Quality improvement ISO experience IN EAG STATES

1. Quality improvementISO experience  IN EAG STATES National Health Systems Resource Centre (NHSRC), New Delhi 9/21/2012

2. PILOT PROJECT IN EAG STATES In line with the objectives of NRHM to enhance quality of services in Govt. Hospitals and strengthen Indian Public Health (IPHS),NHSRC took up a pilot project for improving the quality of services at one district hospital each in eight EAG states respectively Ministry of Health &Family Welfare sent a request letter to all eight EAG states respectively to select one district hospital for the project. The selection of the district hospital was done by the state authorities.

3. Project Objective To facilitate quality improvement as applicable to public health facilities based on : participatory management, patient�s perception rational utilisation of untied funds equity and access To hand hold the health care facility on site through continued presence of competent personnel duly supported by other experts, towards achievement of prevailing ISO 9001 standards and to sustain it.

4. Methodology Detailed Organisational Survey for �As- Is� study Gap Analysis: mainly against the IPHS & other allied standards Action planning to traverse gaps Documenting processes Providing Training/ Building Capacity Implementations of process and protocols Evaluation O O

5. Need for Technical support partners Service of technical support team was obtained for each hospital who provided :- Personnel and know-how for �as-is� survey, for action planning, for continued handholding on site, and for supervision. Development of training and advocacy materials: Audio Visual aids, print materials for all participants/ employees. Implementing Customised training . Materials for quality system documentation: for distribution amongst all document holders

6. Selected Hospitals and certification Status

7. Action Planning Gaps Identified and Categorized: Gaps where local action was required Gaps where district administration�s action was required Gaps where Higher level intervention is required

8. GAPS Categories of Gaps by theme :-

9. Gap Category 1-Safety Security & Dignity Patient�s privacy during general/internal examination in OPD remains compromised

10. Gap Category 1-Safety Security & Dignity

11. Gap Category 2-Regulatory Requirement X ray machines are operating without Atomic Energy Regulatory Board(AERB) clearance

12. Gap Category 2-Regulatory Compliance

13. Gap Category 3- Administrative Process Below Poverty Line (BPL) status verification process causes inconvenience to BPL patients

14. Gap Category 3- Administrative Process

15. Gap Category 3- Administrative Process

16. Gap Category 3- Administrative Process

17. Gap Category 4-Clinical Process While it is ensured that injections are given to the patients, no practice exists to ascertain that admitted patients have actually consumed oral medicines

18. Absence of Blood Bank or Storage Unit Gap Category 4-Clinical Process

19. Gap Category 4 - Clinical Process

20. Gap Category 5-Support Process Common food is served to patients irrespective of their needs. No special provision is made for patients with special conditions like diarrhea, diabetes, hypertension etc.

21. Rodents create a nuisance and cause damage to equipment wires and kitchen food. Gap Category 5-Support Process

22. Gap Category 5-Support Process

23. Gap Category 6- Human Resources The Cycle time of testing and reporting for common tests exceeds one day

24. Gap Category 6 -Human Resources

25. Gap Category 7 -Infrastructure Seepage problem in the walls of the OT, wards, and other sections of the hospital building

26. Gap Category 7-Infrastructure

27. Gap Category 8 -RCH While 80% of newborns at the District Hospitals receive the 1st dose of vaccination, only 14% of the children complete their immunization. There is no system to trace the progress of vaccination in the remaining newborns

28. Inability of most registered pregnant women to complete the three ANCs and receive treatment for severe anaemia. In addition, only 28% of registered mothers receive two doses of Tetanus Toxoid. Gap Category 8 -RCH

29. Gap Category 8 -RCH

30. Gap Category 9 - TOOLS TACKLE EQUIPMENT Clinical skills are available in one of the hospitals, but support equipment to make full use of these skills is not

31. Gap Category 9 - TOOLS TACKLE EQUIPMENT

32. Gap Category 9 - TOOLS TACKLE EQUIPMENT

33. I. GAPS WHERE LOCAL ACTION WAS REQUIRED  The action plan was developed with the name of responsible person and timelines for addressing the gap Review of progress was done on a regular basis Majority of the gaps could be addressed at facility level. Untied funds was used for this purpose

34. II. THOSE GAPS WHERE DISTRICT ADMINISTRATION�s ACTION WAS REQUIRED The issues were collated and were discussed during RKS meeting The review of such issues was in the early stages done once a month during RKS Meeting. Later, spontaneously meeting frequency increased at much higher frequency Use of RKS Funds and mobilization of funds from other District schemes

35. III. Those gaps where Higher level intervention WAS required  NHSRC coordinated the process of gap filling which required state directorate support . Several meetings were held with Director, Mission Director and secretary besides other officials in the States where Project was undertaken Most of the issues at this level had either financials or policy related implications. This role has to be continued by SHSRC/ State level Support arrangements

36. Gaps which needed State Support Human resource shortage Infrastructural development Blood Bank and blood storage facility Procurement of Drugs, Equipment and Consumables . AMC for maintenance of equipments Mobilizing Engineering wing for building maintenance State guidelines for outsourcing services like cleaning, security, laundry, kitchen ,supplementary power supply, Ambulance services, pest control services

37. CHANGES??????????

38.

40. UTILIZATION OF SERVICES for ipd

41. UTILIZATION OF SERVICES for IPD & emergency Department

42. UTILIZATION OF SERVICES no. of deliveries

43. UTILIZATION OF SERVICES for c- section

44. UTILIZATION OF SERVICES for USG & X ray department

45. UTILIZATION OF SERVICES � No of sterilization & JSY beneficiary

46. INCREASED RKS EXPENDITURE

48. Patient satisfaction INDEX

49. Patient satisfaction INDEX

51. Key Constraints Frequent transfers of Civil Surgeons Lack of convergence amongst PHED, PWD, Electrical Department and the Hospital Poor availability of Data and Records Shortage of key personnel Apprehension amongst the Doctors about the process

52. Key Learning's External Support can catalyze the process of Quality Improvement in the public hospital Despite constraints �situation and leadership in the peripheral hospital is not adverse for Quality improvement initiatives��. and service level can be made to look up. Commensurate improvement is achievable for any given level of inputs.

53. Scaling up: A possible approach: From now up to 400 hospitals in two year and 2000 in three years. Build up state level capacities within SHSRCs and with hospital management institutions. Put a professional hospital administrator(MHA ) in place in every hospital above 100 beds and more for higher number of beds . Train a team of four to five in every hospital(above 100 beds) to implement a QMS system. After a certain level of achievement, provide to such hospitals more intensive external support and formal certification(ISO� or any other). Every facility must have annual plan to achieve its targets and to move towards IPHS status through cyclic improvements. Incentivize QMS and make a policy framework.