hospital
Concern Checkpoint
Measurable
Elements
Standard
Checkpoint

Transforming Comprehensive Healthcare in India

 SERVICE
PROVISION

Outcome

Outcome Process

A
Management
Quality Area of
G Structure
Process Concern C

E
Process Process
Process

CLINICAL

SERVICES
Transforming Comprehensive Healthcare in India
 National Quality Assurance Standards
(Areas of Concern)
Service Provision Patient Rights Inputs
Inputs Support Services

Clinical
Wellness &Clinical Infection Control Quality Outcome
Outcome
Care Management

Transforming Comprehensive Healthcare in India

Certification Criteria
1. Aggregate score of the health facility- ≥ 70%
2. Score of each service package of the health facility (minimum 7 packages)- ≥ 70%
3. Segregated score in each Area of Concern- ≥ 60%
4. Score of Standard - ≥60%
a. Standard A1- The facility provides Comprehensive Primary Healthcare Services
b. Standard D3- The facility has defined and established procedure for clinical records and
data management with progressive use of digital technology
c. Standard D4- The facility has defined and established procedures for hospital transparency
and accountability.
d. Standard D5- The facility ensures health promotion and disease prevention activities
through community mobilization
e. Standard G2- The facility has established system for patient and employee satisfaction
5. Individual Standard wise score- ≥ 50%
6. Patient/client Satisfaction Score - 60% or Score of 3.0 on Likert Scale, separately

Transforming Comprehensive Healthcare in India

Certificates and SOPs required for NQAS
• Patient Satisfaction Surveys ( Last 3 months )
• CAPA ( Corrective and Preventive Action ) of lowest performing attributes
• Minutes of Quality Circle team meeting .
• Quality Policy
• Quality Objectives
• Fire Audit and Mock drill certificate
• Referral Policy.
• SOP Communicable and Non Communicable Diseases
• SOP Infection Control and BMW Management
• SOP Rapid Diagnostic Kits ( RDKs )
• Key Performance Indicators ( KPIs ) ( Last 3 Months )
• Authorization from State Pollution Control Board For Deep Burial and Sharp Pit .
• Health Check up record of all the Staff .

Transforming Comprehensive Healthcare in India

Area of Concern A (Service Provision)

• The facility provides

Standard A1 Comprehensive Primary
Healthcare Services

• The facility provides drugs &

Standard A2 diagnostic services as
mandated

Transforming Comprehensive Healthcare in India

Standard
The facility provides Comprehensive Primary Healthcare Services
A1

Child & Family planning

Pregnancy & Child Neonatal & Infant
Adolescent Health Health Services
birth Services Health Service
Service

Communicable Non
Acute Simple Common Eye
Diseases under Communicable
illness & minor ailments
NHP Diseases under
ailments
NHP

Common ENT Emergency

Oral Health Elderly & Palliative
ailments Medical Care- incl.
Aliments Care
trauma & burn

Screening & Health Promotion

Management of & wellness
Mental illness activities
Transforming Comprehensive Healthcare in India
Standard The facility provides drugs & diagnostic services as mandated

A2

Laboratory Drug dispensing &

Services medicine refills

Transforming Comprehensive Healthcare in India

 Area of Concern B (Patients’ Rights )
Standard B1- The facility provides information to the care-seeker, attendants and
community about available services & their modalities

Standard B2 - Facility ensures that the services are accessible to the care-seekers and
visitors including those requiring some affirmative action

Standard B3 -The services are delivered in a manner that are sensitive to gender, religious &
cultural needs of beneficiaries and there is no discrimination on account of economic or social
reasons.

Standard B4- The facility maintains privacy, confidentiality and dignity of patients

Standard B5- The facility ensures all services are provided free of cost to its user

Transforming Comprehensive Healthcare in India

Standard
B1 The facility provides information to the care-seeker, attendants and community about available services & their modalities

Display of services Sensitization & Information

Entitlements & Education thr’ IEC Share- treatment
HWC Branding &BCC & Entitlements

Standard Facility ensures that the services are accessible to the care-seekers
B2 and visitors including those requiring some affirmative action

Accessible from Accessible by

Physical Barrier &
community & vulnerable &
disable friendly
Referral Centre Marginalized

Transforming Comprehensive Healthcare in India

 Area of Concern C- Inputs
Standard C1: The facility has adequate and safe infrastructure for delivery of assured
services as per prevalent norms and it provides optimal care and comfort to the users

Standard C2: The facility has adequate qualified and trained staff, required for
providing the assured services as per current caseload

Standard C3: Facility has a defined and established procedure for effective utilization,
evaluation and augmentation of competence and performance of staff

Standard C4: The facility provides drugs and consumables required for assured
services

Standard C5: Facility has adequate functional equipment and instruments for assured list of services

Transforming Comprehensive Healthcare in India

Standard The facility has adequate and safe infrastructure for delivery of assured services as per prevalent norms and it provides optimal care and comfort to the users

