How to achieve NABH “Governance” Standards in PHCs
Dr J L MeenaState Quality Assurance Officer
Department of Health & Family welfare
Government of Gujarat
Email:- [email protected]
Web:- www.gujhealth.gov.in/quality-assurance-program.htm304
SECTION – C:Governance Standards
21. Ownership of Building
Objective Elements• A building of the facility to be owned by the
government.• It shall have the approved building plan
along with sanction from the local authorities.
• The X-ray facility (at CHC) shall be approved by AERB.
A building of the facility to be owned by the government
A building of the facility to be owned by the government
It shall have the approved building plan along with sanction from the local authorities
The X-ray facility (at CHC) shall be approved by AERB.
22. Quality Assurance
Objective Elements• The facility shall have a quality assurance
manual.• Standards operating procedures to be available
at various patient care area e.g. OPD, Pharmacy, Lab., Imaging and Wards.
• The manual shall include infection control and waste management issues.
• Safety of patients and staff shall have due consideration in the manual.
The facility shall have a quality assurance manual
Standards operating procedures to be available at various patient care area e.g. OPD, Pharmacy,
Lab., Imaging and Wards
Standards operating procedures to be available at various patient care area at Sub centers.
SOPs for Sub Centers NO. CONTENTS PAGES
Introduction and Brief abut Sub-centers 4
1 Village Health and Nutrition Day 7
2 High risk pregnancy cases Identification and treatment 10
3 Prevention and Treatment in case of Anemia 11
4 Treating 36-38 week pregnancy 12
5 After Delivery care 12
6 High risk Infant care 12
7 Biomedical Waste Management 13
8 Chlorination procedure 14
9 Emergency case transfer procedure 16
10 Treatment in case of Fever
National vector borne diseases Control program
17
11 Treatment in case of Diarrhea 18
12 Treatment in case of Pneumonia – 0 to 5 years 19
13 RNTCP 20
14 NLEP 20
15 NBCP 20
16 Family Planning Program 20
17 School Health Program 21
18 Treatment through Outreach OPD 21
19 Measles outbreak control 21
20 AFP S urveillance 22
21 Village Health Committee Meeting 22
22 Registers at sub centre 22
23 Procedure for Reporting 23
The manual shall include infection control and waste management issues
Safety of patients and staff shall have due consideration in the manual
Objective Elements• Rights and responsibility of the patients shall be
accordance with IPHS.• A citizen charter to be displayed mentioning the
user charges, quality of the services, name of the medical officer with the telephone numbers etc.
• The rights of the patients as a consumer have to be respected and displayed e.g. right to choose, right to deny, right to gather information etc.
• A mechanism for grievance redressal to be in place and practiced.
23. Rights and Responsibility of Patients
318
Rights and responsibility of the patients shall be accordance with IPHS.
319
Rights and responsibility of the patients shall be accordance with IPHS.
A citizen charter to be displayed mentioning the user charges, quality of the services, name of the
medical officer with the telephone numbers etc
A citizen charter to be displayed mentioning the user charges, quality of the services, name of the
medical officer with the telephone numbers etc
The rights of the patients as a consumer have to be respected and displayed e.g. right to choose, right
to deny, right to gather information etc.
All redressal mechanisms to be documented.
A mechanism for grievance redressal to be in place and practiced
• All redressal mechanisms to be documented.• Users and providers will be jointly responsible to
maintain the building of the PHC and CHC in an orderly manner.
• Patients to follow the instruction of the health care providers sincerely.
• The patients have the right to their privacy, information and disease condition that shall not be disclosed to others.
• Citizen charter and rights of the patients should be displayed in local language and should be universal for the state.
23. Rights and Responsibility of Patients Cont…
All redressal mechanisms to be documented.
