NQAS HWC ayushman aarogya mandir nqas nqas

Nqas for facilitate

1. Quality in Public Health System Dr. Birender Singh State Quality Assurance Medical Officer (SQAMO) State Quality Cell Commissionerate of Health, Gandhinagar

2. O v er v iew National Quality Assurance Program Kayakalp: S w a c h h B h a r a t S w a s t h B h a ra t LaQshya: Ens u r i ng Qu a l i t y of care d u r i ng d e l i v ery & i mm e dia t e pos t - partum Swachh Swasth Sarvatra: Co n v e r g e n c e w ith Ministry of Jal Shakti National Quality Assurance Standards: For DH, CHC, P H C an d UPHC Mera-Aspataal: P l a t fo r m t o cap t ure v o i ce of Pa t i en t s for imp r o v i n g Qu a l i t y Ser v i c e s AEF I Su r veillance: Ensur i ng Qua l i t y i n A E F I Surveillance Mu s Qan: N Q A S certification of P e di a t rics Services

3. Quali t y i n Publ i c Health System 2013 2015 2016 2019 2018 2017 2014 2020 2021

4. Quality of Care Structure Infrastructure Human Resource Equipment & Supplies Processes C li n i c al Support Administration Outcome Functional Adequ a t e Being Utilized Dimensions of Health Quality Dr Avedis Donabedian (1919-2000)

5. National Quality Assurance Standards District Hospitals & equivalent Community Health Centres Primary Health Centres Health & Wellness Centre- Sub Centre Urban Primary Health Care Centre NQAS For AEFI Surveillance

6. Organizat i onal Structu r e under Quali t y Assu r ance Programmes Dist r ict Level Central Quality Supervisory Committee Facility Level State Qua l ity State Qua l ity Ass ur a nce Com mittee Ass ur a nce Unit District Quality Di s tri c t Qua l ity Ass ur a nce Com mittee Ass ur a nce Unit State Level National L evel Qua l ity Impro v ement Team/ Qua l ity Circle

7. Continuous Internal As s e s s me n t H O S P I T A L D I S T R I C T S T A T E N A T I O N A L Quarterly As s e s s me n t by DQAU Assessment & c ert i fi c a t i on by SQAU National Cert i fi c a t i on NHSRC Periodic Continuous Assessment & Feedback

8. Measurement System Health & Wellness Centre (Sub Centre)

9. Patient’s Expectations

10. What is Quality Measurement? Quantifies healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems. MEASUREMENT is expressing attributes in Numbers and Units by applying a set of rules. Quality is all about Improvement and Measurement is the first Step.

11. Quality Measurement System Area of Concern s Broad area/ themes for assessing different aspects for quality like Service provision, Patient Rights, Infection Control Standards 8 Statement of requirement for particular aspect of quality 48 (A) /50 (A) Measurable Element Specific attributes of a standards which should be looked into for assessing the degree of compliance to a particular standard 122 (A)/125 (B) Checkpoint Tangible measurable checkpoints are those, which can be objectively observed and scored. 550 (12)

12. Quality in Health & Wellness Centre Service Provision Inputs Support Services Clinical Care Infection Control Quality Management Outcome Patient Rights

13. Anatomy of Checklist Area of Concern Statement of Standard Measurable Element Checkpoint Means of Verification Referen ce No. Complianc e Assessment Method Remarks

14. Assessment Methods OBSERVATION ( OB ) STAFF INTERVIEW ( SI ) RECORD REVIEW ( RR ) CLIENT INTERVIEW ( CI )

15. Observation (OB) Compliance to many of the measurable elements can be assessed by directly observing the articles, processes and surrounding environment. Enumeration of articles like equipment, drugs, etc Displays of signages, work instructions, important information Facilities - patient amenities, ramps, drinking water, chairs, complaint- box, etc. Environment – cleanliness, loose- wires, seepage, overcrowding, etc. Procedures like measuring BP, counseling, segregation of biomedical waste,

16. Staff interview (SI) Interaction with the staff helps in assessing the knowledge and skill level, required for performing job functions. Competency testing – Quizzing the staff on knowledge related to their job Demonstration – Asking staff to demonstrate certain activities like hand-washing technique, identification of early signs and symptoms of disease conditions etc. Awareness - Asking staff about awareness off patients’ right, Patient Safety, Quality policy, etc. Feedback about adequacy of supplies, problems in performing work, safety issues, etc.

