QUALITY ASSURANCE AND NATIONAL QUALITY ASSURANCE STANDARDSNTEP.pptx

IT IS A WAY WITH QUALITY, QUALITY ASSURANCE AND NQAS

1. Quality assurance in Health-care Programme with special reference to NTEP Seminar Presentation By Dr. S ubhajyoti Mandal 3 rd yr PGT, MDCM AIIHPH,Kolkata 1

2. Learning Objectives At the end of the session, Learners will be able - To define ‘Quality’ and ‘Quality in Health Care’ To define ‘Quality Assurance’ and how it is different from ‘Quality Control’ To learn History of Quality in Health Care To understand Importance of Quality in Health Care To enumerate Different elements of Quality in Health Care To link Quality assurance processes in various National programmes With special reference to NTEP 2

3. Quality 3 Quality is doing the right things in a right way at right time- first time and every time [WHO, 2010] “ Quality is the totality of features and characteristics of a product or service that bears on its ability to satisfy stated or implied needs” [ISO 8402:1996- Quality Management and Quality Assurance Vocabulary Standard] “ Quality of Care ”-”the degree to which health services for individuals and populations increase their likelihood of desired health outcomes and are consistent with current professional knowledge”[IOM and JCAHO]

4. 4 Quality Assurance in Health Care Quality assurance in health care- planned or systematic actions necessary to provide adequate confidence that a patient services or safety will satisfy given requirement for quality(2) Quality Control: Quality Control “A part of quality management focused on fulfilling quality requirements” (ISO 9000 standard, clause 3.2.10). Quality Improvement: IOM (Institute of Medicine) defines QI as systematic and continuous actions that lead to measurable improvement in health care services and health status of targeted patient groups.(5) It also defines quality in healthcare as direct correlation between the level of improved health services and the desired health outcomes of individuals and populations. Quality Control Quality Improvement

5. 5 Quality System =(QI+QA+QC) Fig 1: Quality System, Quality Improvement, Quality Assurance, and Quality Control Relationships

6. Difference in Quality Assurance and Quality Control Quality Assurance Quality Control Process-based approach Product-based approach To prevent defects To find any defect Proactive process Reactive process Manage quality Verify quality 6

7. Five Principles of Quality Assurance in health care 7 1. 2 . 3 . 4. Towards meeting the needs and expectations of the patients Focuses on the systems and processes Uses data to analyse service delivery processes Team approach to problem solving and quality improvement 5. Uses effective communication to improve service delivery

8. Components of Quality Assurance in Health care Assessment against the set standards Analysing the Problem Preparetion and implementation of action plan Setting up standards and measurable elements Follow up assessment 1 2 5 4 3

9. 9 Dimensions of Quality Fig 2: Diagram showing dimensions of Quality in Health care

10. 10 Need for “Quality” in Health Care Poor quality health systems result in more than 80 Lakhs deaths per year in Low & Middle-Income Countries Health providers in LMICs do less than half of recommended evidence-based actions One-third of patients experience disrespectful care, short consultations, poor communications or long wait Less than 25% of people in LMICs believe that their health system works well, compared with 50% in high-income countries Source: Lancet Global Health Commission on High Quality Health Systems in SDG Era, 2018

11. IPHS 2008 CEA 2012 NQAS 2013,2020,2024 KAYAKALP 2015 My Hospital 2016 LAQSHYA 2017 Journey towards Quality Clinical Establishment Act

12. ELEMENTS OF QUALITY OF HEALTH CARE [4] 12 QUALITY EFFECTIVENESS EFFICIENCY INTEGRATION SAFETY PEOPLE-CENTRED TIMELINESS EQUITY Providing evidence-based health care services Avoiding injuries Individual preferences, needs and values Reducing waiting times and harmful delays Care not varies in quality on account of gender, ethnicity, geographic location and socio-economic status Quality care available of the full range of health services-throughout the life course Maximizing benefits of available resources and avoiding wastes

13. 13 Health care workers (motivated and supported) Health care facilities (accessible and well equipped) Health financing (adequate) Medicines, devices and technologies (safe in design and use) Health information system (continuous monitoring and updating with transparency) QUALITY OF HEALTH CARE Foundation of Quality Health Care Fig 3: A diagram showing the building blocks of Quality of Health Care

