Quality Assurance

Quality Assurance is a program under National Health Mission (NHM) which was launched in November 2014. The program was started in the state of Mizoram since December 2015.

Perceptions of poor quality of health care may, infact, dissuade patients from using the available services because health issues are among the most salient of human concerns. Ensuring quality of the services will result in improved patients/clients level outcomes at the facility level.

Ministry of Health and Family Welfare, Government of India is committed to support and facilitate a Quality Assurance Programme, which meets needs of 

 System in the country and is sustainable. Main focus of proposed Quality Assurance Programme would be enhancing satisfaction level among users of the Government Health Facilities and reposing trust in the Public Health System.

 

Objectives:

·        Facilitate establishment of an inbuilt and sustainable Quality Assurance Mechanism in the Public Health Facility where patients are provided prompt & effective healthcare with privacy and dignity.

·        Setting up quality standards, Measurable Elements & Checklists to provide consistently high quality services. The foremost requirement is to set quality standard -National Quality Assurance Standard (NQAS) against which the performance can be measured.

·        Certification of all Public Health Facilities for NQAS

·        Provide Quality Health care to all citizens of the country in an equitable manner.

 

Vision:  By the year 2030, QA aims in making all health facilities within the state to   

achieve the National Accreditation (National Quality Assurance Standards     Certification).

 

 

 

 

 

 

State Quality Assurance Committee (SQAC):

The broad responsibility of this committee will be to oversee the quality  assurance activities across the state in accordance with the national & state’s  guidelines, and also ensure regular and accurate reporting of the various key indicators.

Members:

1.     Secretary, Health & Family Welfare Dept              -        Chairperson

2.     Mission Director, NHM                                        -        Vice Chairperson

3.     Director of Health Services                                    -        Convener

4.     State Nodal Officer (QA)                                                -        Member Secretary

5.     Director, Hospital & Medical Edu.                        -        Member

6.     Director, ATI                                                        -        Member

7.     Joint Director (Nursing)                                        -        Member

8.     CMO, Aizawl East                                                         -        Member

9.     CMO, Aizawl West                                               -        Member

10.                        Medical Superintendent, CHA                              -        Member

11.                        SPO (RCH)                                                          -        Member

12.                        SNO (RKSK)                                                       -        Member

13.                        SNO (NVBDCP)                                                  -        Member

14.                        SNO (NTEP)                                                        -        Member

15.                        SNO(NLEP)                                                         -        Member

16.                        SNO (NUHM)                                                      -        Member

17.                        SNO (NCD)                                                         -        Member

18.                        SNO (CPHC)                                                       -        Member

19.                        State Immunization Officer                                -        Member

20.                        HoD,           Obs.& Gynae., CHA                         -        Member

21.                        HoD, Surgery, CHA                                             -        Member

22.                        HoD, Anaesthesiology, CHA                                -        Member

23.                        HoD, Paediatric Medicine, CHA                           -        Member

24.                        HoD, Medicine, CHA                                           -        Member

25.                        Director, Synod Hospital Durtlang                        -        Member

26.                        Law Officer from State Law Department               -        Member

27.                        President, IMA Mizoram Sate Branch                   -        Member

28.                        Survellance Medical Officer, WHO                        -        Member               

 

 

 

 

Process of SQAC:

1. The state quality assurance committee will meet at least once in six months.

2. The convener will issue meeting notice at least seven working days before the scheduled date of meeting with the approval of the chairperson/ vice chairperson.

3. While every attempt should be made to ensure that the chairperson and/or the vice-chairperson are able to attend the meeting, however, in the absence of the chair, the Convener shall have the right to convene the meeting and conduct it according to the set agenda. Under such circumstances, the minutes of the meeting should be sent to the chairperson and vice chairperson for information and ratification.

4. The member secretary will ensure the preparation of the agenda notes for meeting, minutes of d. the last meeting and Action Taken Report (ATR), which will also be circulated in advance to all committee members, at least seven days before the scheduled date for the meetings.

5. An attendance by at least one-third of the Committee members will constitute the quorum required for a valid meeting.

6. Member secretary will ensure follow-up actions with responsibilities and timelines for the same.

7. The “State Family Planning Indemnity Subcommittee” would meet as often as warranted at least three members would constitute the quorum of this subcommittee.

