Institutionalization of Quality Assurance Program in District Health Management

Anurag Mishra, M E Khan, and Vivek Sharma FRONTIERS Program,

Population Council, New Delhi

January 30, 2008

Contents

1. Overview of Quality Assurance

2. RCH QA Mechanism

3. QA Experience from Gujarat

4. On going QA Activities in Six States

5. Lessons Learned

6. Place of QA for ARSH

Need for Developing QA Program Globally many tools are available to assess quality of

RH services

Many have been adapted and tested in India

Most have been found too specific to a particular area

of care, or too cumbersome and time consuming to

institutionalize in Indian health care delivery system

They were used for periodic assessments and not

institutionalized with health systems

A comprehensive operational manual covering RCH

components in public health setting was considered

critical to move forward

Development of Checklists and Manual

Checklists and manual were developed- To demonstrate feasibility of

institutionalization of QA systems at district level management

To improve RH Services provided at CHC/PHCs and Sub-centers

To provide a quality improvement model to states that could be replicated and scaled up

RH Quality Framework for Assessment

RH 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

Maternity Care ANC/PNC attendance Normal Deliveries Complications

managed

RTI/STI &

HIV -VCT

Lab tests Case treatment Follow-up

Quality of Care Elements

The manual identifies nine key elements to measure the quality of services -

Five generic elements Four service specific elements

Generic ElementsGeneric elements include – Service environment – infrastructure, basic amenities, clients

comfort, privacy etc. Client provider interaction - nature of provider – client

relationship and information exchanged between them

Informed decision-making - availability of relevant information and service procedures that facilitate informed choice by client

Integration of services - linkage of services and health institutions

Women’s participation in management –Women participation in planning, implementation and monitoring of RH services

Service Specific Elements

Service specific elements include – Access to services – Location, distance, timing of facility,

affordability in terms of travel cost, lost wages etc. Equipment and supplies - Equipment of standard specifications

are available? In working order? Sufficient supplies available? Professional standards and technical competence – providers

competent? Service guidelines/protocols available? Service standards established?

Continuity of care – clients follow up regular and effective? Side effects/complications managed? MIS designed and maintained?

QA Tools/Checklists

Guiding Principle Practical: Possible to complete within 2-3 hrs by 2-3 people

Specific: Critical to assess functionality of services

Independent: Stand alone assessment

Feedback: Could be provided it immediately to facility MOs

Transparent: Prior awareness of visit & criteria for

assessment by QA team

Sensitive: Improvements and change quantified

Contents

1. Overview of Quality Assurance

2. RCH QA Mechanism

3. QA Experience from Gujarat

4. On going QA Activities in Six States

5. Lessons Learned

6. Place of QA for ARSH

Institutional Arrangements

District Health Mission

DQAG (12-15 members)

Nodal Officer

DQAG Teams

State QA Nodal Officer

State Health Mission

2-3 members

DCMO/ADHO/RCHO

DHO/CMO(Chairperson)

Setting up QA Mechanism

The QA Program recommends the following steps: The State should assist districts to setup a QA unit within DPMU The DQAG should consist of 12 to 15 members CDHO will be the Chair of DQAG A team of 2-3 members will make a QA visit Each QA team will visit 3 to 4 facilities per month Review gaps and actions in monthly DQAG meeting District health management should provide all logistic support to

DQAG including POL for visits, computer, office space, stationary etc.

District health Society/Mission should supervises the QA activities Allocate resources in DPIP for actions identified by DQAG

QA visit to CHC/PHC/SCThe QA manual recommends the following planning for QA visit:

Each participating facility should be visited bi-annually

Prepare bi-annual visit plan, share it with DQAG members and

facility MOs.

Confirm availability of facility MO and QA team members at least

one day before the visit

Predefine and divide the assessment work at facility

Debrief the facility MO about assessment and prepare action plan

Within a week after visit, enter visit data, prepare summary report

and place it before CDHO/CMO

During Second Visit to Same Facility

Review gaps and actions of previous visit with MO I/C

Contents

1. Overview of Quality Assurance

2. RCH QA Mechanism

3. QA Experience from Gujarat

4. On going QA Activities in Six States

5. Lessons Learned

6. Place of QA for ARSH

Baseline Survey

Grade C84%

Grade A0%

Grade B8%Grade D

8%

II - Quarter Visit

Grade A50%

Grade C0%

Grade D0%

Grade B50%

Grade A75%

Grade B25%

Grade C0% Grade D

0%

Four Quarter QA visits in Dahod

Grade = ScoreA = 76+%B = 51-75%C = 26-50%D = 1-25%

Grade A77%

Grade B23%

Grade C0%

Grade D0%

III - Quarter VisitIV - Quarter Visit

N=13

N=20

N=20

N=22

Change in Input Scores

0

25

50

75

100

Devga

rh B

aria

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Piplod

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Jesa

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Mira

khed

i

Bandi

war

Bordi

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a ©

Gamdi

Kanje

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Petha

pur ©

Gagar

di

Sevan

iya

Timar

da

Fatep

ura

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Limkh

eda

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Vansiy

a

Chhap

arwad

a

Mar

gala

Dunga

r

Man

dor

Pe

rce

nt

BL QAV-2 QAV-3

Selected MCH Process Indicators

75

8590

7580

90

5560 60

45

55

65

0

25

50

75

100

QA-1 QA-2 QA-3

per

cen

t

ANC cards available and filledDelivery record shows any normal delivery and complicationsAny delivery performed between 8pm and 8am at the facilityAny low birth weight baby kept for 24 hours observation