17. Record Review (RR) To generate objective evidences, triangulated with finding of the observation. Review of clinical records -History, GPE, referral records, follow up and drug dissension, etc. Review of registers like Daily OPD Register, Expenditure Register. Review of licenses , formats for legal compliances like Authorization for BMW management. Review of Work Instructions for adequacy and process Review of records – Outreach session, VHSNC meetings, VHNDs, etc. Random review of Family Folders to ascertain compliance. Review of Patient’s Records to check follow up care post referral.

18. Client Interview (CI/PI) Interaction with patients/clients, their relatives and members of community may be useful in getting information about quality of services and their experience in the hospital. Feedback on quality of services, staff behavior, waiting times, etc. Out of pocket expenditure incurred. Satisfaction of the clients/individuals attending VHND, meetings, PSG meetings etc.

19. RULE NO: 1 (checkpoints without MOV or MOV are explanatory in nature) RULE NO:2 ( Checkpoints with enumerated MOV) COMPLIANCE AND SCORING THE THREE GOLDEN RULES CRITERIA TO BE USED FULL COMPLIANCE PARTIAL (2) COMPLIANCE (1) NON COMPLIANCE (0) CHECK POINT ALL REQUIREMENTS OF CHECK POINTS ARE MET HALF OF THE REQUIREMENTS OF CHECKPOINT ARE MET NONE OF THE REQUIREMENTS MET CRITERIA TO BE USED FULL COMPLIANCE (2) PARTIAL COMPLIANCE (1) NON COMPLIANCE (0) MEANS OF VERIFICATION 100% 50% TO 99% LESS THAN 50%

20. RULE NO:3 (Not as routine) Only when you are Not able to score using Rule 1 and Rule 2. It seems the checkpoint is not applicable. Going beyond obvious. Always look for INTENT in relation to the ME and Standard. COMPLIANCE AND SCORING THE THREE GOLDEN RULES CRITERIA TO BE USED FULL COMPLIANCE (2) PARTIAL COMPLIANCE (1) NON COMPLIANCE (0) INTENT FULLY MET PARTIALY MET NOT MET

21. Services provided at HWC(SC) Details of Services Provided At HWC_HSC 1 Care in pregnancy & Childbirth Mandatory 7 Management of Non Communicable Diseases Mandatory 2 Neonatal & Infant Health Services Mandatory 8 Care for Common Ophthalmic and ENT 3 Childhood & adolescent Health Services Mandatory 9 Oral health care. 4 Family Planning Mandatory 10 Elderly and Palliative health care 5 Management of Communicable diseases Mandatory 11 Emergency Medical Services 6 Management of Simple illness including Minor Elements Mandatory 12 Management of Mental health ailments.

22. Score Card - Overall Score & Area of Concern wise Scores HWC_HSC Overall Score Card HWC -HSC Overall Score & Area of Concern wise Scores Service Provision Patient Rights Overall Score of HWC - HSC Clinical Services Infection Control 100% 100% 100% 100% Inputs Support Services 100% Quality Management System Output 100% 100% 100% 100%

