How to achieve NABH “Governance” Standards in PHCs

Dr J L MeenaState Quality Assurance Officer

Department of Health & Family welfare

Government of Gujarat

Email:- drjlmeena@gmail.com

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