C1

Infrastructure, Safety – Physical, Information ,

space & amenities electrical & fire communication &
technologies

Standard The facility has adequate qualified and trained staff, required for providing the
C2 assured services as per current caseload

Front Health
Availability of CHO workers & support Duty Roster for
staff Staff

Transforming Comprehensive Healthcare in India

Standard Facility has a defined and established procedure for effective utilization,
C3 evaluation and augmentation of competence and performance of staff

Competence & Training plan &

Performance training as per
Evaluation competencies

Standard The facility provides drugs and consumables required for assured
C4 services

Availability of Availability of
Drugs consumables

Standard The facility provides drugs and consumables required for assured
C4 services
Availability of Availability of
Equipment & furniture &
instruments Fixtures
Transforming Comprehensive Healthcare in India
 Area of Concern D - Support Services
Standard D1: The facility has established programme for maintenance and upkeep of the
facility

Standard D2: The facility has defined procedures for storage, inventory management and dispensing of
drugs

Standard D3: The facility has defined and established procedure for clinical records and data
management with progressive use of digital technology

Standard D4: The facility has defined and established procedure for the transparency and
accountability.

Standard D5: The facility ensures health promotion and disease prevention activities through
community mobilization

Standard D6: The facility is compliant with statutory and regulatory requirement

Transforming Comprehensive Healthcare in India

Standard The facility has established programme for maintenance and
D1 upkeep of the facility

Infrastructure &
Sanitation &
equipment
Hygiene
Maintenance

Standard Facility has defined procedures for storage, inventory

D2 management and dispensing of drugs
Estimation & Management of
Storage of drugs &
indenting of drugs Expiry & near
consumables
& consumables expiry of drugs

Standard The facility has defined and established procedure for clinical records and
D3 data management with progressive use of digital technology
Pt. Information Safe storage, and Consultation using
recorded & retrieval of telemedicine
updated in IT records Transforming Comprehensive Healthcare in India
Standard The facility has defined and established procedure for the
D4 transparency and accountability.
Supporting &
Jan Aarogya Community Based
monitoring of
Samitis- activities monitoring
CHW

Standard The facility ensures health promotion and disease prevention

D5 activities through community mobilization
Planning &
implementation Patient Support Multisectoral
of Community groups Convergence
interventions

Standard
Facility is compliant with statutory and regulatory requirement
D6

Transforming Comprehensive Healthcare in India

 Area of Concern E- Wellness & Clinical
Services
Standard E1: The facility has defined procedures for registration, consultation, clinical
assessment and reassessment of the patients

Standard E2: The facility has defined and established procedures for continuity of
care through two-way referral

Standard E3: The facility has defined and established procedure of diagnostic services.

Standard E4: The facility has defined procedure for safe drug administration.

Standard E5: The facility follows standard treatment guidelines and ensures rational use of
drugs

Transforming Comprehensive Healthcare in India

 Area of Concern E- Wellness &Clinical
Services
Standard E6: The facility has defined and established procedure for nursing care

Standard E7: The facility has defined and established procedure for emergency
care

Standard E8: The facility has defined & established procedure for management of
Ophthalmic, ENT, Oral aliments as per operational/ clinical guidelines

Standard E9: The facility has defined & established procedures for screening & basic
management of Mental health aliments as per operational/ clinical guidelines.

Standard E10: The facility has defined & established procedures for management of
communicable diseases as per operational/ clinical guidelines

Transforming Comprehensive Healthcare in India

 Area of Concern E- Wellness & Clinical
Services
Standard E11: The facility has defined & established procedures for management of
non-communicable diseases as per operational/ clinical guidelines

Standard E12: Elderly & palliative health care services are provided as per
guidelines

Standard E13: The facility has established procedure for care of new-born, infant and
child as per guidelines

Standard E14: The facility has established procedures for family planning as per
government guidelines and law.

Standard E15: The facility provides Adolescent Reproductive and Sexual Health services
as per guidelines.

Transforming Comprehensive Healthcare in India

Area of Concern E- Wellness &Clinical
Services
Standard E16: The facility has established procedures for Antenatal as
per guidelines

Standard E17: The facility has established procedure for intranatal

care as per guidelines

Standard E18: The facility has established procedure for post-natal Care

Transforming Comprehensive Healthcare in India

Standard The facility has defined procedures for registration, consultation,
E1 clinical assessment and reassessment of the patients

Empanelment & Registration in

registration of HWC for routine Follow up/
Indiv. & families care Reassessment

Standard The facility has defined and established procedures for continuity of
E2 care through two-way referral

Procedure for
Procedure for
Referred in &
Continuity of care
referred out cases

Standard The facility has defined and established procedure of diagnostic

E3 services.
Transforming Comprehensive Healthcare in India
Standard
The facility has defined procedure for safe drug administration
E4
Identification &
Protocols for safe
cautious
drugs
administration of
administration
High alert drugs

Standard The facility follows standard treatment guidelines and ensures

E5 rational use of drugs
Periodic
Rational use of Monitoring of the
drugs treatment/care
given by CHO

