1. Quality of Health Care services for RSBY Network Hospitals in the State of Gujarat district______

2. Quality in medicine WHO - DALY, LE Long term outcomes -1 yr mortality/ visitation Short term outcomes - Hospital mortally. Process indicators -Response time etc. Structural quality - Availability as per norms 26th September 2012 Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 2

3. 3 Almost 4 years completed by RSBY in state. 28.1 lakh families (approx. 54 lakh population) covered. 29 hospitals (Public-1 and Private-28) empanelled as RSBY network hospitals. No consistent nationally applicable quality improvement process. Introduction of Quality Management System for RSBY Empanelled Hospitals. Introduction 26th September 2012

4. Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 4 – To enable the provision and coordination of health services which are: – Equitable – Patient centered – Safe – Effective – Integrated – Efficient – To maintain continuous improvement in quality of services provided. – To encourage hospitals to achieve levels of quality over a period of time. Objectives 26th September 2012

5. Operational Plan Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 5 Empanelment cum grading criteria 5 Point grading scale (E to A Grade) Comprehensive Quality Criteria Check list provided by Ministry of Labor and Employment Admittance level is “E” Grade Grading mechanism Districts chosen for Pilot (____) Quality Criteria Form Hospitals visited and assessed Analysis and Grade given after assessment 26th September 2012

6. Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 6 Grade-E – Basic Empanelment criteria and entry level. – Includes 10-medical beds, 24 hours drinking water supply, one toilet for every 12 in-patient beds, basic system and internet connectivity. – Medical officer with qualified nursing staff, OT sterilization, PNDT Act followed, clean bed sheet, mattresses, bedpans etc, IPD records, Labor room requirements. – Hospitals not fulfilling Grade-E will be given 3 months time to upgrade to acceptable level. Grading criteria 26th September 2012

7. 7 Grade-D – Grade D is accepted level in RSBY – Includes patient mobility within hospital like ramp, an information provider, documented evaluation and management of patient, informed consent, providing discharge summary and other documents to patient. – OT specifications fulfilling, mopping of all areas of hospital, emergency power back up. – System of registration of patient, provision of privacy, female attendant. – Privacy of patient and emergency power back up etc. – Will be motivated to attain to C Level. Grading criteria-2 26th September 2012 Quality of health care in RSBY : Pilot in the State of Haryana- Ambala

8. 8 Grade-C – Augmenting supportive services. – Dietary services, laboratory, radiological services. – Proper nursing units managed by registered qualified and experienced nurse. – Patient care by medical and nursing professionals, documented rounds, pre-post operative care of patients, arrangements to meet emergency. Grading criteria-3 26th September 2012

9. Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 9 Grade-B – Included Intensive Care Unit. – Blood Bank, documented infection control practices, proper radiology services, mortuary services, – Zoning of OT complex. – AMC of major medical equipments etc. Grading criteria-4 26th September 2012

10. Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 10 Grade-A – 24x7 emergency services. – 24x7 pharmacy facility. – Qualified anesthesiologist to attend ICU. – Hospital management system in place. Grading criteria-5 26th September 2012