14. 14 NQAS (National Quality Assurance Standards)

15. 15 Operational Guideline for Quality Assurance National Quality Assurance Standards for DH National Quality Assurance Standards for CHC National Quality Assurance Standards for PHC National Quality Assurance Standards for UPHC National Quality Assurance Standards for AEFI Quality Guidelines & Standards

16. 16 Framework of NQAS Component DH CHC PHC UPHC HWC-SC Area of Concern 8 8 8 8 8 Standards 75 65 50 35 50 Measurable Elements 380 297 250 200 129 Checklists 21 12 6 12 1 Fig 4: A diagram showing the framework of NQAS Table 1 : A Table showing the Components of Health facilities under NQAS

17. 17 Area of Concern Fig 5: A diagram showing the components of AREA of CONCERN in NQAS

18. Area of Concerns Infection Control Standards Hand Hygiene Measurable Element Hand washing Facility Checkpoint Availabiity of Soap Clinical Care Intrapartum Care Management of third stage of Labour Admnistration of Oxytocin within 1 Min. of Birth Patient Rights Privacy & confidentiality Visual privacy Availabilty of Screen and curtains Quality Measurement System Examples

19. 19 Organizational Framework National Level State Level District Level Facility Level Central Quality Supervisory Committee State Quality Assurance Committee State Quality Assurance Unit District Quality Assurance Committee District Quality Assurance Unit Quality Team

20. 20 Training Duration Level Scope Awareness Workshop 1 day State To sensitize state level officials for quality assurance program Internal Assessor Training 2 Days State / Regional Standards , measurable elements, Internal assessment Methodology Filling up checklists and calculating scores Preparing action Plan QA in NUHM 2 Days State/ Regional Assessment, Gap Closure Action Implementation Training 3 Days Regional/ District Basic concepts of quality Standard operating procedures Patient satisfaction programs Quality improvement tools External Assessor Training 5 Days National/ State Detailed training on standard , measurable elements, assessment methodology, audit trail, code of conduct, filling formats and reporting Capacity Building

21. 21 Assessment Process Scoring System ( OB ) ( SI) ( RR) ( PI ) COMPLIANCE & SCORING RULES- For full compliance=2 For partial compliance=1 Non compliance=0 Weightage- all the checkpoints have equal weightage to keep scoring simple Final score given in percentage to make inter-departmental and inter-hospital comparison.

22. The assessment scores can be presented in three ways- 22 1. Departmental Score Card 2. Hospital Quality Score Card 3. Area of Concern wise Score card

23. 23 Continuous Internal Assessment HOSPITAL DISTRICT STATE NATIONAL Quarterly Assessment by DQAU Periodic Assessment & Sate certification by SQAU National Certification NHSRC Assessment Protocol Fig 6 a diagram showing assessment protocol of NQAS

24. 24 70% or More Over All Hospital Score 70% or More Area of Concern wise Score 70% or More Department wise Score 50% or More Standard wise Scores 70% or More Core Standards Criteria 1 Criteria 3 Criteria 2 Criteria 4 Criteria 5 70% or More Patient Satisfaction Score Criteria 6 Criteria for National Certification for District Hospital

25. 25 Unified Organizational Framework Explicit Measurement System Certification at State & National Level Inbuilt Quality Improvement Model Flexibility in Measurement System Continuous Assessment and scoring Training & Capacity Building Incentives on Achievement & Sustenance 1 3 4 5 6 7 8 2 Summary of NQAS Framework

26. 26 Type of Health facility Area for assessment Type of certification Incentive DH/SDH/ AH/ CHC or equivalent All Departments Full certification (Meeting all criteria) Rs . 10,000 X number of functional beds DH/SDH/ AH/ CHC or equivalent All Departments Certification with conditionality Rs . 7000 X number of functional beds DH/SDH/ AH/ CHC or equivalent Part of Hospital/ services (Labour room, Maternity ward etc.) Full certification (Meeting all criteria) Rs . 10,000 X number of functional beds X no. of applicable checklist/ total no. of checklist DH/SDH/ AH/ CHC or equivalent Part of Hospital/ services (Labour room, Maternity ward etc.) Certification with conditionality Rs . 7000 X number of functional beds beds X no. of applicable checklist/ total no. of checklist Incentives