Standard The facility has defined and established procedure for nursing care.
E6
Identification &
Follow prescribed Use of forms,
periodic
treatment plan formats & records
monitoring of Pat Transforming Comprehensive Healthcare in India
Standard The facility has defined and established procedure for
E7 emergency care

Use of Emergency Disaster

Protocols management plan

Standard
The facility has defined & established procedure for management of Ophthalmic, ENT,
E8 Oral aliments as per operational/ clinical guidelines

Ophthalmic
aliments incl. ENT Aliments Oral Aliments
refractive errors

Standard The facility has defined & established procedures for screening & basic
E9 management of Mental health aliments as per operational/ clinical guidelines

Transforming Comprehensive Healthcare in India

Standard
The facility has defined & established procedures for management of communicable
E10 diseases as per operational/ clinical guidelines

National Vector National TB

Borne disease National Leprosy
elimination
Control Program Eradication
Program
Program

AIDS Control National Viral Integrated disease

Program Hepatitis Control Surveillance
Program Program

Transforming Comprehensive Healthcare in India

Standard
The facility has defined & established procedures for management of Non
E11 communicable diseases as per operational/ clinical guidelines

Hypertension Diabetes Cancer screening

& referral

De addiction &
other locally Promotes health
prevalent diseases & Wellness

Standard
Elderly & palliative health care services are provided as per guidelines
E12

Elderly Care Palliative Care

Transforming Comprehensive Healthcare in India
Standard The facility has established procedure for intranatal care as per
E17 guidelines

Management of Routine care of Primary

Stages of Labour newborn management &
including AMTSL immediately after referral of Obst.
birth emergencies

Standard
The facility has established procedure for post-natal Care
E18

Post partum care Postnatal visits &

to mother counselling of
mother & baby

Transforming Comprehensive Healthcare in India

 Area of Concern F- Infection Control

Standard F1: The facility has established program for infection prevention and control

Standard F2: The facility has defined and Implemented procedure for ensuring
hand hygiene practices

Standard F3: The facility ensures standard practices and equipment for personal
protection

Standard F4: The facility has standard procedure for disinfection and sterilization
equipment and instruments

Standard F5: The facility has defined and established procedure for segregation,
collection, treatment and disposal of General, Bio-medical and hazardous waste

Transforming Comprehensive Healthcare in India

Standard The facility has defined and established procedures for
F5 segregation, collection, treatment and disposal of Bio Medical and
hazardous Waste.

Segregation and Management of Hazardous waste

Storage of BMW Sharp waste management

Transportation
and Disposal of
waste

Transforming Comprehensive Healthcare in India

Area of Concern G- Quality Management
System
Standard G1: The facility has established organizational framework for quality
improvement

Standard G2: The facility has established system for patient and employee satisfaction

Standard G3: The facility has established, documented, implemented and updated
Standard Operating Procedures (SOPs) for all key processes and support services

Standard G4: The facility has established system of periodic review of clinical,
support and quality management processes

Standard G5: The facility has defined Mission, Quality policy and Objectives, and has a
plan to achieve them

Transforming Comprehensive Healthcare in India

Standard The facility has established system of periodic review of clinical,
G4 support and quality management processes

Handholding Non-Compliance
Periodic internal and PDCA
support and
assessment Approach
supervision

Transforming Comprehensive Healthcare in India

 Area of Concern H - Outcome

Standard H1: The facility measures productivity indicators

Standard H2: The facility measures efficiency indicators

Standard H3: The facility measures clinical care indicators

Standard H4: The facility measures service quality indicators

Transforming Comprehensive Healthcare in India

Incentives
For a facility to apply for the state and national certification it is mandatory to apply at least for the following 7 packages:

1. Care in pregnancy and child-birth.

2. Neonatal and infant health care services.

3. Childhood and adolescent health care services.

4. Family planning, Contraceptive services and other Reproductive Health Care services.

5. Management of Communicable diseases including National Health Programmes.

6. Management of Common Communicable Diseases and Outpatient care for acute simple illnesses and minor ailments

7.Screening, Prevention, Control and Management of Non-Communicable diseases..

An incentive of Rs. 18000/- per package per year will be awarded on attainment of National certification and its
maintenance in subsequent years and annual submission of surveillance report.

Transforming Comprehensive Healthcare in India

Model for Quality Improvement
PLAN A CHANGE DO
CHECK
FORMULATE A PLAN FOR IMPROVEMENT-SET GOLAS, IMPLEMENT THE PLAN EVALUATE RESULTS
TARGETS & METHODS FOR IMPROVEMENT EDUCATE/TRAIN MODIFICATIONS NEEDED
ACT
IMPLEMENT PLANNED CHANGES
NOT SUCCESSFUL, REWORK CYCLE

Transforming Comprehensive Healthcare in India

 If you can’t measure something , you can’t understand it . If you
can’t understand it , you can’t control it . If you can’t control it you
can’t improve it .

Transforming Comprehensive Healthcare in India

Thank You

Transforming Comprehensive Healthcare in India