About National Health Mission quality of care initiatives

Limatula Yaden


When the National Rural Health Mission was launched in 2005, the focus was on improving access to healthcare services ,particularly in rural and hard to reach areas. With improvement in access over the years, the focus shifted to improvements in quality of care being delivered through health systems.


National Quality Assurance Standards


Under 12th five year plan,all government and publicly financed private health care facilities were expected to achieve and maintain Quality Standards for which an in-house quality management system was to be built into the design of each facility, that will regularly measure the quality of care. Accordingly, the National Quality Assurances Standards (NQAS) were issued under the National Health Mission (NHM) in November 2013. The National Quality Assurance Standards are organised around eight ‘Areas of Concern’:

  1. Service Provision
  2. Patients’ Right
  3. Inputs
  4. Support Services
  5. Clinical Services
  6. Infection Control
  7. Quality Management and
  8. Outcome.


NQAS is a process-centric standard and it has received international accreditation from International Society of Quality in Healthcare (ISQua), which is a global body, providing accreditation to healthcare standards worldwide. The standards have also been recognised by the IRDA (Insurance regulatory & development authority) for empanelment of the hospitals.


The Quality Assurance (QA) programmerevolves around finding the gaps in each area of concern, as well in each department of health facility, followed by prioritisation of the gaps, and action planning for closure of the gaps. The facilities are required to develop departmental Standard Operating Protocolsand implement them, meeting regulatory compliances such as Blood Bank Licences, Authorisation for Biomedical Waste, Atomic Energy Regulatory Board requirement, Fire Safety, etc., strengthening system of infection control, instituting a system of external quality assurance in hospital laboratories, creating amenities for patients & their attendants, etc.The States are expected create a pool of assessors to conduct assessment on the basis of the National Quality Assurance Standards. After a health facility has successfully closed gaps, which is verified by the state team, the facility may go for the quality certification, for which, assessment of health facilities is undertaken by the empanelled assessors. The empanelment is done by conducting assessor training, arranged by National Health System Resource Centre (NHSRC), which is the technical arm of NHM in GOI . Participants, who successfully complete the training and clear the examination, are empanelled as Assessors.


The district hospital quality team conducts initial assessment of the hospital, followed by assessment of weak areas every month. The findings are shared with the District Quality Assurance Unit (DQAU)and invites the DQAU members to conduct assessment. In case the facility achieves 70% score in the assessment conducted by DQAU, it can apply for the State Level QA certification. For State level certification, the DQAU shares the scores with the State Quality Assurance Unit (SQAU). In case the facility achieves 70% score in the assessment conducted by SQAU, it receives state level certification.


The empanelled assessors at National level then conduct assessment and the facility obtaining 70% or more score and also meeting other criteria is given national certification. An incentive of Rs. 10000/- per bed per year on attaining National certification and maintaining it in the subsequent years is provided to the facility.


Bothe financial and technical support is provided both for closure of gaps as well as for human resource at State level for State quality Assurance units, at District level for District quality Assurance units and at facility level for Quality team. Nagaland has engaged 1 State Consultant and 5 District Consultants.State also has 36 certified Internal Assessors and 3 External Assessors.


Assessment of 10 facilities (9 DH, 1 UPHC) isreported to have been conducted in the State, of which only 1 facility score more than 70%. State had committed for Certification of 1 DH at national level and 5 facilities at state level for NQAS certification in FY 2018-19. However, while UPHC Seikhazou , Kohima wasreported to be certified at state level , it underwent National NQAS Assessment in January 2019 and the NQAS Certification was deferred as the facility did not meet all the required criteria approved by Central Quality Supervisory Committee.Now, reassessment of UPHC Seikhazou is planned to be undertaken shortly. DH Kiphireis reported to be NQAS Certified at State level.


Under NHM funds are being approved under FMR 13 with budget head Quality Assurance.