Users and providers will be jointly responsible to maintain the building of the PHC and CHC in an
orderly manner
Patients to follow the instruction of the health care providers sincerely
Patients to follow the instruction of the health care providers sincerely
The patients have the right to their privacy, information and disease condition that shall not
be disclosed to others
Citizen charter and rights of the patients should be displayed in local language and should be
universal for the state
Citizen charter and rights of the patients should be displayed in local language and should be
universal for the state
Objective Elements• The staff should respect patients' right.• They should carry out their respective job
responsibilities as described in IPHS.• They should demonstrate reasonable skill to provide
care to the patients.• They are entitled to all the benefits (immunization,
healthcare cover through insurance, semi to fully furnished staff quarters as per entitlement and availability, its maintenance and security) due to them by virtue of their employment.
• Employees to be immunized for Hepatitis, Tetanus etc.
24. Rights and Responsibility of Staff
Rights and Responsibility of Staffs
The staff should respect patients' right.
They should carry out their respective job responsibilities as described in IPHS “twins delivery at PHC Salun”
They should demonstrate reasonable skill to provide care to the patients
They should demonstrate reasonable skill to provide care to the patients
They are entitled to all the benefits (immunization, healthcare cover through insurance, semi to fully furnished staff quarters as per
entitlement and availability, its maintenance and security) due to them by virtue of their employment
Employees to be immunized for Hepatitis, Tetanus etc
25. Training Development and Motivation of Staff
Objective Elements• The facility shall arrange for continuous updation
of knowledge and skills of the staff.• Periodic training programs on the subjects of
waste management, infection control, communication etc. to be carried out and documented.
• Training for behavioral change communication shall be carried out and documented.
• Training on all aspects of various national health programs to be carried out.
The facility shall arrange for continuous updation of knowledge and skills of the staff
The facility shall arrange for continuous updation of knowledge and skills of the staff
Periodic training programs on the subjects of waste management, infection control, communication
etc. to be carried out and documented
Training for behavioral change communication shall be carried out and documented
Training on all aspects of various national health programs to be carried out
• Evaluation of all such training to be documented.• Several cash and non-cash incentives to be given
so as to constantly motivate the staff.• All trainings provided must be on both
theoretical as well as practical aspects.• There should be policy on encouragement and
appreciation of performers through incentives and awards.
25. Training Development and Motivation of Staff Cont…
Evaluation of all such training to be documented
Several cash and non-cash incentives to be given so as to constantly motivate the staff
All trainings provided must be on both theoretical as well as practical aspects
There should be policy on encouragement and appreciation of performers through
incentives and awards
NABH ACCREDITATION AWARD FUNCTION BY GOVT. OF GUJARAT & QCI, NEW DELHI
IN “National Conference in Best Health care Practices”.
26. Surveillance of ANMs, LHVs and other Field Workers
Objective Elements• The activities of ANM, health workers female &
male to be reviewed regularly by the Medical officer-in charge (MOIC).
• Feedback mechanisms to exit so as to asses the visits of the above workers in the community.
• PRI to be involved in the surveillance program.• Monitoring of distribution of iron tablets,
motivating patient for institutional deliveries
to be carried out as an on going program.
The activities of ANM, health workers female & male to be reviewed regularly by the Medical officer-in charge (MOIC)
The activities of ANM, health workers female & male to be reviewed regularly by the Medical officer-in charge
(MOIC)
Feedback mechanisms to exit so as to asses the visits of the above workers in the community
Centre should have in use feedback mechanism like use of feedback forms, suggestion forms to be dropped in suggestion / complaint
boxes at identified places
Centre should have in use feedback mechanism like use of feedback forms, suggestion forms to be dropped in suggestion / complaint
boxes at identified places
PRI to be involved in the surveillance program
Monitoring of distribution of iron tablets, motivating patient for institutional deliveries to be carried
out as an on going program
• The field workers shall have sufficient materials for their use.
• A training and motivational program to exist for the above workers.
• Validation of the process should be carried out by higher authorities.
26. Surveillance of ANMs, LHVs and other Field Workers Cont…
The field workers shall have sufficient materials for their use
A training and motivational program to exist for the above workers
A training and motivational program to exist for the above workers
Validation of the process should be carried out by higher authorities
27. Public Private Partnerships
Objective Elements• The organization shall proactively participate in
various public private partnership e.g. referring patients for ultrasound to a private practitioner on the basis of an agreed terms and conditions.