 

 

 

 

 

 

 

 

 

 

State Quality Assurance Unit (SQAU):

SQAU is the working arm under SQAC that will be responsible for undertaking various activities as per ToRs of the unit, and other tasks, as entrusted to them from time to time by the SQAC.

Members:

1.     State Nodal Officer of programme divisions

2.     State Consultant (Quality Assurance)

3.     State Consultant (Public Health)

4.     State Consultant (Quality Monitoring)

5.     Administrative cum programme assistant

The SQAU is headed by the SQAC’s member Secretary, who along with the State Programme Officers provide support to the SQAC for implementation of QA activities in the state. All the positions of this unit should preferably be regular from the state cadre, however in case of non- availability from the state cadre, the post at Sl. No. 3 – 6 can be hired under NRHM till the posts are filled in from the State Cadre.

The number of full time technical persons (consultants) may be increased once the state decides to expand QA for the Disease Control and other programmes as part of the mandate of the State QAC

 

Process of SQAU:

The terms of reference for the SQAU remain the same as of SQAC, since it is the working arm of SQAC. However, some of the important activities of the SQAU are listed below:

1. Adapt check-lists for RMNCH-A services (as well as for Disease Control Programme) to match the state needs.

2. Develop a plan for the Quality Assurance at each level of health institution in a phased manner.

3. Orient the state level assessors, district level QA units on the quality standards, tools for assessment and improvement plans, and the processes to be followed for QA activities. Assistance of QI Division of NHSRC may be taken for organizing the orientation programme.

 

4. Disseminating the quality assurance guidelines & tools and methodology to be followed at district and sub-district level.

5. Develop a field travel plan for independent and joint (with District team) visits to the Districts by member of the State QAU and programme officers.

6. Following these visits, prepare draft report and recommendations for review.

7. Mentor the Programme Officers and facility in-charge at the Districts for improvement measures at the facilities.

8.Compile and collate monthly data received from districts on KPI, especially those related to cases of adverse outcomes/complications in maternal, neonatal & child health; maternal, infant & child deaths (all cases), disease control programmes and share it with the SQAC members and discuss at the SQAC meeting.

9. Send the regular reports on sterilisation related indicators (deaths, complications, failures) to the Centre after ratification of the same by the Chairperson of SQAC.

10. Review the implementation of the National Family Planning Indemnity Scheme/ payment of compensation in the state, based on reports received from the districts as well as from the visits undertaken by the QAU members.

 

 

 

 

 

 

 

 

 

 

 

District Quality Assurance Committee (DQAC):

The broad responsibility of this committee will be to oversee the quality  assurance activities across the distict in accordance with the national & state’s  guidelines, and also ensure regular and accurate reporting of the various key indicators.

Members:

1.     Deputy Commissioner                                          -        Chairperson

2.     Chief Medical Officer                                            -        Convener

3.     Senior Medical Officer                                          -        Member Secretary

4.     District Med. Superintendent                                 -        Member

5.     In charge of CHC & PHC                                     -        Member

6.     District TB/Immunization Officer                          -        Member

7.     Senior-most Gynaecologist                                    -        Member

8.     Senior-most surgeon                                             -        Member

9.     Senior-most Medical Specialist                              -        Member

10.                        Senior-most Anaesthetist                                       -        Member

11.                        Senior-most Paediatrician                                      -        Member

12.                        NS of District Hospital                                          -        Member

13.                        One representative from the legal cell                    -        Member

14.                        One member from private sector/NGO(health care sector)        

15.                        One member from medical professional bodies    

           

Process of DQAC:

1. The district quality assurance committee will meet at least once in a quarter.

2. The convener will issue meeting notice at least seven working days before the scheduled date of the meeting with the approval of the chairperson.

3. While every attempt should be made to ensure that the chairperson is able to attend the meeting, however, in the absence of the chair, the Convenor shall have the right to convene the meeting. Under such circumstances, the minutes of the meeting should be sent to the Chairperson for information and ratification.

4. Member secretary will ensure the preparation of agenda notes, and action taken reports, which will be circulated in advance to all committee members preceding the DQAC meetings.