11. Grading criteria-6 Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 11 ACCESS AND PHYSICAL FACILITIES Management Availability of Staff Evaluation and Care of Patients Operating Department Laboratory services Radiology Diagnostic Services Infection Control Practices Hospital Waste Management Support Services Access to Blood Bank Patient Rights and Education Medical Records Health and Safety Labor Room ICU 10 inpatient medical beds for inpatient health care. Availability of 24 hours drinking water supply One toilet for every 12 in-patient beds Adequate privacy in OPD Running tap water is facility hospital Warm water for winter months. Access to road allowing to Ambulance Hospital accessible by wheelchair; Ramp Reception desk Emergency electric supply. Maintaining of medical record Documented lines of responsibility Management system in place Written and dated job descriptions Written agreement with working Doctors Regular monitoring and review meeting 1 medical officer & 1 nurse at all times 1information provider at all times Registered nurse qualified and/or experienced per ward There is a system for calling specialists in an emergency Emergency department have MBBS 24x7 basis Pre admission physical examination and medical history taken written informed consent is taken A copy of the Discharge summary / Death Summary is provided to the patient/attendant IPD patients are evaluated at least twice a day After examining the course of action on the OPD card is endorsed If patients are transferred to another hospital copies of their clinical notes accompany them OT sterilisation facilities functional. Adequate lights and Air conditioning in each OT Height adjustable OT Table, shadowless lamp The operating theatre fully equipped for its purpose Informed patient concern andPre-operative care Emergency power supply for OT Zoning of OT AMC for all major equipments. Sterilabels used for autoclaving Test results should be recorded in the Lab registers, requisition slip and on the OPD card A system for registration of all investigations for identification Written, dated and signed procedures for the collection, reception, handling, abeled, storage, transportation and disposal of samples All laboratory equipment is subject to a planned inspection, and calibration Staff are offered appropriate immunisations The services and facilities satisfy statutory requirements under the PNDT Act Test results should be recorded not only in the x-ray registers, requisition slip and the OPD card Female attendant to accompany female patients during radiological procedures Arrangements are in place for dealing with out of hours or emergency requests. There is an in-charge radiology/ or the radiologist Signs IN LOCAL LANGUAGE warning women of childbearing age has dangers of radiation in pregnancy. The protection of staff conforms to the BARC guidelines The waste disposal is in accordance with the Biomedical waste management & handling rules 1998 The health facility has a valid license from the PCB Availability of colour coded Bin in each ward Collection of waste done as per guidelines in wards, OPD,OT, labour room. Waste treated with bleach or any solution before disposal Fresh clean bedsheets and changed when required for the patient. Bed mattresses of the patients are in good shape Clean bedpans and urinal pans and dustbin are available. Dietary services are made available to patients. Hygine delivery in place to the IPDs Laundary system in place The health facility has mechanisms in place for adequate quantity of blood without loss of time. Storage center meets the licensing requirement of the Drugs and Cosmetic Act and Supreme Court rules Blood collected is labeled appropriately with the donors name, registration number, blood group, date and time of collection and date of expiry, tests carried out. There is adequate provision for patient privacy in the form of screens and curtains etc Rights and responsibility of the patients/ Information for patient education are displayed at prominent places in the health facility. The facilities available and services provided and the charges are also prominently displayed There is adequate provision for patient privacy in the form of screens and curtains etc There is evidence that there is a documented grievance redressal mechanism which is practised Maintaining of necessary records as required and providing necessary records of the insured patient to the Insurer or his representative / Government / Nodal Agency as and when required. There is evidence that the hospital has a documented policy on creation and maintenance of medical records which is practiced All emergency telephone numbers concerned with Health and Safety are displayed Pictograms indicating fire exits and escape routes are properly displayed Relevant safety information is available including Safety regulations,Fire precautions, AIDS/HIV/Other guidelines Hospitals records should be maintained on all Accidents,Errors, Incidents,Near misses and Violent episodes. There should be evidence of management action arising from incident reporting i.e. each case is individually investigated, evaluated and acted upon. The Labour room/OT should have Delivery table Anesthetic machine with emergency oxygen supplies resuscitation equipment and drugs for infants and adults There is a suitably experienced and qualified doctor responsible for the day to day management of the unit. A trained mid-wife/nurse is present at every birth. Records kept after discharge include maternity notes and birth registration The hospital has 24 hour on-site cover from qualified medical doctors (including anesthesiologist An emergency power system provides heat and light in the event of a mains power failure. A qualified pediatrician to attend Newborn. Designated air conditioned space Standard ICU bed equipment for the constant monitoring for vitals emergency crash cart, defibrillator ventilators, suction pumps, bedside oxygen facility Anesthesiologist-Intensivist Nursing Staff: B.Sc Nursing/Diploma: have 2 years of ICU care of Ratio 1: or 2:1 Mopping of all areas at least twice a day with disinfectant Shredders / needle destroyers are available in all clinical areas Mechanisms to ensure toilet sanitation (duty roasters for sweepers) Documented Infection control protocols in place Regular documented autoclaving of instruments & linen Carbolisation of the OT, Labor Room after every procedure 17 Sub criteria 26th September 2012

12. Grading -7 26th September 2012 Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 12 CriteriaCount Access and facilities23 Management8 Availability of Staff5 Evaluation and care of inpatient8 Anesthesia4 Operating departments10 Laboratory services10 Radiology services13 Infection control7

13. Grading-8 CriteriaCount Hospital waste management7 Support services7 Access to blood bank6 Patient rights and education8 Medical records3 Health and safety9 Labour room if available6 Intensive care unit4 26th September 2012 Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 13

14. Grading mechanism 14 Districts for Pilot Study Hospitals visited and assessed Empanelment cum grading criteria filled11 Infrastructure and services assessed Analysis and grade given after assessment Grade from E to A 26th September 2012 Quality of health care in RSBY : Pilot in the State of Haryana- Ambala

15. Grading Criteria Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 15 GradeBenchmark Below E less than 15 (the hospital will not be meeting in any of given criteria properly. Grade E15 or less than 50% of D Grade DE (>15) + < 14 of D + 25 % of C Grade CE + D + 80 % of C + 80% of B Grade BE + D + 80 % of C + 80% of B + 50 % of A Grade AE + D + C + B + A E-19,D-32,C-32, B-31, A-24 26th September 2012

16. Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 16 a)Hospitals not meeting detailed empanelment criteria will be given time to improve or would be de- empanelled b)Hospitals meeting just the revised empanelment criteria will be placed in the lowest grade E. These hospitals would continue to be empanelled providers but would be advised to work towards achieving next higher grade within next 3 months failing which it will be de-empanelled. c) Hospitals meeting and exceeding the empanelment criteria would be graded from Grade D-A. ( Follow up 26th September 2012

17. Quality of health care in RSBY : Pilot in the State of Haryana- Ambala 17 Thanks for kind attention More details on: www.rsby.gov.in Or Dr K Madan Gopal madan.kavuru@giz.de kmadangopal@gmail.com 9717773732