90 90

23

85

95

15

35

20

85

0

25

50

75

100

QAG-1 QAG-2 QAG-3

per

cen

t

FW records show OCP usage and new acceptance

Any IUD inserted at the facility in last 3 months

Any IUD acceptors screaned for STI with a lab test

Selected FP Process indicators

QA Scale-up in Gujarat

Commissioner and Secretary of Health appreciated the program and decided to scale-up in entire state

Scale-up in all 25 districts was planned in phased manner

A State Nodal Officer appointed to coordinate QA activities

QA budget allocated separately in state PIP Decentralized approach suggested. Block level QA

teams constituted and trained to conduct QA visits FRONTIERS Program provided TA in scale-up

Scale-up Coverage

1072 PHCs and 272 CHCs covered in entire state

128 state and regional level officials oriented

2261 providers of different level trained, including– 38 District Program Coordinators and M&E Assistants

263 DHOs, ADHOs and BHOs

593 Block Health Visitors and Block IEC officers

1234 CHC/PHC Medical Officer In-charges

5 District statistical Assistants

Contents

1. Overview of Quality Assurance

2. RCH QA Mechanism

3. QA Experience from Gujarat

4. On going QA Activities in Six States

5. Lessons Learned

6. Place of QA for ARSH

QA Pilot in Six States

As part of NRHM, slightly modified version of

QA checklists is being piloted by MoHFW in 7

districts of six states of India

Population Council is providing TA in one

district each of Maharashtra and Karnataka.

UNFPA is providing financial and technical

inputs for piloting in these states

Current Status 80 and 100 QA visits have been completed during first

round in A’nagar, Maharashtra & Tumkur, Karnataka.

Both input and process elements have shown

significant service delivery gaps

On an average 28 and 43 actions have been identified

at CHC/PHCs of A’nagar and Tumkur districts

A mechanism to review gaps and initiate actions has

been established in both the districts

61 percent and 43 percent of actions have been

executed so far in A’nagar and Tumkur districts

Typical Examples of Gaps Observed

At CHC/PHC Training of providers in EmOC, RTI/STI, partograph use Non-adherence of maternal and immunization service standards Shortage of important equipmentsAt Sub-centers No display of citizen’s charter and other information Poor waste management practices Poor knowledge of IUD, OCP and ECP among ANMsCommon to all Short supply of medicines and contraceptives Poor infection prevention practices Poor maintenance of facilities No proper updating of records Non-availability of protocols and jobs-aids

Examples of Input Indicators - CHC/PHC

Input IndicatorsPercentage

A’nagarn=40

Tumkurn=34

A doctor trained in EmOC 63 21

A separate labor/delivery room 72 56

Complete delivery kit with scissor/blades, cord ties/clamps and forceps available

92 85

Oxygen cylinder with tubing and wrench and disposable masks available in working order

73 21

Proper waste disposal arrangements 70 59

All essential drugs for active mgmt of infections/ complications in pregnancy

13 0

RTI/STI – management protocols available 25 18

Normal delivery guidelines available 58 53

Examples of Process Indicators Observed- CHC/PHC

Process IndicatorsPercentage

A’nagar Tumkur

OCP usage and new acceptance records are maintained in last 3 months

45 (40) 79 (34)

Client Counseled on how method works 56 (34) 69 (13)

Women screened for signs of anemia 61 (36) 61 (23)

ANC women counseled on danger signs 29 (35) 40 (23)

Measels vaccine being administered at 9-12 months of age

63 (33) 63 (32)

Records show children are managed for RTI 35 (40) 40 (34)

Temperature record card maintained and updated

89 (37) 88 (33)

Providers wore gloves when required 68 (23) 79 (21)

Figures in bracket show the denominator

71

61

7671

57

69

86 89 92

7984 80

0

25

50

75

100

Facility 1 Facility 2 Facility 3 Facility 4 Facility 5 Facility 6

Per

cent

First QA visit

Second QA visit

Preliminary assessment of QA Impact – Ahmadnagar

Contents

1. Overview of Quality Assurance

2. RCH QA Mechanism

3. QA Experience from Gujarat

4. On going QA Activities in Six States

5. Lessons Learned

6. Place of QA for ARSH

Lessons Learned

QA checklists considered useful in monitoring and improving

quality of services

QA could be institutionalized within district health

management

Greater state’s stake is required to resolve problems such as

frequent rescheduling of QA visits, delayed initiation of

district/state level actions etc.

Mechanism for monitoring actions need to be strengthened

Beside inputs focus should be put to address process gaps

TA for capacity building of districts/state required until it

migrates from project to program mode

Contents

1. Overview of Quality Assurance

2. RCH QA Mechanism

3. QA Experience from Gujarat

4. On going QA Activities in Six States

5. Lessons Learned

6. Place of QA for ARSH

Possibilities for Including ARSH Services in QA

QA checklists already include many indicators which have been

considered crucial under seven standards of ARSH strategy

AFCs will be an activity by same facility and human resources.

However, infrastructure and services such as ARSH training, IEC

material, outreach programs for community awareness need to

be ensured.

Extending role of DQAG by including more people seems more

feasible and cost-effective than making AFC QA a stand alone

program.

However, AFC QA project should be first piloted separately to

finalize QA tools and assess their usefulness.

Thanks

FRONTIERS Program

Population Council

53 Lodi Estate, New Delhi – 110 003

Tel: 24610913/E-mail: frontiers@popcouncil.org