23. Service Packages 1. Care in Pregnancy and Child-birth. C a r e Neonatal and Infant Health Care Services C hildhood and A dol e s ce nt H e alth Services. 4. F amily P lanning, C ont r a ce ptive S er vi ce s and other Reproductive Health Care Services 5. M anag e m e nt of C ommuni c able D i s e a s e s : National Health Programmes Basic Oral Health Care Emergency Medical Services including Burns and Trauma Care for Common Ophthalmic and ENT Problem Elderly and Palliative Health Care Services Screening and Basic Management of Mental Health Ailments 4 Services made available at HWC Services* being added in incremental manner G e n er al Ou t -pati e nt C a r e for Ac u t e Simple I lln e ss e s and M inor A il m e n t s S c r ee ning, P r eve ntion, C ont r ol and Management of Non-communicable Diseases and Chronic Communicable diseases like Tuberculosis and Leprosy . *Many states in south have started adding above services AYUSHMAN BHARAT-HEALTH AND WELLNESS CENTRES

24. AOC (Area Of Concern)

25. S t an d a r d A1 The Facility provides comprehensive Primary Healthcare Services A1.3:- Child and Adolescent Health A1.4:- Family Planning Services Identification, Primary Management, referral & fo ll ow- u p of Childhood Ailments Education, Counselling & referral for A d o les c e n t Provision of contraceptive including ECP, OCP, injectable, Condoms, IUCD Education, counselling and referral services for FP A1.1:-Care in Pregnancy and Child Birth A1.2:-Neonatal & Infant care Functional ANC clinic with 4 ANC, First Aid, referral & follow-up for high risk p r e g n a n c y Identification, Primary M a n a g e m e n t & pr o m pt r e f e rr al of sick new born and infant Immunization Services Post natal new born care A1.5:- Communicable Diseases as per NHP Preventive and Promotive Services Case detection, treatment, referral and follow up under various NHPs A v a i l ab i l i t y of normal vaginal delivery and Prompt referral for Obstetric emergency

26. S t an d a r d A1 The Facility provides comprehensive Primary Healthcare Services A1.8:- Common eye ailments A1.9:- Common ENT Services Screening and referral of blindness, refractive errors, visual acuity, Dry eye, trachoma, foreign body Awareness Common cold URI, Tonsilitis, Pharyngitis, Sunusitis etc. Preventive and Promotive services A1.6:-Acute Simple illness and Minor ailments A 1 . 7 : - N o n - Communicable D i s e a s e as p e r NHPs Fever. URIs, ARIs, Diarrohoea, Scabies, Rashes/Urticaria, Dysentery, Typhoid, Helminthiasis, Headache, body ache etc. fo r Services Hy p e r te n s i on, D i ab ete s , No n - alcoholic fatty liver d i s e a s e , c an c e r s , respiratory disease, E p i l e p s y , L o c a l l y prevalent disease & substance abuse. P r e v en t i v e an d Promotive Services under NCD generation- Vit-A A1.10:- Oral Health ailments Identification of Cleft lip & palate, abnormal growth, patch, ulcers Gingivitis, Periodontitis, Dental carries Preventive and promotive services

27. S t an d a r d A1 The Facility provides comprehensive Primary Healthcare Services A1.11:-Elderly and Palliative care A 1.12: - E m er g en cy Medical care, Trauma & burns Awareness about Healthy life style, social security Mapping of elderly Home visits for psycho support and basic nursing care Stabilization and referral services for Minor injuries, animal bites, poisoning, burn, CVA, fracture, Shock etc. reduction etc. A1.13:- Mental Health A1.14:- Health Promotion Activities & Wellness Identification, counselling and referral for Anxiety, Hysteria, Depression, Neurosis, Awareness generation, Stigma VHSNCs/Self-help group, health promotion campaign and multi sectoral convergence Yoga, Health modification, EAT right, EAT safe

28. S t an d a r d A2 The Facility provides drugs and diagnostics as mandated A2.1:-Laboratory Services A2.2:-Drug dispencing & medicine refills A v ai l ab i l i t y of b a s i c d i a g n o s t i c s e r v i c e s in clu d in g NH P - R D K HB , UPT, Urine dip stick (albumin & sugar), Blood sugar, Malaria, Sputum collection for TB, HIV RCT, VIA etc. Linkage with the central diagnostic units (Hub & Spoke) Availability of drugs as per EDL and scope of services Availability of drugs for refill for chronic cases

