A Success Story

Quality Improvement Programme- Gujarat, India

“Setting high standards (NABH for PHC / CHC) of services and continued improvement,

showing high leadership qualities and improving employee motivation etc”

Department of Health & Family Welfare

Govt of Gujarat, India

Introduction:

There is now a growing recognition of the need for quality of care in Health programmes. A part of reason for

poor quality services in the Health services lies in limitations in the public systems such as limited capacity, lack

of programme standards and guidelines, and an obsession with quantified targets rather than client satisfaction.

Quality Council of India already has the National Accreditation Board for Hospitals and Health Care Providers

(NABH) and National Accreditation Board for Testing and Calibration Laboratories (NABL) Standards for

Hospital, Blood Bank & Laboratories.

The Department of Health & Family Welfare, Government of Gujarat has identified quality health services and

the efficiency of Government managed Primary Health Centre & Community Health Centre as key contributors

for building trust and confidence for the Primary Health Centre & Community Health Centre in the hearts of the

citizen of the state though the actively pursuing quality improvement programme in these facilities as per the

National Accreditation Board for Hospitals and Health Care Providers (NABH). NABH Standards for PHC /

CHC was prepared by Government of Gujarat with the help of Quality Council of India. Primary Health

Care services are important elements of any well ordered and humane society for preventive, promotive and

curative services and will indisputably would play key role in nurturing of society hence health care centre

should be a place of safety not only for the staff but for the patients and General public because patients are of

greatest importance. As a result of inception of quality management systems we have achieved an organized

manner to provide patient care with their safety, thus respecting their rights and responsilities and obtaining

their valuable feedback for improvement in services. The system has enabled the Primary Health Centre to

demonstrate commitment to quality care. The dimensions of patient care has elaborated in concept ,every

patient coming to the Primary Health Centre is receiving uniform care, patients are well informed for what they

will be going through. The system has incorporated changed practices, for patients. NABH Standards are as

follows:-

NABH Standards for Primary Health Center (PHC) / Community Health Center (CHC)

S. No. Section Standards Objective Elements (PHC) Objective Elements (CHC)

1 Infrastructure standards 7 61 63

2 Process standards 13 102 103

3 Governance standards 12 49 49

4 Outcome standards 6 21 21

Total 38 233 236

SECTION – A: Infrastructure Standards (Total objectives Elements for PHC 61 & CHC 63)

Improve Physical Facilities (Total objectives elements 15)

Proper Functional Plan (Total objectives elements 6 CHC & 4 PHC)

Maintenance, proper functioning and utilization of the Equipments and Instruments (Total objectives

elements 8) Human resource management e.g. Man Power requirement & skill development of the Staffs (Total

objectives elements 9) Management of medication e.g. Inventory of Drugs. (Total objectives elements 11)

Proper & Safe Transportation and having Acute Cardiac care life support (ACLS) / Basic Cardiac care Life

support (BCLS) Ambulances. (Total objectives elements 7)

Using the best presently available technology for Communication. (Total objectives elements 7)

SECTION – B: Process Standards (Total objectives Elements for PHC 102 & CHC 103)

Easy Access to the patients / Community. (Total objectives elements 3)

Adequate & skilled staff should be Available 24 hrs X 7. (Total objectives elements CHC 7 & PHC 6).

Evaluation of the Patients through the patient feedback & suggestions. (Total objectives elements 8)

Quality Care of patients. (Total objectives elements 18)

Page 1-10

Infection Control in our health care facilities. (Total objectives elements 15)

Proper & safe biomedical waste practice. (Total objectives elements 10)

Improvement in Sanitation, Hygiene and Potable Water facilities. (Total objectives elements 7)

Proper Counseling and IEC as per requirement and area specific. (Total objectives elements 6)

Mainly focused on the Preventive Health care services. (Total objectives elements 10)

Best implementation of all National Health Programs (Total objectives elements 3)