 

5. An attendance by at least one third of the Committee members will constitute the quorum required for a valid meeting.

6. Member secretary will ensure follow-up actions with responsibilities and timelines for the same.

7. The “District Family Planning Indemnity Subcommittee” would meet as often as warranted.

8. At least three members would constitute the quorum of this subcommittee

 

 

District Quality Assurance Unit:

DQAU is the working arm under DQAC that will be responsible for undertaking various activities as per the ToRs of the committee and also entrusted to them from time to time by the DQA Committee.

Members:

1.     District Family Welfare Officer/RCHO/ACMO/equivalent (head of DQAU)

2.     One Clinical (Surgical/Medical)

3.     District Consultant (QA)

4.     District Consultant (Public Health)

5.     District Consultant (Quality Monitoring)

6.     Administrative cum Program Assistant

The DQAUs is headed by the Member Secretary DQAC, who along with the District Programme Officers provides the support to the DQAC for implementation of QA activities in the district. All the positions of this unit should preferably be regular staff from the government. However, in case of non- availability of the regular cadre staff, posts at sl. no 3 to 6 can be hired under NRHM till the regular cadre become available.

                       

 

 

 

 

          Process of SQAU:

1. Ensure roll out of standard protocols for RMNCH-A services (as well as for Disease Control 1. Programme implementation).

2. Develop a plan for the Quality Assurance at each level of health institution in a phased manner.

3. Disseminating the quality assurance guidelines & tools and methodology to be followed at district and sub district level.

4. Develop a field travel plan for independent and joint (witth State teams) visits to the health facilities in the districts by members of the DQAU.

5. Following these visits, prepare the draft report and recommendations.

6. Mentor the facility in-charges at the districts for implementing quality improvement measures at the facilities.

7. Compile and collate monthly data received from facilities on outcome level indicators, especially those related to cases of adverse outcomes/complications in maternal, neonatal & child health; maternal, infant & child deaths (all cases), disease control programmes and share it with the DQAC members and discuss with DQAC meeting.

8. Send the regular reports on sterilisation related indicators (deaths, complications, failures) to the State after ratification of the same by the Chairperson of the DQAC.

9. Review the implementation of the National Family Planning Indemnity Scheme/ payment of compensation in the district, based on reports received from the facilities as well as from the visits undertaken by the DQAU members.

 

 

 

 

 

 

 

 

 

Kayakalp

Award to public health facilities was launched in October 2015 by the Health & Family Welfare Dept, Government of India. It is a National Initiative to give awards to those public health facilities that demonstrate high levels of cleanliness, hygiene and infection control. There are categories – District Hospital (DH), Sub-District Hospital/Community Health Centre (SDH/CHC), Primary Health Centre (PHC) and Urban Primary Health Centre (UPHC).

 

Objectives:

·        To promote cleanliness, hygiene and infection control practices in public health care facilities.

·        To incentivize and recognize such public healthcare facilities hat show exemplary performance in adhering to standard protocols of cleanliness and infection control.

·        To inculcate a culture of ongoing assessment and peer review of performance related to hygiene, cleanliness and sanitation.

·        To create and share sustainable practices related to improved cleanliness in public health facilities linked to positive health outcomes.

·        To link performance under ‘Mera Aspataal’ (Clients satisfaction) under Kayakalp scheme.

 

State Level Award Nomination Committee

Members:

1.     Mission Director, NHM       -        Chairperson

2.     Deputy Med. Superintendent, State Referral Hospital

3.     Central YMA, Health & Sanitation Sub-committee chairman

4.     SE (Monitoring), Office of Engineer in chief, PHE

5.     Member Secretary, Mizoram State Pollution Control Board

6.     All members of SQAC.

           

The ToRs of this committee would be to:

1.     Disseminate the criteria and methodology of this National Initiative to public healthcare facilities in the state.

2.     Constitute state level external assessment team for the purpose of facility assessment and scoring

3.     Enable training of external assessors on the defined criteria.

4.     Co-ordinate the process of assessment and validation of internal scores.

 

 

5.     Finalize the list of award winners and runners up based on the assessment.

6.     Facilitate an award ceremony at the state level and transfer award money to the respective facilities.

7.     Resolve any conflict during the nomination and assessment process.