27. 27 NQAS for NTEP National Tuberculosis Elimination Programme Departments come under observation for NTEP: 1. OPD 2. Laboratory services 3. IPD 4. Public Health laboratory Dedicated AREA OF CONCERN and STANDARD for NTEP: Standard A4 & E23 B1 and C2 There were 2 types of Quality Assurance for PHL 1. External QA 2. Internal QA

28. 28 Standard A4 Measurable Element Checkpoint Assessment Method Compliance Score ME A4.2 The facility provides services under national tuberculosis elimination programme as per guidelines. Availability of Functional DOTS clinic SI/OB ME E23.2 Facility provides service under National TB Elimination Program as per guidelines Staff is aware of symptoms or signs Presumptive pulmonary TB as per revised guidelines SI/RR Staff is aware of Signs and symptoms of Extra pulmonary Tuberculosis SI/RR Staff is aware of signs and symptoms of presumptive paediatric TB cases as per revised guidelines SI/RR OPD

29. 29 Standard Measurable Element Checkpoint Assessment Method Compliance Score Staff is aware of presumptive DRTB cases as per revised guidelines SI/RR Staff is aware of classification done on the basis of Medicine resistance as per revised guidelines SI/RR Diagnosis and treatment of Presumptive pulmonary TB as per revised guidelines SI/RR Diagnosis and treatment of smear positive and presumptive multi Medicine resistance TB (MDR-TB) as per revised guidelines SI/RR

30. 30 Standard Measurable Element Checkpoint Assessment Method Compliance Score Diagnostic algorithm for pulmonary, extra pulmonary and paediatric TB as per revised guidelines are readily available SI/RR Management of extra pulmonary TB cases as per revised guidelines SI/RR Management of MDR/RRTB(without additional resistance) as per revised guidelines SI/RR Management of Paediatric Tuberculosis SI/RR Management of Patients with HIV infection and Tuberculosis SI/RR

31. 31 Standard Measurable Element Checkpoint Assessment Method Compliance Score Patient and family is counselled before initiating TB treatment SI/RR/PI Treatment card and TB identity card is given SI/RR Monitoring and follow up of patient done as per protocols SI/RR There is functional Linkage between DMC and ICTC SI/RR

32. 32 Standard Measurable Element Checkpoint Assessment Method Compliance Score ME A4 The facility provides services under national tuberculosis elimination programme as per guidelines. Indoor treatment of TB patients requires hospitalization SI/RR LABORATORY ME A4 The facility provides services under national tuberculosis elimination programme as per guidelines. Availability of Designated Microscopy Center (AFB) SI/OB Availability or Linkage with CBNAAT SI/OB ME E23 Facility provide service for Integrated disease surveillance program Weekly reporting of Confirmed cases on form "L" from laboratory SI/RR IPD

33. 33 Standard Measurable Element Checkpoint Assessment Method Compliance Score ME A The facility provides services for promotion, prevention and treatment of communicable diseases as mandated under National Health Program/state scheme Preventive & promotive measures under NTEP SI/RR Case detection, treatment, referral & follow up of cases under NTEP SI/RR ME E The facility provides services under Revised National Tuberculosis Elimination Programme (NTEP) Identification of presumptive case & their referral RR AAM (SC) support, supervision & manage presumptive, confirmed & on treatment cases including DR-TB patients OB/RR HWC

34. 34 Standard Measurable Element Checkpoint Assessment Method Compliance Score Staff is aware of follow up protocol after treatment completion SI/RR NTEP register & records are maintained RR

35. 35 Standard Measurable Element Checkpoint Assessment Method Compliance Score ME A4.2 Availability of case detection and Early diagnosis of TB SI/RR Availability / Linkage to microscopic centre SI/RR Availability of functional DOT Centre SI/RR Treatment of tuberculosis SI/RR Management of Common complication and side effects of treatment SI/RR Linkage for chest X ray and culture sensitivity of Mycobacterium bacilli for diagnosis of TB SI/RR PHC (24X7)