The center shall practice a bi-directional or standardized referral system. (Total objectives elements 5)

Continuous Community Mobilization though interaction with the PRI. (Total objectives elements 5)

Social Responsibility by creating a sense of ownership of the facility by the community. (Total objectives

elements 6)

SECTION – C: Governance Standards (Total objectives Elements for PHC 49 & CHC 49)

Ownership of Building. It shall have the approved building plan along with sanction from the local

authorities. (Total objectives elements 3)

Quality Assurance practice & monitoring by implementing Standards operating procedures at various

patient care area and Safety of patients and staff should be considered. (Total objectives elements 4)

Rights and Responsibility of patients. The rights of the patients as a consumer have to be respected and

displayed e.g. right to choose, right to deny, right to gather information etc. (Total objectives elements 9)

Responsibilities of staff by a mechanism for grievance redressal to be in place and practiced. (Total

objectives elements 5) Provide Skill based Training with evaluation and Motivation of staff (Total objectives elements 8)

Surveillance of ANMs, LHVs and other workers through the feedback mechanisms to exist so as to assess

the visits of the above workers in the community. (Total objectives elements 7)

Public private partnerships with involving a private provider for scavenger services

Pricing and services e.g. Patients to be informed about the charges. (Total objectives elements 3)

Community Based Health Insurance thro a co-operative approach to exist so as to cater to the requirements

of the patients. (Total objectives elements 4)

License and Statutory requirements concerning patient and staff safety and welfare shall be met by the

facilities e.g. Narcotics, waste management, BARC, AERB, fire safety etc as applicable. (Total objectives

elements 2) Respect for local social customs to be given by the organization. (Total objectives elements 2)

Centre to provide appropriate respect and dignity to the dying and the dead. Centre should carry out Death

Audits periodically. (Total objectives elements 4)

SECTION – D: Outcome Standards (Total objectives Elements for PHC 21 & CHC 21)

Facility to record & monitoring all parameters on the basis of Utilization of services e.g. OPD, IPD, labor

room, Man power, laboratory services, Referral services, etc to be analyzed and maintained for continuous

quality improvement. (Total objectives elements 2)

Statistics in terms of OPD attendance, BOR, ALOS, BTO, birth rate, death rate, and minor and major

operations etc. to be documented and reported. (Total objectives elements 2)

Reporting & registration of birth, death and other details (Total objectives elements 4)

Medical Records shall be provisions for storing and retrieval of the records. (Total objectives elements 6)

Patient & Employees Satisfaction survey, by feedback mechanism like use of feedback forms, suggestion

forms to be dropped in suggestion/complaint boxes at identified places. (Total objectives elements 4)

Health Information system, Reporting of all the details e.g. IMR, MMR, Birth rate, Death rate etc through a

web based health information system. (Total objectives elements 3)

MISSION:

To finalized the NABH standards for PHC / CHC and provide Quality Health care services continuously with

appropriate technology with community participation in an atmosphere of confidentiality & privacy at a cost of

the community / country afford. Page 2-10

VISION:

Increase the credibility of the Govt. Healthcare organization through world class standards of accreditation.

PROJECT OBJECTIVES:-

Finalization of the NABH standards for Primary Health Center / Community Health Center.

Implementation of safety and quality practices.

Incorporation of management tools

Building sustainability

Benchmarking the indicators

Continuous Quality Improvement

To provide 24 hours quality services to the community

To give patient care as per standard treatment guideline

To ensure safety of patients & employee

To give satisfaction to patients & employee

Strategies adopted /mode of transformation with details of role of various stakeholders:

Finalized the NABH standards for CHC & PHC with the help of QCI and Sensitization of state government

towards importance of quality healthcare services.

Policy framework for NABH accreditation of Primary Health Center / Community Health Center.

Approval and sanction of budget for NABH accreditation / certification.

MOU signed between Government of Gujarat and Quality Council of India, New Delhi on 7th July, 2007.