29. S t a n d a r d B1 The facility provides information to the care seeker, attendants and community about available services and their modalities B1.1 Display its services and entitlements B1.2 Sensitize and educate through appropriate IEC/BCC B1.3 Information about treatment is shared 8/10/21 17

30. What is this?? 10/08/21 Q I- NH S R C

31. What is this?

32. Signage like this..?? 10/08/21 Q I- NH S R C

33. Uniform signage system Floor directory Departmental pictorial signage

34. IEC activities

35. “ Eat Right Movement” built on two broad pillars- “Eat healthy” and “Eat safe” Fit India Movement for a healthy life style Promotion of Yoga Annual Health Calender- 39 health days Raising people’s awareness of primary health care via community level campaigns through folk and local media/VHSNC and MAS AYUSHMAN BHARAT-HEALTH AND WELLNESS CENTRES Health Promotion activities

36. Communication through local art

37. S t a n d a r d B2 Facility ensures that the services are accessible to the care seekers and visitors including those requiring some affirmative action B2.1 Accessible from community and referral center B2.2 Accessible without any physical barrier and disable friendly B2.3 Affirmative action to ensure that vulnerable and marginalized section can access the facility 8/10/21 28

38. B2.2: Physical Access 10/08/21 Q I- NH S R C Wheelchair/ Stretcher Ramps- at least 120 cm width, gradient not be steeper than 1:12 with hand rails Floor non slippery Disable friendly Toilets Maintained Internal Paths/ Circulation Area

39. S t a n d a r d B3 Services are delivered in a manner that are sensitive to gender, religious and culture needs and there is no discrimination on account of economic or social reasons B3.1 Sensitive to gender, religious and culture needs B3.2 Staff is aware about patient Rights and responsibilities B3.3 Defined and established grievance redressal system 8/10/21 34

40. S t a n d a r d B4 The facility maintains privacy, confidentiality and dignity of patients B4.1 Adequate visual privacy at every point of care B4.2 Confidentiality of patient records and clinical information is maintained B4.3 Ensures behavior of staff is dignified and respectful, while delivering the services 8/ 10/ 21 37

41. S t a n d a r d B5 The facility ensures all services are provided free of cost to its users Cashless services as per prevalent government scheme/norms 8 / 10 / 21 40

42. Human & animal anatomical waste Soiled waste Ex p i r e d / D i s c a r d e d medicine Discarded linen and bedding Laboratory waste Yellow Categories Waste Yellow Colored Non-Chlorinated bags

43. Syringes without needles Intravenous Tubes Urine Bags T u b i ng G l o v es Red Categories Waste (Recyclable) Red Colored Non-Chlorinated bags/Containers

44. Syringes with fixed needles S c a l p e l Needles from Needle tip cutter or burner Metal Sharps White Categories Waste (Translucent) Puncture Proof, tamper-proof and leak proof Containers

45. Ampules Metallic Implants V i a l s Broken or contaminated Glass Blue Categories Waste (Glassware) Glass Slides Puncture Proof and leak proof Boxes or containers with blue colored marking

46. General Waste Management Bio-degradable waste Non Bio-degradable waste (Recyclable)

47. Area of Concern G- Quality Management The facility has established organizational framework for quality improvement S t anda r d G1 The facility has established system for patient and employee satisfaction S t anda r d G2 Area of Concern-Quality Management cover aspects like establishment of organizational framework for quality improvement, measurement, assessment and usage of patient satisfaction ; compliance to display and usage of work instructions ; regular audit using NQAS, Kayakalp and other checklists for the improvement and sustenance of Quality. The standards in this area concern are the opportunities for improvement to enhance quality of services and patient satisfaction.

