1. Quality Assurance for RH services Maharashtra

2. How we defined quality “ Attributes of a service program that reflects adherence to professional standards, in a congenial service environment and satisfaction on part of the user”

3. RCH Quality Framework for Assessment RCH facility based Services to be assessed INPUTSPROCESSOUTPUTS Family Planning  Building  Infra-structure  Equipment  Personnel- training  Supplies  Clinic-wide procedures e.g.-Schedules, Hygiene, Asepsis  Technical competence  Client Provider interaction  FP method mix  Complications  Follow-up Maternal Health including abortion care and infection prevention  ANC/PNC  Norms at Deliveries  Complications managed RTI/STI and HIV  Lab tests  Case treatment  Follow-up Child Health/Immunisation  Cold chain maintenance  Safe injection practices  AD syringe use and disposal

4. Coverage under QA 2006-07 - Pilot project in Ahmednagar 2009-10 - Six Districts covered (Riagad, Kolahpur, Aurangabad, Chandrapur, Ahmednagar and Akola) 2010-11 - Six additional Districts covered (Amrawati, Jalna, Thane, Satara, Wardha and Nashik) 2011-12 - Six more districts added (Jalgaon, Buldhana, Parbhani, Beed, Osmanabad and Bhandara) Operationalized during 2012-13 2013-14 - Program expanded to cover entire State with NRHM support.

5. Overview of QA program Unique internal system of quality assessment and improvement. Assessments conducted by DQAG teams ( Officers from district health system) Action plans for quality improvement prepared on the day of the visit itself. Followed up through meetings, field visits for taking corrective actions. Assessors are themselves mentors.

6. Quality Assurance Process Internal and external users Assess Analyze Plan Action Improve ment Monitor Find Gaps Prioritize and suggest solutions Implement Reassess

7. Implementation frame work Creating structures at state and district level – State QA cell PHI and SFWB key implementing partners Appointment of state QA consultant – District QA cell Identification of Nodal Officer for QA Appointment of QA coordinator Processes for QA implementation – Selection of health institutions (Initially 50 in each district expanded to additional 25 facilities in Phase I and II districts) – Formation of District Quality Assurance Group (DQAG)- CS, DHO, Specialists – Training of DQAG members – Conducting QA assessment of identified institutions – DQAG meetings

8. Institutional structure for Implementation of QA District level structure DQAG was created under chairpersonship of Civil Surgeon/DHO as part of expanded scope of district FP Quality Committee Space, Computer, data entry Operator provided to District QA cell Identified a Nodal Officer for QA District Quality Coordinator was appointed 20-24 members were identified as members of DQAG from the district level programme managers, clinical specialist, doctors, faculty of DTT/HTT, PHN and staff nurse

9. Health Facilities covered 1231 in 18 Districts

10. Type of Health Facilities covered

11. QA: The process Creating an enabling environment Orientation workshops held for district level Officials and service providers to explain purpose and processes of QA Workshops were held to orient medical officers on purpose and process of QA initiative. (Informed that QA is not fault finding or monitoring exercise) QA checklists shared and explained MOs were told to hold similar orientation for the facility and field staff during regular monthly meeting

12. QA: The process….Contd Capacity building of DQAG members DQAG members trained for 4 days on quality assurance, concepts, assessment and improvement Training was skill oriented and focused on: – assessment of quality of RH services using checklists – briefing and debriefing of facility staff – findings gaps in quality of care – Helping the facility staff to think about options for addressing the gaps for improving quality – helping facility staff to develop a work plan for quality improvement

13. QA: The process….Contd Live and vibrant checklists Input indicators Process assessment Output indicators NRHM interventions and state specific schemes Questions in the checklist are designed to make objective assessment, there is no scope for subjectivity Separate checklist developed for SDH/CHC, PHC and SC

14. Steps in a QA visit Briefing in-charge and other staff of the facility Collecting data using quality checklist Analysis of data, determining overall quality of RH services using total scores and finding gaps Sharing summary findings with facility staff Discussion with the facility staff on sub-elements with low scores and assess root causes Discuss possible and doable solutions Help facility develop quality improvement action plan with responsibility of implementation clearly defined

15. Facility Grades based on quality assessment Category Aggregate Score Category A+91Percent and above Category A76 -90 percent Category B51-75 percent Category C26-50 percent Category DUp to 25 percent

16. Quality Improvement Facility In-charge accountable to take action on plan prepared for improvement by DQA team. 60-70 percent gaps in quality need local action, which facility In-charge can take using NRHM/RCH untied funds and involving RKS. In cases of 20-25 % gaps, district level actions are required. State level interventions are needed to address 10-15% gaps. Quality assessment provides an opportunity to identify gaps in infrastructure and other inputs for which the facility or district could plan in next year’s district PIP especially when these inputs needs more resources than what is available as flexible or untied funds.