Involvement of staffs (by Skill Mapping & Motivation)

State, Regional, District & Facility authorities were tour to NABH accredited hospitals & Labs.

Study Mission to Nonmember Countries on the Application of Quality Management in Healthcare to USA.

Nomination of qualified District Quality Assurance Officers at district level,

Development, Review and Implementation of policies and procedures for implementation of Quality

Management system (NABH).

Development of committee with scope of work as per requirement (e.g. Quality Assurance Committee for

implementation of the NABH standards). Objective oriented role and responsibility of all committee members are defined and trained.

On-site study to analyze the prevalent status and practices to identify gaps (Infrastructure, Equipment,

Documentation, Processes and Practices) were executed.

NABH lead assessor training to administrators, clinicians, paramedical & staff nurses etc.

Distance learning Post Graduation Certificate Course in Quality Management and Accreditation of Health

care Organization (PGQM & AHO) to state level, Regional level, District level, Block level and facility

level officers.

Other training as per requirement of NABH / NABL standards (e.g. Standards & objectives of NABH,

Infection control, biomedical waste management, Job chart, Basic life support, Fire safety, Disaster

management, Policies & Procedure etc.

Quality manual and mock drills.

MOU for Accreditation of the

hospitals & Laboratories as

per NABH / NABL (7/7/07)

MOU for Accreditation of the

CHCs & PHCs as per NABH

(13/1/09 in Vibrant Gujarat)

Page 3-10

Development, Review and Implementation of policies and procedures.

Defining, monitoring & evaluating the Quality Indicators

Development of Quality Management System (e.g. Patient / Employee Satisfaction, Clinical Record

Indicators and quality indicators etc )

Up gradation of facility as per requirement e.g. Infrastructure, Human resource, equipments & training.

Calibration and testing of medical equipments.

Required civil construction work / structural re-allocation of health departments was done by program

implementation unit (PIU), hired architect along with the assistance of NABH/NABL consultants.

Hospital compliance to the license, statutory acts & regulatory norms of the state.

Intensive & continuous trainings

Regular Process Monitoring

Internal assessment by quality team and fulfilled the identified gaps.

Application for Pre – assessment to NABH.

Pre-assessment done by the NABH / NABL assessors form NABH Board.

Gaps identified during NABH pre – assessment are fulfilled.

Application for Final – assessment to NABH.

Final audit done by NABH / NABL assessor form NABH Board.

Gaps identified during NABH Final – assessment is fulfilled and reports send to NABH Boards & NABH /

assessor.

Review the report in NABH board meeting and finally give the accreditation after discussion on the report.

Accreditation of the facility as per NABH standards.

PRACTICES IMPLEMENTED:

Patient satisfaction survey.

Employee satisfaction survey.

Develop and implement the Clinical protocols

Develop and monitoring of the Quality Indicators

Implement Code alerts during emergency as per below e.g.

RED for FIRE,

YELLOW for EXTERNAL CALAMITIES,

BLUE for CARDIAC ARREST,

BLACK for BOMB THREAT,

PINK for CHILD ABDUCTION

Disaster Preparedness Plan.

Basic Infection Control Practices.

Implementation of Patient Rights & Responsibilities.

Management of Medication.

Facility Management Practices.

Incidence Reporting System.

Hospital Safety Programme.

Patient Information. Continuous monitoring & evaluation of program me Page 4-10

Monitoring by PRIs

Satisfaction survey

Verification of activities

Verification of field visits

Inventory Management.

Quality Control & Safety in diagnostics.

Purpose and priorities of the initiative:

Quality health care to improve health infrastructure of state (Primary Health Centre (PHC) & Community

Health Centre (CHCs) after assess the existing service delivery standards, suggest & implement structural

alternations and to identify the baseline level of all quality indicators and meet the healthcare needs as per

national healthcare quality standards.

To develop healthcare standards based on total quality management principles.