• Involving a private provider for scavenger services.
• Involving a private transporter for transporting patients.
The organization shall proactively participate in various public private partnership e.g. referring patients for
ultrasound to a private practitioner on the basis of an agreed terms and conditions “108”
• Launch Date : 29th August, 2007 (14
Ambulances).
• Existing Fleet of : 506 Ambulances.
• Calls Answered : 99% in Two Rings.
• Total Emergencies Attended: 24,99,025
– Medical : 24,64,721
– Police : 29,066
– Fire : 5,238
• Pregnancy Related Cases: 8,25,616
• Trauma: 3,86,063
• Cardiac: 1,24,371
• Lives Saved: 1,23,879
• Deliveries in Ambulance & at Scene: 22,011
The organization shall proactively participate in various public private partnership e.g. referring patients for
ultrasound to a private practitioner on the basis of an agreed terms and conditions “Chiranjeevi Scheme”
Total Deliveries
under Chiranjeevi
scheme
Estimated Maternal
Death
Maternal death
reported under CY
Mothers saved
under CY
Estimated Early Neo-
Natal death
Early Neo-Natal death
reported under
Chiranjeevischeme
Early Neonates
saved
689127 1020 102 918 33078 2305 30773
Outcome of Chiranjeevi Scheme: ( Up to September-11)
Normal Deliveries: 612495
C-Section: 42895 (6.2%)
Complicated Deliveries: 33737 (4.9%)
Private specialist enrolled: 646
(Source: State MIS)368
Involving a private provider for scavenger services “Institutional Delivery”
The organization shall proactively participate in various public private
partnership
- PHC Salun building is donated by Mrs. Sudhaben Patel, London &
PHC Jetalpur building donated by Swaminarayan sanstha
The organization shall proactively participate in various public private
partnership
Involving a private transporter for transporting patients
28. Pricing and Services
Objective Elements• Unifield pricing mechanism as per the policy of
the state concerning the user fee to be applied.• Patients to be informed about the charges.• Always a receipt to be given to the patients.• Proper accounting of the collections to be
maintained.
Patients to be informed about the charges
Always a receipt to be given to the patients
Involving a private transporter for transporting patients
Proper accounting of the collections to be maintained
Objective Elements• A mechanism for micro health insurance
through a co-operative approach to exist so as to cater to the requirements of the patients.
• PRI and co-operative society to be involved to arrange for certain basic expenses for the patients.
29. Community Based Health Insurance
A mechanism for micro health insurance through a co-operative approach to exist so as to cater to the
requirements of the patients
PRI and co-operative society to be involved to arrange for certain basic expenses for the patients
Through Rogi Kalayan Sameeti (RKS)
30. License and Statutes
Objective Elements• All licenses to be available in the facility e.g.
Narcotics, Waste management, BARC, AERB, fire safety etc as applicable.
• Statutory requirements concerning patient and staff safety and welfare shall be met with.
All licenses to be available in the facility e.g. Narcotics, Waste management, BARC, AERB, fire
safety etc as applicable
Biomedical waste management & handling rulesLicense for procurement, storage and use of spiritRegistration of vehicleNOC from fire safety officerCertificate for FARBuilding safety certificatePermission for building construction
Statutory requirements concerning patient and staff safety and welfare shall be met with
Biomedical waste management & handling rulesLicense for procurement, storage and use of spiritRegistration of vehicleNOC from fire safety officerCertificate for FARBuilding safety certificatePermission for building construction
31. Local Social Customs
Objective Elements• Respect for local social customs to be given by
the organization.• Myths concerning health availing practices to be
evaded e.g. taking of local pudia for viral hepatitis (jaundice), isolating post partum mothers etc.