17. Key Achievements Overall improvement in quality of indicators at majority of facilities. Improvements in key issues like BMWM, physical amenities, cleanliness, availability of equipments, medicines etc. Increase in output indicators and utilization of services in some facilities. Increased awareness of MOs and staff on issues related to quality and client satisfaction.

18. Quality Improvement in facilities- Phase I districts. Percentage of facilities in category A and A +

19. Quality Improvement in additional facilities- Phase I districts. Percentage of facilities in category A and A +

20. Quality Improvement in facilities- Phase II districts. Percentage of facilities in category A and A +

21. Quality Improvement in additional facilities Phase II districts. Percentage of facilities in category A and A +

22. Findings of Evaluation of QA project knowledge and awareness about Quality processes and indicators among facility in- charge and staff better in QA facilities than non-QA facilities. Significant increased consciousness amongst staff about ‘Quality’ of RCH services Major responsibility to improve quality taken up by persons from within the system. Minimal additional HR involved.

23. Key recommendations of the evaluation The QA action plans have met grand success in resolving issues at the facility level, moderate success at the district level issues; however, almost no efforts were made for resolution of issues at the state level. Issues not resolved at State level Availability of skill mix at SDH/RH Availability of trained MOs in Minilap, MTP, NSV at PHC Training in RTI/STI- Mos, Staff Nurses, LHVs, Lab.Tech Training in SBA for ANMS Training in BEmOC for MOs Availability of Protocols and guidelines

24. Gaps not addressed at District/ facility level Cleanliness and Infection Prevention Practices (segregation and disposal) Empanelment of trained MOs. Availability of referral Register. Availability of sterilization case cards and consent forms. Availability of equipment such as emergency tray, oxygen cylinder, suction apparatus, etc. as per prescribed standards. Registration of ARI/diarrohea for under 5 yrs.

25. How gaps were addressed DQAG members act as mentors and help facility staff bridge identified gaps. Monthly meetings of DQAG with CS/ DHO to discuss action taken report on gaps identified. Participation of State QA consultant in District meetings. Quarterly review meetings at State level.

26. Challenges- Systemic issues Vacancies and high turn over of staff Lack of ownership and interest especially by clinical members of DQAG leading to cancellation or rescheduling of some visits Lack of willingness to involve civil society Ensuring commitment from district level program mangers for Quality assessment and improvement through monthly review meetings, sparing members for QA visits and timely action on district level actions identified for improvement Constitution of DQAG and keeping it together as a cohesive group

27. Other Challenges Changing strategy to address differential needs of persistently better and laggard health institutions on quality indicators Developing strategies for universal coverage in context of local realities Maintaining motivation level of health facility staff and DQAG members

28. Learnings It is a feasible and effective intervention Majority of gaps in quality of care can be addressed at local level, some at district level and only few at state level It provides many collateral benefits such as team building and on job improvement in knowledge and skills Local capacities can be developed to reduce dependency on external support for implementation and up-scaling With community involvement it becomes more effective It is a cost effective intervention

29. Forging Ahead Initiated a pilot for synergy between CBM and QA in Beed District. After QA Assessment and preparation of action plan a meeting of DQAG team members, MS/MO & staff and CBM NGO members as well as RKS members is organized at the facility to discuss the action plans prepared under QA and under CBM. The QA action points are followed up by CBM NGO members when they visit the facilities for CBM work. Process for incorporating a gender index as part of the checklists underway.

30. Synergy between RMNCH+A and QA Main objective common- Addressing identified gaps for client satisfaction. Checklists- QA checklists comprehensive covering input, process and output indicators and could be used for monitoring. Visits- In RMNCH+A, One District monitor visits two- three facilities a day. In QA a four member DQAT visits 10-15 facilities a month. Visits more meaningful. Could the two be clubbed and District Monitors become part of DQA Group?