To lay down all documentation and implementation of Apex Manual, Master Document, Policy Documents

and SOP’s at facility level.

To enhance the quality of healthcare services by providing specialized medical treatment and preventive

healthcare as per Standards Operation Procedures (SOPs) at free / affordable cost.

To develop a pool of healthcare professionals in the public health sector trained in the implementation of

health care quality standards and carry out Mock Drills & Rehearsals to bring productivity and effectiveness

in health care delivery system of the state.

Accurate and standard health indicators measurement for evaluation and monitoring.

Process Case Study of PHC: Gadboriad, Taluka: Nasvadi, District: Vadodara

Period Activities

Jan-

March

08

Gap Assessment of all clinical and non clinical areas

Distribution of Gujarati and English version of NABH standard book

Sensitization of staff towards NABH

Constitution of Various Committees

April 08

– July 09

Initiation of Documentation

Initiation of Medical Audits

Beginning of Indicator Monitoring System Continuation of Training & Monitoring Development of Quality Indicators (Patient Satisfaction and Clinical Record Indicators) Self assessment with NABH Standards PRI Evaluation. Identification of Pioneers and Internal Assessors Identification of training needs and Initiation of Training Committee meetings Infrastructure renovation Finalization of QA manual, Infection Control, SOPs & training to all the respective department

staff Conducting different mock drills Review of statutory compliances

July-

Sept 09

Applied for Pre-Assessment Pre assessment done ( on 22nd July 09) Pre-assessment gap closure activities initiated Continuation of Training & Monitoring Development of privileges & credentials for medical and nursing staff Renovation of Laboratory , radiology department Closures of Non-Compliances identified during Pre-assessment Different codes identification Filing the application for Final Assessment Second Internal Assessment Development and training based on our non compliance Final assessment completed on 10th August 09 and compliance submitted to QCI, New Delhi. 1st NABH Accredited Primary Health Centre in India on Date: 17th August 2009. By Quality

Council of India

Page 5-10

Outcomes i.e. impact/benefits resulting from the project:

Before July 2007 Today Lack of standards in public health services. NABH Standards for CHC and PHC.

There will be no any Gap analysis report in standards

format.

We have Gap analysis report in standards format.

Lack of Statutory requirements (e.g. Licenses, Acts,

Rules& Certificates).

All Statutory requirements are available (e.g. Licenses,

Acts, Rules & Certificates).

Absence of written policies & procedures for healthcare

delivery.

We have written policies & procedures for healthcare

delivery.

Poor sanitation and cleanliness in facility. Neat and clean Facility environment

Staff shortage e.g. security staff, staff nurses etc. Recruitment of staffs as per workload through RKS.

Absence of trained health care staff for emergency

(resuscitation) services. Availability of trained staff in BLS.

Inadequate infrastructure for handling biomedical waste

and infection control safety practices.

All required materials are available for handling

biomedical waste and infection control safety practices.

Damaged and poor condition of the building and campus Repairing & renovation done by Local level, PIU &

PWD as per requirement.

Shortage of equipments and ambulances to meet the

scope of service.

Sufficient equipments are now available and continuous

purchase is going on and meets the scope of service.

No Calibration of the instrument & Equipment All the instrument & Equipment are Calibrated.

Lack of accountability & planning in delivery of care to

patients.

We have the policy and processor for care of the patients

Absence of quality standards such as medical audit,

management of medication, care of patient, facility

management and safety, information management system

& infection control.

All quality standards e.g. medical audit, management of

medication, care of patients, facility management and

safety, information management system & infection

control are available.

Poor signage system in public hospitals. Well developed signage's and displays for patient

information

Absence of Patient & Employs satisfaction monitoring

system.

Patient & Employs satisfaction monitoring system is

available.

No measurable parameter for patient safety. Measurable parameter for patient safety are available (e.g

BOR, ALOS, HIR etc.)

