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
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1. Quality improvement ISO 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 :
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
Providing Training/ Building Capacity
Implementations of process and protocols
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
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
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.