36. 36 Standard Measurable Element Checkpoint Assessment Method Compliance Score ME E Prior to start of treatment patient identity card and and treatment card is prepared SI/RR Medical officer also discuss about near by DOT centre with the patient SI/RR Duplicate treatment card is issued to DOT provider/ community DOT provider if DOT provider is situtated outside the healthcare centre SI/RR Medical officer issue Patient wise box (PWB) for entire duration for treatment to Peripheral Health worker/DOT provider SI/RR

37. 37 Standard Measurable Element Checkpoint Assessment Method Compliance Score The facility provides services under Revised National TB Control Programme as per guidelines Original treatment card is updated at regular intervals by PHW SI/RR All the doses of intensive phase is taken as per guideline SI/RR In continuous phase doses is taken as per guideline SI/RR What action taken by DOT provider if they fail to retrieve such patient What action is taken if patient misses DOT on 2 occasion in Intensive phase Side effects of anti TB treatment is identified by DOT provider and reported to MO SI/RR

38. 38 External Quality Assurance EQA  is a process to assess laboratory performance by comparing laboratory results with a laboratory in higher tier i.e.Intermediate Reference Laboratory (IRL)/ National Reference Laboratory (NRL) through  on-site evaluation, panel testing and random blinded rechecking of slides

39. 39 Key Components of RBRC The sample contains a sufficient number of randomly selected slides to be representative. A system utilizing  Lot Quality Assurance Sampling (LQAS)  method is in use for RBRC. The supervisor of the laboratory (controller) must be unaware of the original result of peripheral laboratory technician to prevent bias, i.e. is “blinded”. Discrepant results are resolved by a second controller. There must be a system to provide timely feedback and improvements to the laboratories that are supervised. RBRC Random Blinded Rechecking   (RBRC) is an External Quality Assurance (EQA) method that provides reliable assurance that a district has an efficient Acid-fast Bacillus (AFB) microscopy laboratory network to support National TB Elimination Programme

40. 40 Internal Quality Control   is a process of effective and systematic internal monitoring of the working practices. It includes technical procedures such as checking instruments, quality of new batches of staining solution, smear preparation, grading, equipment infection control measures, waste management. . For the purpose of IQC, it should be ensured that all staining reagents’ dye content is mentioned on the bottle, concentrated acids are stored carefully in separate containers and stains are filtered before use. Further, after each new batch of reagents is made, Quality Control Positive (QCP) and Quality Control Negative (QCN) slides should be prepared by the Senior TB Lab Supervisor (STLS) for quality control. QCP slides should be prepared by pooling 3+ grade sputum samples, QCN slides are to be prepared by pooling negative sputum samples with an adequate number of pus cells (≥10 pus cells/ field). One set of QCP-QCN slides should be stained by STLS and another set should be given to the Designated Microscopic Centre (DMC) Lab Technician (LT) along with the reagent, and the results of both should be entered in the batch register/ IQC document. All quality control slides should be stored for a minimum period of four months.

41. 41 General points for review during the IQC activities For the microscope, the lens should be cleaned with tissue paper after examining each slide and stored inside a microscope box at the end of the day. The microscope box should contain silica gel and an electric bulb of 10-15 watts for desiccation to prevent fungal growth on the lens. The silica gel should be dehydrated periodically under direct sunlight. All microscopes should be covered under the Annual Maintenance Contract (AMC) with routine preventive maintenance.

42. 42 Usmani F. Quality Assurance vs Quality Control [Internet]. PM Study Circle. Available from: https://pmstudycircle.com/2012/01/quality-assurance-vs-quality-control/ . [Accessed 2021 Jan 11]. Bisoi S. Handbook of Health Planning and Management: Quality Management. 1st ed. Kolkata: Academic Publishers; 2019. World Health Organization (WHO). Universal Health Coverage [Internet]. Geneva: WHO; 2019 [updated 2019 Jan 24; cited 2021 Jan 12]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) . World Bank Group, WHO, OECD. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage. Paris: OECD Publishing; 2018. National Health Mission, Ministry of Health and Family Welfare. National Quality Assurance Standards for Public Health Facilities 2020 [Internet]. New Delhi: Government of India; 2020. Available from: http://qi.nhsrcindia.org/sites/default/files/National%20Quality%20Assurance%20Standards%202020.pdf . Reference

43. 43 Thank You