No realization of our problems and weaknesses A clear understanding of what is lacking and what needs

to be done

No monitoring or reporting of adverse events, needle

stick injury, Sentinel events etc.

These are being reported and are monitored on an

ongoing basis.

Practically non-existing security arrangement. Availability of well trained and uniformed security

guards.

No implementation of Different codes in the facilities. RED for FIRE, YELLOW for EXTERNAL

CALAMITIES, BLUE for CARDIAC ARREST,

PINK for CHILD ABDUCTIO

Achievement:

India’s 1st NABH Accredited Primary Health Centre Gadboriad, Dist: Vadodara

India’s 1st NABH Accredited Community Health Centre Bardoli, Dist: Surat

Page 6-10

NABH Certificate Given to PHC Gadboriad by Hon’ble Health Minister, Govt.

of Gujarat & Secretary General Quality Council of India.

NABH Certificate Given to PHC Mahuvas by Hon’ble. Health Minister, Govt.

of Gujarat & Secretary General Quality Council of India.

Benefits to Patients:

High quality of care

Credentialed and privileged medical staff

Access to a quality focused organization

Rights are respected and protected

Understandable education and communication

Patient Satisfaction is evaluated

Involvement in care decisions and care process

Focus on patient safety

Pain management

Vulnerable patient

Safe transport

Continuity of care

Primary Health Center: Mahuvas Primary Health Center: Gadboriyad

Primary Health Center: Gadboriyad Primary Health Center: Mahuvas

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

4.47 4.75 4.72

3.924.46

10.009.30 9.33 9.17 9.45

Before After

PHC GADBORIAD NABH ASSESSMENT SCORE

Benefits to Staff

Improves professional staff development

Provides education on consensus standards

Provides leadership for quality improvement within medicine and nursing

Increases satisfaction with continuous learning, good working environment, leadership and ownership

Provided babykits to new born toprevent hypothermia

85% Hospital Accord Infection prevent only after proper

HAND WASHING

Quality of Care Quality of Care cont…

Page 7-10

Benefits to Health Care Facility

Improves care

Brings in Corporate Governance

Stimulates continuous improvement

Demonstrates commitment to quality care

Raises community confidence

pportunity to benchmark with the best

After All the Services provided by PHC Gadboriad are

displayed in all the villages & roadside

Benefits to the Community:

Quality revolution

Disaster preparedness

- Epidemics

- Physical

Access to comparative database

Benefits to the Government:-

Efficiency of Government managed hospitals as key contributors for building trust and confidence for

the hospitals in the hearts of the citizen of the state though the actively pursuing quality improvement

programme in various facilities.

It has given a sense of pride to the government for ensuring quality services to the poorest of the poor.

Confidence has been reposed of the community in Govt hospitals

Commitments:

• Continued training of personnel to imbibe quality as a culture among its people.

• Strictly adhering to the quality manual in all its operations.

• To be abreast of the latest technology to become innovative.

• To be a bench mark in healthcare services and support.

• To create an excellent work environment and maintain good housekeeping.

Changing

Page 8-10

Road Ahead:

To get all the Medical Colleges, District Hospitals, Blood Banks, Laboratories, PHCs & CHCs across the state

accredited by NABH/ NABL.

Highlights/features of the initiative:

Transparency and stakeholder participation:

The process to develop implement and monitor of Quality Improvement Programme was developed by

Govt. of Gujarat with technical support from Quality Council of India, New Delhi. The facility level micro

planning of implementation, monitoring and review is also jointly done by Department of health and Quality

Council of India Consultant. Now with training and advocacy process initiation at facility level and

formation of committees and defined scope of work as per requirement.

Innovativeness of the initiative and its replicability:

Resource identified for continuous enrichment of knowledge and up gradation of systems as per the latest national

healthcare standards.

Opportunity of upgrading one’s skills and technical competence in a standard based healthcare system.

Employee recognition for adherence to defined standards.

Periodic assessment by NABH.