48. The facility has established, documented, implemented and updated Standard Operating Procedures (SOPs) for all key processes and support services S t anda r d G3 The facility has established system of periodic review of clinical, support and quality management processes S t anda r d G4 The facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them S t anda r d G5 Area of Concern G- Quality Management

49. The facility has established organizational framework for quality improvement S t anda r d G1 ME G1.1 Quality Team The facility has a quality improvement team and it review its quality activities at periodic intervals The HWC (SC) has Quality team in place CHO, ANM/Staff nurse, MPW & ASHA Team members are aware of their respective responsibilities and roles viz. ensure hygiene and infection control practices, internal audits are conducted, feedback taken etc. Review of activities in monthly meeting Review of pe r f o r m an c e indicators Review of a ss e ssm en t plan Review of Kayakalp, NQAS assessment Identify the issues to be addressed at PHC review meeting Review of time bound action plan

50. ME G2.1 Patient Sa t i s f a c t i o n Survey The facility ensures mechanism for conducting patient satisfaction survey The facility has established system for patient and employee satisfaction S t anda r d G2 Patient satisfaction survey is done Analysis of low performing attributes is done Actions are taken on lowest performing factors

51. Attribute Pt. 1 Pt. 2 Pt. 3 Pt. 4 Pt. 5 Pt.6 Pt. 7 Pt. 8 Pt. 9 Pt. 10 Average Availability of sufficient information 3 2 4 3 3 3 4 5 2 4 3.3 Waiting time at the registration counter 4 4 3 4 4 4 5 4 3 5 4 Behaviour & attitude of staff 3 3 2 2 4 3 3 3 4 3 3 Amenities in waiting area 3 4 4 4 2 3 1 3 3 3 3 Attitude & communication of Doctors 1 1 1 2 2 1 2 3 3 2 1.8 Consultation & examination time 4 3 2 4 3 2 2 2 4 2 2.8 Availability of Lab facilities within hospital 3 3 3 2 2 2 1 2 2 3 2.3 Promptness at Med distribution counter 4 5 4 4 3 5 4 5 4 4 4.2 Availability of prescribed drugs 3 1 1 1 2 2 2 1 1 2 1.6 Your overall satisfaction during the visit to the hospital 2 2 2 3 4 3 3 2 4 4 2.9 Average 3 2.8 2.6 2.9 2.9 2.8 2.7 3 3 3.2 2.89 Patient Satisfaction Survey Analysis

52. ME G3.1 Work I n s t r u c t i o n Updated work instructions for all key clinical processes are available Instructions for using RDK are available Work instruction for RMNCHA services Work Instructions are updated as per current practices The facility has established, documented, implemented and updated Standard Operating Procedures (SOPs) for all key processes and support services S t anda r d G3

53. ME G4.1 Handh o ld support Handholding support and supervision is provided to HWC (SC) by PHC, block/ district/state teams Regular review of Service delivery and performance by MO PHC Quarterly - By Block nodal officer, Bi Annual by District Nodal officer Gaps have been identified and actions are taken The facility has established system of periodic review of clinical, support and quality management processes S t anda r d G4 ME G4.2 Internal Assess m e n t The facility conducts periodic internal assessment Gaps closed as per last quarter report Periodic assessment using NQAS checklist (at least once in a month) Periodic assessment using Kayakalp checklist (Quarterly)

54. ME G4.3 Action plan Non compliances are recorded and action plan is made on the gaps found in the assessment/ review process using quality improvement methods Non Compliance found in the internal assessment are recorded Gaps are identified and time bound action plan is prepared Root cause analysis is done The facility has established system of periodic review of clinical, support and quality management processes S t anda r d G4 Using brainstorming, Fishbone analysis or why-why analysis Action are taken using PDCA approach Improvement on identified non compliances

55. ME G5.1 Mission, Values, O bje c t i v es The facility has defined Quality policy and quality objectives Quality policy are defined, displayed in local language SMART Quality objectives are defined System for monitoring of performance toward quality objectives The facility has defined Mission, Values, Quality policy and Objectives, and approved plan to achieve them S t anda r d G5

56. Mission Mission describes present i.e. what organization wants to do now to achieve desired level. It defines the customer(s), critical processes and it informs the desired level of performance.