Kayakalp

Preventing Spread of infection through pathogens such as bacteria or viruses is important in many public places such as schools, leisure centres and work places or community gathering, etc., but it is more important and critical in healthcare facilities. Cleanliness, or Swachhta, is one of the most important aspects of preventive healthcare. People visiting health facilities are already susceptible to the infection due to their lowered immunity and they can carry back these germs to their families, so it is important to make sure that effective cleaning mechanism are in place for patient care areas as well as waiting rooms, corridors, reception areas.A clean environment in healthcare facility is also of utmost important for comfort and dignity of patients. It reflects the concern of health facility towards patients, their families and communities.Besides it supports creation of safe and positive environment for working healthcare provider staff.The perception of patients and the public regarding the level of cleanliness and ambience of a facility directly affects the level of confidence they have in the health care offered in a facility. There is no more visible parameter about Quality than cleanliness in public health facilities.


Hence asa complementaryto the quality initiatives, ‘’Kayakalp – Awards to public Health Facilities was launched as a national Initiative in 2015 to give awards to those public health facilities that demonstrate high levels of cleanliness, hygiene and infection control. The award scheme is currently applicable to District Hospital, CHC, SDH and PHC. The awards are distributed based on the performance of the facility on the following parameters that are tabulated to scores:


• Sanitation and hygiene
• Infection control
• Hospital Upkeep
• Waste Management
• Hygiene Promotion
• Public Participation
• Area outside the boundary wall of hospital/health centre


The awards are given based on three tier assessment -Internal, Peer and External assessment for public health facilities under NHM. The State, District and facility levelQuality team also looks after the implementation of Kayakalp also.


Awards to District Hospitals /CHC and SDH/PHC are as below:

Best two Community Health Centres/Sub District Hospitals are awarded in large States while the award is limited to one in small States.


Commendation awards are given to those facilities that score 70% and above. As per the guidelines 25% of the award money may be given to the staff of the award winning facility as incentive. The weightage of the scores are broadly as below:

Funds for Kayakalp are being approved under sub head FMR- 13.2 under broad head of Quality Assurance. The Kayakalp Guidelines are available at


//nhm.gov.in/nhm/index1.php?lang=1&level=1&sublinkid=197&lid=136
Approvals given to Nagaland in the last five years are as below:

The reported prize winners are as under:

Biomedical Equipment Management & Maintenance Programme

To ensure functionality of equipment in hospitals and health centres, Guidelines on Biomedical Equipment Management and Maintenance Programme (BMMP), was issued. The envisaged uptime of bio medical equipment is 95% in District hospitals, 90% in Community Health centres, and 80% in Primary health centres.Uptime is the ratio of the total time during which an equipment is operational or the production time to the total available time, that is the total time for which the equipment is available.The implementation of Biomedical Equipment Management and Maintenance Programme (BMMP) is aimed at providing assured quality diagnostics services in public health facilities, thereby reducing cost of care and improving the quality of care particularly for poor patients.


Under this initiative, not only should the functionality of bio medical equipment be maintained as per guidelines but the emphasis is also on preventive maintenance and timely calibrations to ensure accurate diagnosis.For implementing this the state should have carried out an inventory mapping of all biomedical equipment and then segregate them to functional, repairable and those to be junked. NHM provides support for equipment mapping as well as for outsourcing medical equipment maintenance comprehensively for all the equipment across all the facilities through an open transparent tender process.The guidelines are available at


//www.nhm.gov.in/nhm/index1.php?lang=1&level=3&sublinkid=1224&lid=586


The approvals given to state for implementing this programme in the last five years are as under:


(Rs in lakhs)

Funds for BMMP are being approved under sub head FMR- 6.1.3.1.Bio Medical Equipment Maintenance & Management Programme (BMMP)has reportedlybeen implemented in the State and is out sourced to Sindoori Faber under an MoU signed on 2016.


Limatula Yaden, the writer is Commissioner, Indirect Taxes and Customs and served as Director NHM Policy, Ministry of Health and Family Welfare, Government of India for over 6 years . The views expressed are personal.