Respect for local social customs to be given by the organization “Gaytri Yagan”
Respect for local social customs to be given by the organization “Gaytri Yagan”
Myths concerning health availing practices to be evaded e.g. taking of local pudia for viral hepatitis
(jaundice), isolating post partum mothers etc
32. End of Life Care
Objective Elements• Center to provide appropriate respect and
dignity to the dying and the dead.• All death cases to be recorded and reported.• Death certificate (MCCD-Medical Certificate for
Cause of Death) to be issued to the next of kin.• Centre should carry out Death Audits
periodically.
Center to provide appropriate respect and dignity to the dying and the dead
S. No. Detailed NC = 0 PC = 5 FC = 10
1
All weather approachable road with Road light
and sounding cleanliness.
2
Counseling room with table and chairs for Doctors
and relatives.
Human Anatomy Charts Male & Female (Internal
&External body Part).
3 Office Room contain as per below.
Table and Chairs for Doctors.
Storage space for supplies (Gloves, Apron, Gum
boots, Goggles, Agarvati, Machish and Masks as per
requirements).
Storage space for equipment (PM Set, Suturing
material, Cotton, Bandages, Electric saw for cutting of
the skull bone, Empty Specimen bottles and salt as per
requirement etc).
Cold Storage space (Domestic freeze) for specimens.
Storage space for dead body cloths.
Within 48 hrs specimen and cloths should be giving to
the police.
End of life care (Mortuary Facility) Checklist
NC (Non Compliance = 0), PC (Partial Compliance = 5), FC (Fully Compliance = 10)
S. No. Detailed NC = 0 PC = 5 FC = 10
4 Post Mortem (Autopsy) Area.
Proper Exhaust facility.
Post mortem platform (Autopsy table) with 24 hrs running
water and proper drainage facilities.
Proper space around Post mortem platform (Autopsy table).
Work counter with a sink equipped for hand washing.
A deep sink for washing of specimens.
Proper Natural or near Natural light.
Proper Biomedical waste facility.
Display the Standard Operation Procedure (SOP) for
Autopsy.
5 Refrigerated facilities for dead body holding.
Refrigerators for dead body holding.
Display the Standard Operation Procedure (SOP) for
Refrigerators.
Regular temperature monitoring of Refrigerators with
regular AMC & CMC.
Cabinet for record keeping.
Proper Exhaust facility.
NC (Non Compliance = 0), PC (Partial Compliance = 5), FC (Fully Compliance = 10)
End of life care (Mortuary Facility) Checklist
S. No. Detailed NC = 0 PC = 5 FC = 10
6 Cleanliness of the postmortem room.
Every day once in a morning with high
concentrate (2 %) Sodium Hypocloride
Solution.
Immediate after Autopsy clean with high
concentrate (2 %) Sodium Hypocloride
Solution.
Detailed Cleaning with standard methods
(Walls, windows, doors, cabinets, Fens,
instrument, equipment and surrounding area
etc) at least once in a week.
All instruments, Equipment should be clean
with high concentrate (2%) Sodium
Hypocloride Solution.
7 Proper signage's.
NC (Non Compliance = 0), PC (Partial Compliance = 5), FC (Fully Compliance = 10)
End of life care (Mortuary Facility) Checklist
Center to provide appropriate respect and dignity to the dying and the dead
All death cases to be recorded and reported
INFORMATION OF INFANT MORTALITY RATE
P.H.C.-JETALPUR
sr. no. Year
Total
live
birth
Child Death of 0 to 1 year
Total IMR -24 hour 1 to 7 Day
8 to 28
Day
29 day to 1
year
1 2004-2005 1069 6 3 3 5 17 15.9
2 2005-2006 842 14 5 6 11 36 42.85
3 2006-2007 878 5 10 7 5 27 30.75
4 2007-2008 901 6 4 4 6 20 22.2
5 2008-2009 920 8 8 5 2 23 25
6 2009-2010 915 5 7 3 4 19 20.8
Death certificate (MCCD-Medical Certificate for Cause of Death) to be issued to the next of kin
Centre should carry out Death Audits periodically
Centre should carry out Death Audits periodically “Causes of < 5 mortality & Neonatal Mortality”
Centre should carry out Death Audits periodically
Health for All