57. Qu a lity is a T e a m W o r k “The very first requirement in a hospital is that it should do the sick no harm.” …… Florence Nightingale

58. Road map of NQAS Certification for HWCs

59. A G ENDA 1 2 3 4 State Level District Level Facility Level National Certification

60. 65 % or More Over All Score of HCF 6 5 % or More Score in each Area of concern 65 % or More Score of each service Package (Min 7) 45 % Or More Individual Standard score 55 % or More Core Standards* A1, D3, D4, D5 and G2 * A1- Facility provide Comprehensive Primary healthcare Services, D3- Clinical records and data management, D4- Hospital transparency and accountability, D5- Health Promotion and Disease prevention activities through community mobilization G2:- Patient and Employee satisfaction Criteria 1 Criteria 3 Criteria 2 Criteria 4 Criteria 5 Crite r i a fo r State Certi f icatio n SC-( HWC) P a ti e n t S a ti s f acti o n Score 55 % Or 2.75 (Likert) scale More Criteria 6

61. 70% or More Over All Score of HCF 60% or More Score in each Area of concern 70% or More Score of each service Package (Min 7) 50% Or More Individual Standard score 60% or More Core Standards* * A1- Facility provide Comprehensive Primary healthcare Services, D3- Clinical records and data management, D4- Hospital transparency and accountability, D5- Health Promotion and Disease prevention activities through community mobilization G2:- Patient and Employee satisfaction Criteria 1 Criteria 3 Criteria 2 Criteria 4 Criteria 5 Crite r i a fo r Nationa l Certi f icatio n (HWCs) P a ti e n t S a ti s f acti o n Score 60% Or 3(Likert) scale More Criteria 6

62. Roadmap for the District S. No Activities Task Responsibilities Time Line 6 National Level Certification HWC (SC) to apply for National level certification MO PHC & CHO April 2024

63. Step-2:- Orientation of Quality Teams at HWCs WHAT WHO WHEN Feb-2024 CHO with support of MO PHC Orientation of Quality Team regarding National Quality Assurance Standards, Assessments, Scoring system and its implementation methodology. 9

64. Step- 3 :- Internal Assessment & GAP Analysis WHAT WHO WHEN March-2024 CHO with support of Quality team The Quality team will conduct internal Assessment & GAP Analysis.

65. Step- 4 :- Ensure monthly Quality meetings WHAT WHO WHEN Ongoing after formation of Quality team CHO with support of Quality team The Quality team will conduct monthly meetings to discuss their status of implementation and record their proceedings.

66. Step- 5 :- Quality Assurance Activities WHAT WHO WHEN Ongoing after formation of Quality team Quality team The Quality team will initiate various QA activities in the HWCs like PSS, Quality Policy & objectives, analysis of indicators, work instructions etc. 1

67. Client/ Patient Satisfaction Survey Collect Monthly feedback in a structured format defined by the state. Minimum 30 OPD patients & Client Satisfaction Survey to be collected in a month in type A sub-centres; whereas all delivered patient PSS to be collected additionally at type B sub-centres. Analyze and identification of lowest scoring attributes Take actions to close the gap.

68. Outcome Indicators Capture the Outcome indicators on monthly basis. Ana l yze, r e view an d utili z e data f or mon t h l y meetings. Report to DQAC/ SQAC for monitoring purpose. quality t eam

69. Work Instructions (WIs) WIs are step -by-step approach to perform the activity. For standardization of the processes, define WIs. Ex i sting WI g i v en in o p e r at ional guidelin e s of National He a lth Programs may be use. State may provide standard templates of WIs Implementation of the defined WI to be ensured

70. Step-7:- Certification Activities WHAT WHO WHEN After Closure of gaps and reach bench mark score of 65 % for State Certification & 70% for National Certification DQAU & SQAU A p pl y f o r S t ate C ertification t hroug h D QA C and National Certification through SQAC 9

71. T h a nk you