Annual inspection of regulatory bodies.

Renewal of licenses.

Committed leadership towards implementation and adherence to quality policies and SOPs.

Increased efficiency of the process and effectiveness of outcome:

The complete planning of quality improvement project was possible due to valuable input and support extended by

the state authorities in bringing the expertise of QCI, NABH consultancy services and allocation of valuable district

quality assurance officers in this drive towards excellence in healthcare delivery at ground level.

Assessment of Health care facility (PHCs & CHCs) was conducted and detailed project plan was developed to

document the standard operating procedure, policies, to implement the NABH standards & to train the employees as

per standards requirement towards improving the technical competence.

State health officers, administrators, clinicians, staff nurse and district quality assurance officers were trained in

NABH lead assessor training program.

Regular audit, inspections of the facility, medical records assessment, and patient care were conducted as per the pre –

defined. Special emphasis was laid upon compliance with statutory requirements and calibration, testing of medical

equipments.

Gaps were identified and the requirements were fulfilled. Pre assessment was done by NABH and the compliance

report is submitted to the Health care facility & state health authorities with respect to the non conformity as

mentioned in the report which were observed during mock audit. NABH has given a time frame to comply with the

reported non – conformance with the respective standards. This drive of achieving excellence in the quality of public

health services has benefitted the entire state.

Display of leadership/team work by the nominees sustainability of the initiative:

The Department of Health & Family Welfare, Government of Gujarat has identified quality health services

and the efficiency of Government managed Primary Health Centre & Community Health Centre as key

contributors for building trust and confidence for the Primary Health Centre & Community Health Centre in

the hearts of the citizen of the state though the actively pursuing quality improvement programme in these

facilities as per the National Accreditation Board for Hospitals and Health Care Providers (NABH) which is

prepared by Government of Gujarat with the help of Quality Council of India. Department of health

and family welfare took lead role in the Policy planning and implementation.

Page 9-10

The program initiatives are sustained since inception (> 2 years) and the coverage under the same is

showing increasing quality health care service to poorest of the poor

Gujarat is the pioneer for Quality Improvement Programme in the public health care institute as per NABH

in India.

The encouraging outcome indicators are effectively disseminated to sustain the efforts and enthusiasm.

Strategies Adopted for sustainability:

Appointment of Quality Assurance officers at State level & District level, Quality Assurance Committee at

Facility level.

NABH PHC / CHC assessor training (Total trained persons 327 for PHC / CHC) to administrators,

clinicians, paramedical & staff nurses etc.

Distance learning Post Graduation Certificate Course in Quality Management and Accreditation of Health

care Organization (PGQM & AHO) to the state level, Regional level, District level, Block level and facility

level officers. (Total trained persons 679) etc.

Extra budget as per requirement of NABH / NABL are sanction from 13th finance commission, Government

of Gujarat and NRHM.

Formation of the state level review committee under the Chairmanship of Commissioner of Health, Medical

Service & Medical Education and Member secretary is State Quality Assurance Officer and district level

core group..

Award instituted by any other National/ International organization:-

A. Certificate of Appreciation awarded to Ministry of Health and Family Welfare Government of Gujarat for

establishing Quality Assurance framework in providing quality healthcare to the people of Gujarat in 5th

National Quality Conclave, New Delhi on 19th Feb 2010.

B. Appreciation awarded to Department of Health and Family Welfare Government of Gujarat for their

pioneering effort to spearhead the Quality and Accreditation Programme in health care organization. In 3rd

International Health Care Quality Conclave on “Role of Quality in Globalization of Indian Healthcare”. Place:

- Gurgaon, Hariyana Date: 30th August 2010.

C. FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal

2013, New Delhi Date: 2nd Sept 2013

D. Operational excellence award in IndiZen 2014 to Govt. of Gujarat-department of health and family welfare

was achieved.

E. FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal

2014, New Delhi Date: 1st Sept 2014

Paper Cutting: