Shimla Report (Workshop On Quality)

4th-8th June, 2008, Shimla
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Workshop for
Senior and Mid-level
Managers on Improving
Quality of Care in Health Sector
NIHFW
Organised by: Supported by:
Partner for the Future.
Worldwide.
Jointly Organised by
National Institute of Health and Family Welfare
and
World Bank Institute with Technical Support of GTZ
Baba Gang Nath Marg, Munirka, New Delhi 110067
Email: director.nihfw@nic.in
Website: www.nihfw.org
Report
4th-8th June, 2008, Shim la
W orkshop for Senior and M id-level
M anagers on Im proving
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NIHFW
Organised by:
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Supported by:
Worldwide.
Jointly Organized by National Institute of Health and Fam ily
W elfare and W orld Bank Institute with Technical Support of GTZ
Report
3 Quality of Care in Health Sector
Contents
S. No. Page
Abbreviations 4
Preface 5
Executive Summary 6
Background 7
Record of Proceedings 10
Overall Course Framework and Strategy 25
Next steps 29
Annexure 1: Workshop Agenda 32
Annexure 2: Workshop Presentation by Ms. Sylvia Sax and Dr. Monika Krengel 34
Annexure 3: Workshop Presentation by Ms. Sylvia Sax 37
Annexure 4: Presentation by Dr. Aniruddh Mukerjee 41
Annexure 5: Presentation by Dr. Preeti Kudesia 49
Annexure 6: Presentation by Dr. Monika Krengel 52
Annexure 7: Presentation by Dr. Raghu, Block Medical Ofcer 58
Annexure 8: Workshop Terms of Reference and Results: Group work 1 65
Annexure 9: Workshop Terms of Reference and Results: Group Work 2 69
Annexure 10: An Introduction to NIHFW 74
Annexure 11: List of Participants 75
AHA Academy of Hospital Administration
CHC Community Health Centre
CMOs Chief Medical Ofcers
DQCG Directorate of Quality Core Group
EFQM European Foundation for Quality Management
GOI Government of India
HAP British Hospital Accreditation Program
HRD Human Resource Development
IPHS Indian Public Health Standards
ISO International Organisation for Standardisation
J CI J oint Commission/ US
MOHFW Ministry of Health and Family Welfare
NABH National Accrededited Board of Hospitals and Healthcare providers
NIHFW National Institute of Health and Family Welfare
NRHM National Rural Health Mission
OPD Out Patient Department
PDCA Plan Do Check Act
PHREC Public Health Research and Education Consortium
PLA Plan, Learn and Act
QA Quality Assurance
QACs/ Gs Quality Assurance Cells/ Groups
QAP Quality Assurance Programme
QC Quality Circles
QCG Quality Core Groups
QCI Quality Council of India
QI Quality Initiatives
QM Quality Management
QR Quality Representative
RCH Reproductive and Child Health
SIHFW State Institute of Health and Family Welfare
SMOs State Medical Ofcers
SOPs Standard Operating Procedures
SQCG State Quality Core Group
STG Standard Treatment Guidelines
UNFPA United Nations Population Fund
WBI World Bank Institute
WHO World Health Organisation
Abbreviations
Quality of care in the health sector is a priority. Policy makers in our country have been struggling to probe and
decide on the quality indicators which could be integrated in the existing and new initiatives for desirable
outcomes. In this direction, a workshop on Developing Training Curriculumfor Improving Quality in Health
Sector was conceptualised and conducted for senior and mid-level health managers at Shimla in J une, 2008.
We, at the National Institute of Health and Family Welfare, thank the World Bank Institute for actively
collaborating with us in this initiative and helping us in organising this workshop.
Special thanks are due to the teamof Prof. Peter Berman, Ms. Alexandra Humme and Ms. Sheeja Nair for their
constant support. GTZtook the initiative to invite international experts - Ms. Sylvia Sax and Dr. Monika Krengel
to facilitate the workshop and lead the teamof experts to develop the curriculum. Their efforts are laudable.
Dr. J .P. Steinmann, Programme Advisor, GTZ, Dr. K.B. Singh, Mr. S. Malikarjuna, Mr. Amit Paliwal and Ms. J hanavi
Das fromGTZdeserve special thanks for their support.
We owe our gratitude to Ms. Aradhana J ohri, IAS, J oint Secretary, Ministry of Health and Family Welfare for her
guidance and support to this activity. Dr. I.P. Kaur, Dr.Dinesh Boswal and Dr. S. Sikdar fromMOHFW, GOI are
sincerely thanked for their valuable advice. We are grateful to Dr. Dinesh Agarwal, UNFPA, Dr. Praveen Srivastava
and Dr. S.K. Das, Government of India (GoI), for sharing the documents on Quality of Care.
Thanks are due to all the experts at the workshop, who took time out fromtheir very busy schedules to attend
and to enrich the deliberations with their vast knowledge and experiences to design a suitable curriculum.
The workshop could not have been organised at a short notice without the hard work put up by
Dr. A.K. Bharadwaj fromShimla and his team.
Prof. Deoki Nandan
Director, NIHFW
Preface
The mission of development of a Quality Management Course Curriculum towards improving quality of care in
health sector in the formof a workshop from4th-8th of J une, 2008 was carried out at Shimla, India.
The mission was divided in two phases:
1. Facilitation of a workshop on Planning and Designing a Training Course for Improving Quality of Care in the
Health Sector.
2. Drafting of curriculum, identication of further requirements and discussions on training contents and tools.
The objective of the curriculumdevelopment was: To design the framework of a course for mid-level health
ofcials on Improving Quality of Health Care so that they are able to conceive and frame policies and
strategies to improve the quality parameters in the health care systemat all levels.
Expected Outcomes were: A course framework for addressing quality issues by state level health ofcials,
suggestions for course materials and case studies; an agreed way forward on how to implement the course.
The decision to develop a nation-wide course reects: (i) a situation of extreme shortage of resource persons for
providing training in quality management in health care, (ii) the need to integrate and exchange efforts and
good practices fromdifferent states and institutions, and (iii) the need to build capacity amongst policy makers
in quality management.
The course would contribute to the capacity building of policy makers and faculty members and other trainers
and teachers involved in quality management.
By the end of the mission, a draft curriculum(Annexure 9), based on training gap analysis, prioritisation, etc.
was developed, presented and discussed with all stakeholders, including faculty members of NIHFW,
representatives of the World Bank and GTZ, HSS. The approach and outcomes, documented and presented by the
international experts, were well received by the audience. Suggestions on how to continue with the formulation
of the contents and materials to be used in the course are mentioned as curriculumessentials in the report. It is
planned to nalise the further preparations by the end of October, 2008 and to conduct the rst workshop
during the second half of November, 2008.
Executive Summary
Workshop for Senior and Mid-level
4th-8th June, 2008 Shimla
Background
Increased investment by the government in social sectors like health and education over the last few years has
generated widespread interest not only in the outcomes but also raised serious concerns about the quality and
sustainability of these outcomes. In the past twenty years , the concept of improvement of health systems has
moved away fromtop down control, compliance and punishment towards bottomup development , selfregulation
and incentives; quality measurement has also shifted fromresource inputs to performance outputs. It is widely
acknowledged that in spite of the wealth of experience in quality the problemfrequently faced by policy-makers
at country level is to know which quality strategies complement or can be integrated with existent strategic
initiatives to have the greatest impact on the outcomes delivered by their health systems despite available
funds. The failure of quality initiatives lies in too much focus on standards and measurement rather than on
changing the way people and organisations work. The report of the National commission on Macroeconomics and
health attributes failures in the health systemto poor governance and dysfunctional role of the state, lack of
strategic vision and weak management.
It has been clearly established that any sustainable change in terms of institutionalisation of Quality Assurance
(QA) will come fromwithin the systemand not fromoutside. The GTZalong with other donor partners is
supporting the government of India and the states to develop a comprehensive framework and an achievable
plan to improve the quality and safety of the health system.
A WHOreview has broadly classied the approaches to quality improvement into the following categories (also
called the strategic framework):
Empowerment of consumers
Institutional development
Management development
Clinical practice development
Professional development
Currently in India the environment is very conducive for integrating strategies to improve quality in the health
system. There is a strong political commitment for such action and increased funding to the sector. The
Government of India under the National Rural Health Mission (NRHM) has re-emphasised the need to enhance
quality of care in the health sector. The NHRM though focussing on rural health in general and RCH in particular,
also seeks to dene standards (the Indian public health standards) at all provider levels which relate primarily to
the availability of services, staff and equipment. However, the Ministry of Health and Family Welfare,
Government of India is actively pursuing improvements in the quality of reproductive and child health (RCH)
care provided through the vast network of public health institutions, RCH/ sterilisation camps and outreach
services. Assessing continuous improvement in the quality of RCH services is one of the thrust priorities of the
NRHM/ RCH II programme. In order to establish and institutionalise quality assurance and improvement in RCH
services, an attempt is being made to set up a functioning District Quality Assurance Cells.
The Family Planning Division of GOI has formalised the Quality Assurance Cells( QAC) and by now all the states
in the country are having a state and district quality assurance committee. Most of themhave also updated
these QACs as per the new pattern of memberships as per the guidelines of GOI. The challenge, therefore, is to
operationalise these very QACs. An operational manual has also been developed by UNFPA.
A course curriculumshould be developed keeping in view the membership prole of these committees since the
ambit of these committees have been enhanced by including the maternal health, child health and other
RCH activities also.
Recently a need assessment study was carried out jointly by NIHFWand WBI in three states, namely UP, Rajasthan
and Orissa. It has brought out the need for training health ofcials at state and district levels in improving the
systemand service delivery through capacity building, to initiate and implement the various reformprocesses
initiated in the health sector especially the Quality Assurance in the systemand service delivery.
To take forward these objectives, NIHFWin collaboration with WBI and with technical support of GTZ, organised
a workshop to plan and design a training course for improving quality of care in health sector within a strategic
framework so that quality does not remain the purview of few but of the whole workforce in the health sector.
Hence the main purpose of the workshop was to design the framework for a course on Improving Quality of
Health Care for senior and mid-level health ofcials including the members of the District Quality Assurance
Group, so that they are able to conceive and frame policies and strategies to improve the quality parameters in
the health care systemat all levels.
The consensus building approach adopted, was a stakeholders workshop with a mix of experts national and
international in quality assurance for hospital and health sector as a whole.
The participants were represented by the following categories (Annexure-11):
1. Ofcials fromthe Ministry of Health and Family Welfare
2. Ofcials fromthe Health Departments of State Governments and Training Institutions
3. Faculty fromNIHFW
4. Experts fromHeidelberg University
5. Representatives fromDevelopment Partners
6. Representatives fromPrivate sector, Hospitals, Associations, Medical Colleges, Academic Institutions, etc.
1. The World Bank has established a website and databank for the collection of training material, case studies, literature, as a supportive instrument for
the development and execution of courses. They will continue this activity and it is planned to later hand this over to the NIHFW.
2. See Quality Assurance for District Reproductive and Child Health Services in Public Health System. An Operational Manual, Ministry of Health and
Family Welfare, Government of India, New Delhi, April 2008; Quality Assurance Manual for Sterilisation Services, Research Studies & Standards Division
Ministry of Health and Family Welfare, Government of India, October 2006.
The methodology used in the workshop was plenary discussion to outline the existing situation and share the
results of the pilot projects conducted by GTZ, World Bank and UNFPA. After assessing the various options
available, the members were divided into groups to brainstorm, do gap analysis and prioritisation on the ve
areas of Strategic Frame Work according to given TORs and come out with suggestions which were then
presented in a plenary session. This process was carried on till an agreed upon consensus was reached about the
contents to be included in the course. The course would contribute to the capacity building of policy makers,
faculty members and other trainers and teachers involved in quality management courses.
The international experts Ms. Sylvia Sax, University of Heidelberg, Germany, and Dr. Monika Krengel, EPOS Health
Consultants, Germany, facilitated the whole workshop with the support of faculty members of NIHFW, especially
Prof. Madhulekha Bhattacharya, Dean of Studies and the coordinator of the course. The mission was guided by
Prof. Deoki Nadan, Director, NIHFWand supported by the inputs fromthe World Bank Institute team, Ms. Alexandra
Humme, Dr. Preeti Kudesia and Ms. Sheeja Nair. Mr. Amit Paliwal and Mr. S. Mallikarjuna, fromGTZHSS, also
accompanied the mission.
The objective of the curriculumdevelopment was: To design the framework for a course for Top and Mid Level
Health Ofcials on Improving Quality of Health Care so that they are able to conceive and frame policies and
strategies to improve the quality parameters in the health care systemat all levels.
The outcomes were:
Course framework for addressing quality issues by state and district level health ofcials
Suggestions for course materials and case studies
An agreed way forward on conduction of the course.
Following the workshop, the teamof international experts, Ms. S. Sax and Dr. M. Krengel worked with the faculty
at NIHFW, to further work out the details and nalised the course curriculum. The agenda (Annexure-1) of the
workshop was followed and the salient features of the day wise deliberations are given in the report.
Record of proceedings
4th June 2008
Inaugural session of the workshop was chaired by a panel comprising of Prof. Deoki Nandan, Director, National
Institute of Health and Family Welfare, Ms. Alexandra Humme, fromthe World Bank Institute, Ms. Sylvia Sax,
expert fromGTZand Dr. Madhulekha Bhattacharya, Dean of studies and Head, Community Health Administration,
National Institute of Health and Family Welfare and coordinator for the workshop. The session began with Prof.
Deoki Nandan extending a warmwelcome to all the participants, mainly comprising of the ofcials fromthe
WBI, GTZ, Ministry of Health and Family Welfare, Government of India and states, experts fromrelevant elds
and the faculty fromthe NIHFW(list annexed). This was followed by a self introduction by the participants.
In his opening address, Prof. Deoki Nandan gave a brief introduction of NIHFWon being an apex training
Institute in the eld of health and Family Welfare and specially highlighted the collaborative activities with the
development partners and the PHERC(Public Health Education and Research Consortium) initiative. Emphasizing
on the need for a course on quality assurance in healthcare, he hoped that the workshop would provide the
desired platformfor designing the same. Ms. Alexandra Humme dwelled on the fruitful partnership with the
NIHFWand explained the importance of quality management in healthcare. Elaborating on its agship
programme on Quality, she emphasised on the need for public private partnership in health combined with high
levels of accountability. Ms. Sylvia Sax gave a brief insight into the Quality course being conducted by the
Heidelberg University. This was followed by a vote of thanks by Prof. M. Bhattacharya.
Plenary Session: began with Prof. Bhattacharya explaining the objective and the expected outcomes of the
workshop.
Ms. Sylvia Sax and Dr. Monika Krengel presented the strategy/ approach for Quality Assurance (Annexure-2)
to be adopted during the workshop as given below:
Empowerment of consumer
Ms. Sylvia Sax in her presentation on Improving Quality of Care in India (annexure-3) explained the denition
and dimensions of quality. She presented a simple model for quality including the (PCDA) quality cycle. And how
it should be applied to the systempyramid which depicted involvement of functionaries at all levels responsible
for achieving quality.
A panel discussion on dimensions of quality had the following members as panelists for the discussion:
Dr. P.H Rao, Prof., Adminstrative Staff College of India, Hyderabad.
Dr. S.K Sikdar, Ministry of Health and Family Welfare, New Delhi
Mr. Bejon Misra, VOICE (A consumer organisation), New Delhi
Dr. N.A Khan , Academy of Hospital Administration, Noida
Dr. C.A.K Yesudian, TATA Institute of Social Sciences, Mumbai.
Prof. Deoki Nandan, Director, NIHFW.
Dr. B.S Garg, Prof. & Head, Deptt. of Community Medicine, Medical College, Wardha.
Dr. Bhattacharya initiated the panel discussion with the following questions:
Why quality was on the agenda?
How quality assurance needed to be institutionalised?
And why it was important to value quality?
Taking the panel discussion further Dr. Monika put forth before the panelists the following two questions:
What are the priority areas for improving quality services in India?
At what level in the health sector should the main efforts be directed to bring about this improvement?
Summary of Panel Discussion
Need to keep the quality focus on secondary and primary health services.
Quality vs. quantity dilemma in health care
To create a competitive environment in the health sector.
Creating quality awareness by implementing quality at both district and community level.
Quality standards should be made uniformly applicable to both the public and the private sector as the same
would also facilitate the public private partnership model for delivery of healthcare.
Building of the human resource capacity for implementing quality.
Infrastructure and development of standards (IPHS)
patients charter and an effective complaint redressal system
Skill development for managing consumer complaints/ disputes.
Need for dening quality
3 As viz accessibility, availability and adaptability in relation to quality.
Building empathy and communication skills in the cadres involved in healthcare.
Change should start fromsomething of immediate need and visibility
Link medical education with service delivery and to extend quality to beyond life services like post mortem.
Community version of health rights
Curriculumto manage the needs of the poor
Guidelines for healthcare providers
Prescription and provision of Drugs
Build in accountability for quality in both government and private
Training on statutory regulations, standards and audits.
Audit not a fault nding exercise but rather a monitoring mechanismlegislation for consumers (Right to
information),
Cost of poor quality, generating resources for quality
Customer needs internal, external, community should be an essential reference point for all quality
initiatives, including right to information Emphasis on health and safety, customer protection (legal
dimensions) and emergency of care.
Political understanding and will to improve quality
Change frommanagement to leadership
Customer Feedback to providers as an opportunity to improve
Standards to be communicated to patients in a user friendly and understandable way
Communities and consumers to be involved in planning, to have joint responsibility
Mr. Bijon Misra informed about the Hospital ranking study which had been published recently in magazine of
Consumer Voice. Dr. N.A Khan made a power point presentation on the objectives of his academy (AHA) and
briey informed about the courses and programs being run by themespecially the ones relating to improving
quality and role of National Accrededited Board of Hospitals and Healthcare providers (NABH) and the Quality
Council of India (QCI)
5th June 2008
Ms. Sylvia Sax and Dr. Monika Krengel gave a presentation on Strategic Framework for Quality Improvement in
Health
Quality Challenges in Health
Health organisations are complex systems clinical standards not enough
Cultural and organisational challenges
Competing power structures politicians, Ministries and Departments, doctors, nurses, managers
Greatest challenge is to build capacity to manage these complexities
The principles and strategies of the strategic framework for improvement were explained. The pillars of the
strategic framework was slightly changed fromthe framework given in GTZ
Consumer empowerment, protection, information, education, focus
Institutional development, regulations, framework, set-up
Management
Evidence based practice
Leadership and Human Resource Development
The presentation concluded with a note on the need to develop methods and tools for the above mentioned
strategies keeping in view the cultural acceptability and also identify the ones responsible to implement,
monitor, evaluate and adapt the same.
Dr. Annirudh Mukherjee made a presentation on QAP in West Bengal. The quality initiatives at primary level
piloted in district Hoogly, and at the secondary hospital level piloted in two district hospitals and one sub
divisional hospital. The secondary level initiative and the focus was mainly on standards and documentation.
The excel sheet based standard checklist (37 standard elements and 11 quality circles) developed was also
demonstrated (Annexure 5).
The learning points were:
Keep on harping that QAP is not being enforced fromthe top- make it part of the system.
Identify champions in the systemand utilise themin initial period. After some time QA becomes a culture.
Overcome initial scepticismwith intense hand holding- authorities at higher levels should show personal
involvement
Keep focus on documentation- only policies and SOPs that are written get practiced
Keep documents simple- no document should cover more than 1 side of an A4 paper in 10 font size
Address training needs of all staff- keep themshort, simple and focussed to needs
Develop a monitoring and evaluation plan right fromthe beginning
Develop measurable indicators for monitoring
Be patient- the start of the programme requires in extra effort. Hurrying up may be counter productive.
However, ask the facilities to prepare their timelines and monitor that they are being stuck to
Facilitation should be on site as far as practicable
Ensure physical comfort in all activities
Scale up with caution, QA requires intense hand-holding
The presentation by Dr. Preeti Kudesia, World Bank (Annexure 5) was on the state experiences of the secondary
level hospital, quality improvement and management. The focus of the approach adopted was explained through
the following case studies in a project undertaken by them:
The Quality improvement processes were:
Drug inventory and Rational Use of Drugs
Standard Treatment Protocols/ Guidelines
Guidelines for action in emergency, OT, Labour room, OPD
Equipment Maintenance
Audits (case sheets, death reviews, prescription audits)
Patient Flow Management (time spent at different sites, overcrowding)
Hospital timings and rationalisation of duty hours
Healthcare Waste Management
Further dwelling on the mechanismof monitoring and evaluation, the key tools identied were hospital
information systems, activity and performance indicators, quality indicators, bench-marking and grading. The
other areas, critical to quality initiatives were housekeeping, free services for the disadvantaged populations and
behavioural changes in service providers. The presentation concluded with an enlisting of processes pertaining
to quality enhancement and hospital systems improvement teams and process (HSIT).
A short lmon quality improvement through HRD under the Maharashtra Health Systems Development Project
(World Bank) was screened.
Dr. Monika Krengel made a presentation on Quality Management (QM) initiatives in Hospitals at Himachal
Pradesh. A diagrammatic presentation of the QM process was given along with the structure and levels of
responsibility and how the development of standards took place through RUMBA approach. (Annexure 7)
The salient points of presentation are given below.
Steps of Introducing QMin HP
2002-2004: Basic Assessment, formation of Quality Circles, Quality Core Group and Quality Representatives in
6 Pilot Hospitals - 2004 onwards:
1. Development and testing of Standards, using the Standards of the British Hospital Accreditation Programme
as a model for adaption, in 13 Hospitals (1st batch QM hospitals).
2. Establishment of Directorate Quality Core Group (DQCG) and attempt to establish an Inter-sectoral Quality
Group.
3. Surveyor training and conduction of Self Assessments against the Standards, followed by gap analysis and
action planning in 26 Hospitals in 2005-2006 (1st and 2nd batch QM hospitals).
4. Training of Peer Reviewers and conduction of external Peer Reviews in 13 hospitals (1st batch).
5. Conducted case studies in 6 pilot hospitals (2006).
6. Re-establishment of State Quality Core Group (SQCG) in 2006.
7. Further revision of Hospital Standards (Version 3) in 2007
Tasks of the Hospital Quality Core Group (QCG)
Formulation of Hospitals QM Strategy and Policy
Sensitisation of Staff and awareness raising for quality improvement
Annual action planning and review of activities
Identication of training needs and development of training plans
Support and supervision of Quality Circles and activities
Reporting of QM progress to the Directorate
Tasks of the Quality Representative (QR)
Mediator between staff, QCand QCG
Report to QCGon the performance of the QCand progress of QM improvement plans
Monitoring, evaluation and documentation of QM activities, including follow up of the Annual Action Plan
Tasks of Quality Circles (QC)
Identify problems or areas for improvement
Analyse problems or processes
Identify solutions
Prepare Action Plans
Implement Improvement measures
Development of HP Hospital Standards
Steps in Quality programme for setting standards
The project and members of the Directorate studied and compared Standards and QM systems used by other
countries, e.g. EFQM (European Foundation for QM), ISO, J CI (J oint Commission/ US), British Hospital
Accreditation Program(HAP)
Outcome
Basic contents and principles of all standards are very much the same: e.g. focus on patient satisfaction, on
processes (instead of infrastructure), and on leadership and communication.
The Himachal Pradesh Standards were selected as a model, because they were:
designed for small and middle scale hospitals,
Easily understandable, detailed and not leaving much scope for Interpretation
The British and the Indian Health Systemhave some similarities
HAP allowed the Government of HP to use their standards as a model
The HAP Standards were reviewed and customised to local requirements through intensive group work at
hospital (5 regional groups) and directorate level, following the RUMBA approach. Is the Standard
R Relevant
U Understandable
M Measurable
B Behavioural (culturally acceptable and practical) and
A Achievable (within the next 5 years)
Review and integration of local/ national laws and regulations, e.g. Consumer Protection Act, Regulation of
BIS, was done and new relevant criteria were added.
It took about 6 months to draft the rst version (J une to Dec. 2004), and another 9 months (J an to Sep
2005) for testing and drafting of the second version.
The third version of the HP Hospital Standards was reviewed by members of the SQCGand printed in 2007.
Some Achievements and Benets of Quality programme
Himachal Pradesh is the rst State in India that developed and applied Hospital Standards for the Public
Sector, that provide a monitoring tool for performance and improvement.
Compliance with the Standards is already quite satisfactory (40 % in the rst Self Assessment, improved to
53 % in the second Self-Assessment.
A teamapproach for problemsolving and quality improvement has been initiated in all QM hospitals,
through Quality Circles.
Action planning and monitoring with an emphasis on Quality Improvement takes place for the rst time in
those hospitals.
Rationalisation of facilities/ manpower and improved resource utilisation has started.
Innovative models for local good practices are implemented: e.g. improvement and monitoring of patient
satisfaction and communication, medical records, signage, bio-medical waste management, health and
safety, repair and maintenance of medical equipment.
More scope for staff initiative and education and for exchange of best practices.
The Quality of healthcare in the QM Hospitals has visibly and measurably improved, following the approach
to focus on promotion of competition between hospitals and introduction of low-cost incentives and
learning through the exchange of best practices.
Easy reachable, visible and mandatory changes, like improvement of sanitation, signage, patient information
and safety.
Strengthening of communication skills and means.
Most hospitals accepted QM as an opportunity to strengthen their position towards the Centre, Court
(consumer protection act) and Politicians
Efcient knowledge transfer, through emphasis on high coverage in reaching professionals; see large amount
of trainings and workshops and successive inclusion of all districts (examples),
A group of about 20-30 key professionals who actively used concepts and material developed in their
environment and developed tools on their own, like in-house training modules for staff, standard operating
procedures, draft publications on safety issues, rst aid and so on (even starting websites),
A good documentation and dissemination of all trainings, workshops and tools
The next presentation was by Dr. Raghu, Block Medical Ofcer, CHC, Nagarota (Annexure 7) on implementing
quality. He expressed quality as :
1. Achievement of pre-dened Standards / Targets.
2. Doing the right thing in right way at right time.
3. Generating resources and using themfor further improvement
4. Minimizing Conicts.
He explained the mechanismof monitoring standards through formation of quality core group and quality
circles. He outlined the specic policies and procedure adopted to operationalise quality. He informed about the
facility of a medicine bank, suggestion box, the format of the patient exit formand the effort on funds
generation. He explained how the income generated was being used to improve the surroundings and for the
repair and maintenance of the equipments and infrastructure of the hospital.
He concluded by thanking GTZand the Rogi Kalyan Samiti for their support to the quality initiative.
Ms. Sylvia made a presentation on the key elements of curriculumdevelopment in which she explained the
concept of the hierarchy of competencies and the general principles and the processes to be followed while
developing a curriculum.
Group work 1 on Strategic framework
The participants were split into the following ve groups based on the ve pillars of the strategic framework for
implementing quality:
Group 1-Empowering consumers (EC)
Group 2-Institutional development ( ID)
Group 3-Management (M)
Group 4-Evidence based practice(EBP)
Group 5-Leadership and human resource development (L)
Ms. Sylvia enlisted the participants group-wise and explained the terms of reference (TORs) for the gap analysis
for curriculumdevelopment for each group separately given at annexure 8.
Prof. Deoki Nandan, Ms. Sylvia, Dr. Monika and Dr. Preeti Kudesia were the oating facilitators (common to all
groups).The groups were required to select amongst themselves a chairperson, a rappoteur and a presenter, if
required.
6th June 2008
The ve groups were given three hours to deliberate on the questionnaire given to themon the gap analysis.
Each group was then required to make a presentation on their group work deliberations and conclusions:
Workshop Results Group Work 1
Common Themes
Group Theme Further details Who should be
responsible
EC
EBP
M
Dissemination of services available at
various facilities (citizens charter),
(including Evidence based education
for patients)
Lack of dissemination of information to
consumers regarding their rights and
responsibilities
Preparation of CCs, services available,
benets available for vulnerable
section and fromwhere, rights and
responsibilities of external/ internal
clients?? EBP
ALL IECactivities should focus on
above EBP
Programme ofcers
and Hospital
Managers EBP
EC Guaranteeing service availability
EC Making services transparent and
accountable
EC Effective complaint redressal
mechanisms at the service delivery
points
Patient/ Clients feedbacks, large scale
surveys, exit interviews ,
questionnaires should be used in a
regular manner EBP
Hospital Managers
and respective
Programme
Manager/ PMU EBP
responsible
EBP Case Management Decisions to be
based on Standard Treatment
Guidelines
Improved medical record keeping,
proper collection, collation, etc.
Developed and
implemented by the
state authorities
Peer review process
based on STG
EBP
L
Standard Treatment Guidelines
Checklist/ standards at different levels
of health care facility and staffs
Developed and implemented by the
state authorities
Peer review process based on STG
EBP A dedicated unit for dissemination of
research ndings at State Level, may
be SIHFW
Dissemination of research ndings
ID Standards and role clarity Customised standards are not
universally available
Existing standards are not
comprehensive
Supportive mechanisms are not in
place
Performance based incentives
mechanism
Standards would also increase levels
of transparency and accountability
EBP Adapt and adopt available national/
international standards
At the state level a
dedicated unit (State
Quality Group) for
this purpose
L Compulsory registration/ licensing
registration required for all facilities/
institutions and staffs
Develop accreditation guidelines for
members and to be involved in CPD
M Monitoring
Appropriate appraisal mechanisms to
be put in place
They need to know the monitoring
mechanisms that are in place at all
levels in the health system
M Evaluation
Need for further mechanisms for
evaluating quality initiatives
Train in the process of evaluating
quality (ex auditing for quality)
responsible
EBP
L
M
All health care institutions should be
considered as reporting units &
monitored for timeliness, completeness
& correctness & reporting
Accountability
Need for performance benchmarks in
core areas (nance, personnel etc.)
including accreditation criteria
Quality indicators need to be developed
and incorporated in HMIS. To measure
and improve quality
Institutes should set own standards/
targets
A dedicated unit for
this purpose at the
State Level
ID Institutional arrangements for QM Link to M&E, MIS, & P&D
Regulatory mechanism
Self regulation
Peer groups assessments
Accreditation, licensing, external
assessments
State directives
Statutory regulations
EBP Manpower audit
Service requirement audit
Posting based on audits ensuring
qualication, experience and training
are taken into consideration
L
EBP
Role clarity/ job description at all levels
Manpower planning
What type of manpower and training
of manpower, what is needed?
Senior management
level with some
exibility at the
institutional level
EBP Gap analysis and training need
assessment
M

L
Knowledge gap relating to creating and
enabling environment for quality and
for strategic planning for quality
Train and sensitise the managers to
the existing policies
Training of leaders in QM, continuous
training
M Skills for decision making and building
leadership capabilities
Train in leadership and requisite skills
for decision making for identifying
personnel needed for implementing
quality
responsible
M Resource management for achieving
quality outcomes
Training for understanding input-
process-output related to quality
(resources going into implementation
of quality
Who are the
managers?
M Communications management Need for effective communication
skills and mechanisms
ID Communication mechanisms Lack of clarity of intent at the time
of policy development
Lack of proper mechanismfor policy
dissemination fromthe Center to
State, State to District and below,
and follow up
Lack of capacity for local
adaptability. policy/ guidance
Formal mechanisms do not exit for:
Lateral communication
Internal communication within
institution
Feedback mechanism
L Participatory approach Need based and formally
communicated to TORs by a written
communication
L QA Plan Introduction of QM course in medical
and nursing institutions at all levels
fromtop to bottom
QM at all levels of induction program
Continuous professional development
Self assessment
Peer assessment
External evaluation including
periodical and randomobservation
Documentary evidence
Provision of problemsolving skills
and tools
Immediate
supervisor
Head of the
organisation
Senior health
managers
Group Work 2 on Formulation of Key competencies, learning objectives, contents and
learning methods
Next the TORs for the second round of the Group work were explained and distributed. The main tasks for group
work 2 were to reconsider the identied gaps and to formulate key competencies and learning objectives
suitable to ll the gaps, to identify course contents that could help to attain the competency and to suggest
learning methods that would enable the learning process. The groups were asked to prioritise the overall
learning objectives and to select only two priority areas each.
7th June 2008
The groups continued their deliberations and the presentation began on schedule. Prof. Deoki Nandan welcomed
Dr. I.P Kaur, Deputy Commissioner (Trg.), Ministry of Health and Family Welfare and requested her to chair the
proceedings for the day( Details of presentation group work 2 at Annexure 9).
The rst presentation was made by the group on Empowering Consumers. Mr. Bejon Misra projected the
following three areas as priority:
Consumer education and awareness
Developing relationship between service providers and patients
Complaint redressal and mechanism
He explained the course content for each of the areas mentioned above and also listed a variety of learning
methods ranging fromlectures to screening of short documentaries to achieve the desired learning objectives.
In the discussion, following the presentation, the learning objective pertaining to consumer feedback was
widely debated and one of the participants suggested that the termfeedback should be placed by a more
constructive termpartnership.
Dr. Sanjay Aggarwal made a presentation for the group on Institutional Development and identied
communication and standards as the priority area for curriculumdevelopment. The suggested course content and
methods of learning were outlined with clear objectives in place.
The participants were concerned about the focus of institutional development to be limited to only two areas, it
was however explained that the same was being done so as to avoid repetition of course content due to overlap
of areas between ve pillars of the strategic framework.
Prof. Bhattacharya gave a presentation on behalf of the Management Group. She informed that since the area of
management was very wide the group had chosen ve areas of priority each representing one session. The areas
identied were:
Sensitisation on quality management
Rationalisation of resources available for quality
Identication and interpretation of quality indicators
Supportive supervision and monitoring
Evaluation
Responding to the presentation, the participants discussed the limitations of using the existing HMIS for
monitoring quality and also debated on the importance of supportive supervision.
The group on Evidence Based Practice made their presentation wherein Dr. Aniruddha Mukherjee identied the
following three areas for priority:
Methods of acquiring data
Analysing data and preparing action plans
Hospital standards including standard treatment procedures
In the open session following the presentation, it was suggested that clinical data be generated using ICD-10
and there was also suggestion to include information on intellectual property rights in the course content of the
area relating to methods of acquiring data. The issue of generating resources by disseminating data was also
raised by one of the participants.
The nal presentation was on Leadership and Human Resource Development. Mr. Mallikarjuna identied the
following two areas as priority for curriculumdevelopment:
Overview and concept of quality management in healthcare.
Human resource development for QM in health care
In response to the presentation, the approach to QM was debated wherein the PLA (Plan, Learn and Act)
approach and the 3As (Accessibility, Availability and Adaptability) approaches were suggested.
The post lunch session was a plenary discussion on the presentations; Dr. I.P Kaur was requested to chair the
same. Prof Bhattacharya opened the session by inviting Ms. Sylvia to explain the future course of action in
relation to development of the training course. Prof. Nandan requested the plenary to discuss the modalities for
piloting the course and emphasised on the need to adopt the approach involving minimumnancial and HR
implications. Accordingly the participants dwelled on the issues like course design, practical implementation,
specicity of the course content and focus on quality aspects. There was also a suggestion to set up a repository
for literature on quality studies in India. One of the participants suggested setting up of a documentation cum
research cell on quality at NIHFW. The participants were informed that the GTZis preparing a document on
quality initiatives in India and the same would be available in August this year. Dr. Kaur wanted an integrated
approach to be adopted by the state in implementing quality initiatives with a specic reference to the Quality
Assurance Cells/ Groups (QAC/ Gs) already set up at the district levels and also suggested a linkage between the
SIHFWs and NIHFWin conducting comparative studies. Prof. Nandan was also of the view that since the QAGs at
the state end district levels were mandatory, their members should also be empowered to implement quality.
This was followed by a discussion on the QAGs, their present status and mandate. One of the participants
suggested that while conducting resource mapping all the available institutions for implementing quality can be
listed and assigned responsibilities keeping in view their capacities. The participants were informed that the
curriculumdeveloped through the deliberations of the group work would be further worked upon by a smaller
group of experts. Thereafter, the Chairperson Dr. Kaur summed up the plenary by insisting on convergence
through a dynamic and synergistic approach leading to integration of programmes and institutions. She also
stressed on the need to produce quality within existing resources and felt that the quality improvement process
has to be in continuum.
The session for the day concluded with Ms. Sylvia thanking the participants for their valuable contributions.
8th June 2008
Session began with Ms. Sylvia giving a presentation on the agreed draft curriculumdeveloped wherein she had
divided the curriculuminto two categories namely priority 1 and priority 2. She informed that the categorisation
had been done on the basis of the priorities given by the groups and that during the training course the areas
in the category 1 would be given more time than those listed in category 2. The areas under each category were
as follows:
Priority 1 Priority 2
Quality management system
Communication
Standards
Evaluation
(i) Models and methods
(ii) Quality indicators
Management overview
Monitoring and supervision
The suggestions following the presentation included the ones relating to inclusion of supporting quality
improvement as the fth area under category 1, building values, teammanagement, maintenance of medical
records and accreditation.
Dr. Raghu made a brief presentation on the database developed to monitor maternal and child care.
This was followed by a closing address fromDr. Monika and Ms. Sylvia wherein they once again thanked the
participants for their valuable contribution and their commitment towards the workshop. Prof Bhattacharya
requested the participants to give their parting comments wherein most of the participants thanked the
organisers and described the workshop as a great learning experience and promised to extend their full co-
operation and support to the cause of promoting quality in healthcare in India. The participants were also very
appreciative of the initiative taken to adopt a systematic and scientic approach to curriculumdevelopment in
the workshop.
Prof. Deoki Nandan concluded the session by stating that the workshop had achieved its purpose and
accordingly called for a standing ovation for the organising teamheaded by Prof Bhattacharya and comprising
of Dr. A. Bhardwaj and Dr. Nair. Prof. Nandan also thanked the World Bank for extending the nancial support
and the GTZfor providing the technical expertise on the subject and stated that he looked forward to a very
fruitful partnership between NIHFWand the Heidelberg University. Prof. Nandan also thanked the senior ofcials
fromthe Ministry of Health and Family Welfare for extending their co-operation in organising the workshop.
Discussion and nalisation of the contents of the training programme and
brainstorming about the technical inputs required at NIHFW, New Delhi
In the course of the second week the curriculumessentials were completed and a rst draft of the course
contents and learning methods was completed in discussion with the faculty members and presented to them
and verbally approved by the Director of NIHFW, Prof. Deoki Nandan. The group of NIHFW, GTZand international
experts then drafted a daily schedule for the draft curriculum. An overview of the curriculumessentials and the
main steps and outcomes in the curriculumdevelopment process is provided in the following:
Curriculum Essentials
Course title: Improving quality of care in the health sector
Target audience: Mid-level policy makers, including national (e.g. MoH), state (e.g. Senior ofcers from
Directorate and Principals/ faculty of the SIHFW) and District level (e.g. CMOs and SMOs of District Hospitals).
Number of participants: 20
Selection criteria: It was discussed at length if the application of selection criteria, apart fromthose determined
by the target audience, is feasible in a Government setting. To add a percentage for female participants (e.g.
20%) was a suggestion by the consultants, 15 years experience and clear 5 years left in service were also
discussed.
Length of the course: 6 days
Time frame: It was proposed that the rst course should take place in the 2nd half of November 2008 and that
further preparations for the course content should take place in September, 2008. Further courses would be
planned for 2009, e.g. in February and in May/ J une 2009.
Sponsors: It was suggested that GTZHealth Sector Support will sponsor this course.
Resource persons will be recruited fromthe NIHFWfaculty itself and fromother institutions in India. In the
beginning, e.g. the rst two courses, it is planned to involve 2-3 international experts to provide a kind of
tandemteaching and to exchange and share the material so that local and international perspectives and
approaches are integrated.
Educational strategy: To design a framework for senior and mid-level health ofcials so that they are able to
conceive and frame policies and strategies to improve the quality parameters in the health care systemat all
levels.
Overall course aim: To increase the competencies of decision makers to understand and apply concepts of
quality management in healthcare and to support and promote the implementation of the same.
Learning objectives and contents:
Seven Overall Learning Objectives were identied (below bold) and subdivided in specic learning objectives
(bullets). The overall and specic learning objectives of the course will be that, by the end of the course, the
participants will be able to:
1. Describe a quality management systemincluding its major components
Dene quality in healthcare
List principles in a quality management system
Explain user focus as central to a QM system
Recognise an effective Citizens Charter
Identify different quality management frameworks
Provide examples of the cost of poor quality and savings through implementing a QM system
Identify key legislation relevant to QM
Overall course framework
and strategy
Course Content Methodology
1. History of Quality, gurus, basic concepts
2. Principles of QM
3. EFQM, ISO, TQM, J CI
4. QI Tools
5. PDCA
6. Concept of client orientation, client rights and
responsibility, terminology of client/ patient/
customer
7. Citizen charters- key elements
8. Mechanisms for attaining client orientation
9. Client perspective on Quality of Care
10. Consumer Education and Awareness
11. Examples of cost implications for quality
12. Examples fromthe list of health care legislation
1. Lecture
2. Group exercise on Principles of QM
3. Group exercise on client orientation, client
perspective and mechanisms for feedback
4. Group exercise on QI tools
5. Case Study
6. Field trip to facility
2. Identify communication methods and tools supporting the quality management system
To recognise an effective feedback mechanism
Identify skills essential to build positive relationships between service providers and patients
Demonstrate improvement in basic communication skills
Express the importance of teams and teamwork
1. Different kinds of best practices in internal and external
feedback mechanisms
2. Relationship building skills
3. Methods of effective communication
4. Teamconcepts and building effective teams
5. Teams in quality such as quality circles, quality
committees etc.
1. Case Study
2. Role Play
3. Film(s)
4. Interactive lecture
3. Relate standards to their current work environment
To discuss the purpose of standards
To describe the difference between Standards, Guidelines and Standard Operating Procedures (SOP)
To identify examples of evidence based practice in different health care settings and relate these to
standards
To formulate strategies to apply standards
1. Standardisation including terminology such as Standards,
Guidelines, Standard Treatment Protocols, Standard
Operating Procedures (SOP), Benchmarking etc.
2. Evidence based practice
3. Healthcare standards and related documents in India
4. Overview of standards related organisations in India
5. Principles of good standards
1. Lecture
2. Case Study
3. Group exercise
4. Field exercise
4. Compare and contrast different methods to evaluate quality
Identify strengths and weaknesses of different models and methods to evaluate quality (accreditation,
certication, audit, clinical audit, self-assessment etc.)
Provide supportive feedback during an evaluation
Identify measurable quality indicators
Discuss different methods to manage the performance of health personnel
1. Difference between monitoring and evaluation
2. Different methods of evaluation such as accreditation,
certication etc.
3. Assessor skills such as observation, interviewing, report
writing, providing feedback
4. Quality indicators
5. Mechanisms for professional credentialing and continuous
professional development
6. Performance appraisal systems
1. Lecture
2. Role Play
3. Case Study
4. Field exercise, including group work
5. Develop an action plan to support Quality Improvement in their work environment
To identify the means to create a learning environment (learning fromour mistakes, not an inspection
model, mentoring, training on QI)
Use data for managing and improving quality
To develop strategies/ mechanisms to support access to results
1. Creating a learning environment (learning fromour
mistakes (near misses and sentinel events), not an
inspection model, mentoring, training on QI)
2. Methods of acquiring data, analysis, recording etc.
3. Action planning (PDCA) including different types of action
plans, linkages/ coordination between action plans
4. Mechanisms to enable different stakeholders to access
results of quality of care (i.e. results of evaluation,
research on quality, consumers access to quality of health
care facilities)
1. Lecture
2. Case Study
3. Field Exercise
4. Group Exercise
5. Readings
6. Recall health sector management concepts and tools
To relate basic health sector management concepts and tools to quality management
1. Management concepts and tools
2. Managing resources (human, nancial, logistics etc.)
3. Change management
4. Risk management (critical events, near misses etc.)
1. Interactive lecture
2. Case study
7. Review basic concepts of human resource development and leadership essential for quality
management
Identify human resource processes that enable management of quality
To discuss the impact of transformational leadership and service orientation on quality outcomes
To identify mechanisms that can impart specic values that enable staff commitment to improving quality
1. Human resource processes and terminology relevant to
QM such as capacity building, manpower planning, job
descriptions, performance appraisal systems
2. Values/ philosophy
3. Mission, vision, code of conduct, ethics
4. Motivation, conict management
1. Lecture
2. Group exercise
3. Case Study
4. Field Visit
Next steps
There is a need to orient the state level secretaries and mission directors to the need of such courses which
can help themidentify the needs of the state, prioritise themand then look for possible solutions. For this
there can be an advocacy group formed at NIHFWalong with the MOHFWand development partners which
can try and convince the secretaries and other authorities about the usefulness of these courses.
Regular feedback mechanismof interacting with participants needs to be developed. There is also a need to
have some updation and re-orientation training after a certain period. This may be through the proposed
e-health setup which NIHFWproposes to have by the year 2008-09.
More active canvassing by NIHFWfor the upcoming state level courses with the help of the development
partners is needed.
Having a web based resource centre where documents, presentations and case studies will be stored is also
contemplated with the help of the WBI. This will help in updating the knowledge of the participants on a
regular basis.
This course on Quality of Care should be carried forward this year and GTZhas promised support for initial
few courses, subsequently it will be institutionalised in the states also.
Another short course is also proposed in collaboration with Harvard for only bureaucrats and director
generals with support of WBI.
Annexures
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Annexure 2
A Strategic Framework for
Quality Improvement in Health
Sylvia Sax and Dr. Monika Krengel
Shimla, June 2008
Quality Challenges in Health
Health organisations are complex
systems clinical standards not enough
Cultural and organisational challenges
Competing power structures
politicians, Ministries and Departments,
doctors, nurses, managers
Greatest challenge is to build capacity to
manage these complexities
Why a Strategic Framework?
Need for explicit leadership and direction
Response to challenges arising from
limited resources, identified needs, and
increasing complexity
Need for measurable processes,outputs
and outcomes
Need to be able to say no
What can a Strategic Framework do?
Validating leadership (possibly even stabilising leadership)
Supports collaborations, agreements and
commitment to decisions
Ensuring technical, political and financial
sustainability
Managing change (e.g. merging departments or
changing their role, involving specific stakeholders)
Determining priorities
Providing a sense of continuity and direction
(road map, time lines)
Principles Quality Strategies
Values Empowering
consumers
Policies
Framework
Professional
development
Legislation Institutional
development
Existing
mechanisms
Management
development
Clinical practice
development
5
Principles of improvement
Transparency sharing information
Ethical practice professionalism
Evidence-based practice science
Top-down and bottom-up balance
From blame to improvement culture
Accountability everybodys business
Information sharing and communication
- brings sustainability
6
Presentation A Strategic Framework for Quality Improvement in
Health (Workshop)
Strategies for improvement
Empowering consumers
Over the next few days we will examine strategies
for improvement and ensure that they are
relevant to the Indian context.
7
S1: Consumer empowerment, protection,
information, education, focus ..
e.g.
Improvement of patient communication
Improvement and definition of patients rights and
obligations
Improvement of patient satisfaction, monitoring
and evaluation
Public access to information on health services
quality
Client focus always enjoy the top-priority in JCI, QCI and
other
Quality standards include internal and external clients
S2 Institutional development,
regulations, framework, set-up
Licensing and supervision
National/state standards for service
delivery
Reliable assessment processes and
training
Feedback and organisational development
Inter-institutional communication and
knowledge sharing
Safe and appropriate environment
9
S3: Management
General Management
Policy, planning, implementation, supervision, feedback
Decentralisation
Giving skills and authority to local managers
Resource management
Good services do not waste money
Risk management
Systematic learning from mistakes
Prevention of damage and litigation
Communications management
sharing good practices etc.
S4: Evidence based practice
Unacceptable variations in clinical practices
Use data for decisions
Research support evidence based practice
Commitment to evidence based medicine
Knowledge about the latest medical research
results, change of practice
Sharing best practices
Applying standard Operating Procedures
S5: Leadership and Human
Resource Development
Technical competence of staff is essential to
effective health care
Unethical behaviour has killed patients and
damaged organisations
Shift to multidisciplinary team working, which is
not possible without an effective organisation
Ensure the right people are in the right job
Leaders are committed to quality improvement
Basics Legal Challenges
CMEs
Performance
Appraisal
Incentives/
Motivation
Job descriptions
Registration
Licensing
Adherence to
Standards and
Regulations
Ethics
New modes of
communication
and knowledge
management
13
Methods and Tools of Principal
Strategies
To be developed and agreed on in this
workshop?
To be based on already approved
approaches and on their cultural
acceptability?
To be implemented, evaluated, monitored
and adapted by whom?
Annexure 3
2
UniversittsKlinikum Heidelberg
Improving
Quality of Care in India
Sylvia Sax. RN, BSN, MPH
University of Heidelberg, Germany
3
Definition of Quality
The proper performance (according to
standards) of interventions known to be Safe,
Affordable, and have the ability to produce an
Impact on mortality, morbidity, disability, and
malnutrition.
(Roemer and Aguilar, WHO, 1988)
4
Dimensions of Quality
QUALITY
1 1
ACCESS ACCESS Services
at the right place
and right time
irrespective of
income,
culture,
geography 2 2
APPROPRIATENESS APPROPRIATENESS
Services designed
around needs of client
groups and skills and
knowledge to provide
services
3 3
CONTINUITY CONTINUITY
Uninterrupted,
coordinated service
across services and
levels and
over time
4 4
EFFECTIVENESS EFFECTIVENESS
Achievement of
desired results in
the time frame
expected
5 5
EFFICIENCY EFFICIENCY
Cost effective
use of resources
and value for
money
6 6
RESPONSIVENESS RESPONSIVENESS
Services are
acceptable to
clients; clients
participate in
services and are
respected
7 7
SAFETY SAFETY
Potential risks of a
treatment or the
environment are
identified,
avoided or
minimised
5
Why does Quality matter?
1. Increases the health status
of individuals and the
population
2. Poor quality can do harm
3. Social and economic
benefits
6
Simple Model for Quality
INPUTS
ENABLERS
PROCESS OUTCOME
RESULTS
7
The Blackbox of Service Delivery
Enablers (i.e. People, equipment, money)
Results
evaluation,
indicators
short cut
Processes
Standards, criteria,
specifications etc.
Presentation Improving Quality of Care in India (Workshop)
8
Cycle of Quality
9
PDCA
Planning for Quality on Health Care
Develop a Quality
Strategy
Develop standards for
health care services
Design Training
courses in quality
concepts and tools
Convene an Infection
Control Committee in a
health facility
10
PDCA
Do: Implementation
Health education
messages (posters,
charts with minimal text
and more focused on
pictures) are visibly
posted in prominent
areas within the facility.
11
PDCA
Check the Quality of Care
12
PDCA
Act-Improve
Identify the areas to
be improved
Agree on actions
Include actions in
planning process
13
Unplanned Results
Medical waste is
often not disposed of
in a functional pit,
needles and other
medical waste were
scattered in the
vicinity of the
healthcare facility.
14
Planned Results
Managing Medical Waste
Standard:
Medical waste is
disposed of in a
functional pit (e.g. not
accessible to children
and animals) within the
compound
15
Stories of success
Improved drug storage at RHC Improved drug storage at RHC
16
Quality -
Services and Systems
Policy &
Infrastructure
Performance Monitoring &
macro management
Operations & Governance
Health Services Provision:
Professional accountability and patient satisfaction
National
National &
regional
Institutional
Individual
17
Quality is Everyones
Responsibility
Capacity and commitment are needed
at all levels, starting at the top
Everyone must know how they
contribute to quality
Standards give staff guidance
training gives them confidence and
competence
The Quality Management Course
being planned is what all countries
want and need
18
A Quality Culture exists in
Aviation
19
Does a Quality Culture exist here?
20
No quality management system works
unless people are empowered and
committed to take responsibility for quality
-as an ongoing process
in the end, quality becomes part of
people's behaviour and attitudes
21
Annexure 4
Quality Assurance Programmes
(QAP) in West Bengal
Dr Aniruddha Mukherjee
Technical Officer, Strategic Planning
& Sector Reforms Cell
Govt. of West Bengal
Types of Quality Assurance Initiatives
At the primary health care level (Pilot in
Hooghly)
Focus on RCH
Types of facilities covered: Rural Hospitals (CHC),
BPHCs, PHCs, Sub Centres
At the secondary hospital level (Pilot in 2
District Hospitals & 1 Sub Divisional Hospital)
Focus on all case management activities
Types of facilities to be covered: District Hospitals,
Sub divisional Hospitals, State General Hospitals
Both initiatives facilitated by GTZ
QAP on
RCH II in
Hooghly
The beginning The beginning
M & E Division of the MoHFW, GOI, M & E Division of the MoHFW, GOI,
decides to introduce QAP in RCHII decides to introduce QAP in RCHII
Develops Operational Manual from Develops Operational Manual from
field experience of UNFPA field experience of UNFPA
Decides on piloting in seven districts Decides on piloting in seven districts
of six states of six states
GTZ supports in Assam and West GTZ supports in Assam and West
Bengal Bengal
PATH as field partner PATH as field partner
Action taken from the Action taken from the
DoH&FW DoH&FW, , Govt Govt of West Bengal of West Bengal
Participated in the Launching of the Participated in the Launching of the
Programme at the National Level on Programme at the National Level on
21.12.06 21.12.06
Signed MoU with the National Signed MoU with the National
Government 22.01.07 Government 22.01.07
Constituted a State Working Group Constituted a State Working Group
on Quality Assurance Programme in on Quality Assurance Programme in
March 2007 March 2007
Identification and notification of Identification and notification of
State Nodal Officer State Nodal Officer
Action Taken at District Level Action Taken at District Level
Formation of District Quality Assurance Group Formation of District Quality Assurance Group
and identification of District Nodal Officer. and identification of District Nodal Officer.
Training of DQAG (7th to 10th May 2007) and Training of DQAG (7th to 10th May 2007) and
constitution of DQA Team constitution of DQA Team
DQAG members DQAG members- -20 20
Team members Team members- -12 12
Training of Facility Managers on 14th & 15th Training of Facility Managers on 14th & 15th
May 2007 May 2007
No. of Institutions included during the pilot: No. of Institutions included during the pilot:
RH 8(100%) RH 8(100%)
BPHC 9 (100%) BPHC 9 (100%)
PHC 21 (33%) PHC 21 (33%)
S.C. 66 (10%) S.C. 66 (10%)
First round of visits completed by December First round of visits completed by December
2007, 2 2007, 2
nd nd
round during Feb to May 2008 round during Feb to May 2008
Presentation by Dr. Aniruddh Mukerjee, West Bengal
QAP Process QAP Process
DQAG Team DQAG Team
Facility visit by QA Teams
Facility wise checklists filled up on input,
process and patient satisfaction
Facilities graded, problems and solutions
identified
Timeline on action plans prepared for local,
district and state.
Follow up after six months
QAP Process QAP Process District level District level
Compilation, analysis, discussion and follow up Compilation, analysis, discussion and follow up
action action
Coordinate the visits to ensure adherence to Coordinate the visits to ensure adherence to
schedule schedule
Review visit reports and compilation reports Review visit reports and compilation reports
Ensure technical quality of assessments Ensure technical quality of assessments
Take up issues from the action plans that require Take up issues from the action plans that require
action at the district level and facilitate them with action at the district level and facilitate them with
CMOH office CMOH office
Take up issues from the action plans that require Take up issues from the action plans that require
action at the State level with relevant authorities action at the State level with relevant authorities
in the Department in the Department
Ensure regularity and participation of DQAG review Ensure regularity and participation of DQAG review
meetings meetings
Network with other stakeholders such as general Network with other stakeholders such as general
administration for necessary support administration for necessary support
QAP Process State level QAP Process State level
Provide technical support Provide technical support
Visit selected facilities to ensure Visit selected facilities to ensure
standardization of assessment standardization of assessment
Provide administrative and managerial Provide administrative and managerial
support to overcome bottlenecks support to overcome bottlenecks
Participate in review meetings at Participate in review meetings at
district level district level
Organize state level review meetings Organize state level review meetings
Assist in institutionalization of the Assist in institutionalization of the
process to facilitate process to facilitate scaleup scaleup
Oversight of the whole process to Oversight of the whole process to
ensure that the pilot yields expected ensure that the pilot yields expected
results results
Role of GTZ and PATH Role of GTZ and PATH
1. 1. Training of Nodal Officers: District Training of Nodal Officers: District
and State and State
2. 2. Training of DQAG and Facility Training of DQAG and Facility
Heads Heads
3. 3. Identify bottlenecks and inform Identify bottlenecks and inform
district and state district and state
4. 4. Process documentation Process documentation
5. 5. Contribute to standardization of Contribute to standardization of
the assessment the assessment
6. 6. Support the Department to Support the Department to
institutionalize the initiative institutionalize the initiative
Output Output
Facilities visited against planned Facilities visited against planned
Month Visits planned Visits made
May 07 12 10
June 07 14 10
July 07 16 16
August 07 24 22
September 07 20 17
October 07 9 12
November 07 8 17
103 104
No of facilities visited and their categorization No of facilities visited and their categorization
during first six months during first six months
Type of facility No Category
RH 8 A 5(62 %), B 2(25%), C 1 (12%), D
0
BPHC 9 A 0, B 6 (66%), C 3 (33%), D 0
PHC 22 A 2 (9%), B 8 (36%), C 11 (50%), D
1 (4%)
SC 66 A 37 (56%), B 29 (43%), C 0 , D 0
Action points identified at Action points identified at
different levels different levels
Local Local
Provision for clinic space (excepting GPHQ/
Govt Building)
Signage: Services/micro plan
Logistics for examination of Blood/Urine
Utilization of fund untied /JSY
Hands on training on IUD, RTI/STI
Management of sharps
Physical facilities for clients
SubCentre
BPHC/RH BPHC/RH
Supply and orientation on SOPs Supply and orientation on SOPs
Utilization of RKS fund to maintain services Utilization of RKS fund to maintain services
Utilization of JSY fund to popularize Utilization of JSY fund to popularize
institutional delivery institutional delivery
Inform district on requirement of training Inform district on requirement of training
Put up signage on available services Put up signage on available services
Improvement of physical facilities for client Improvement of physical facilities for client
Supply of equipment and medicine Supply of equipment and medicine
Intersectoral Intersectoral coordination (PRI/ Block coordination (PRI/ Block
Health Health Samiti Samiti) )
Improving Bio Medical Waste Management Improving Bio Medical Waste Management
and Infection Control Practices and Infection Control Practices
District District
Identification of training needs and Identification of training needs and organising organising
training programmes training programmes
Inclusion of QAP during District Inclusion of QAP during District Samiti Samiti meetings meetings
along with sensitization of RKS and PRI during along with sensitization of RKS and PRI during
inter inter- -sectoral sectoral meetings meetings
Ensuring regular flow of RKS/JSY/ untied funds Ensuring regular flow of RKS/JSY/ untied funds
Improving physical facilities at peripheral units Improving physical facilities at peripheral units
Ensuring regular supply of equipment, Ensuring regular supply of equipment,
contraceptives and medicines contraceptives and medicines
Improved monitoring and supervision with Improved monitoring and supervision with
compilation and sharing of assessment reports compilation and sharing of assessment reports
Improving Bio Improving Bio- -Medical Waste Management Medical Waste Management
Regular feed back to the state Regular feed back to the state
State State
Training of different health staff on Training of different health staff on
priority basis priority basis
Allocation of budget for QAP Allocation of budget for QAP
Increased supervision and Increased supervision and
monitoring monitoring
Regular state level meeting on QAP Regular state level meeting on QAP
Finalization of BMWM strategy and Finalization of BMWM strategy and
implementation implementation
Providing for infrastructure Providing for infrastructure
development development
Filling up of vacancies Filling up of vacancies
Bottle necks Identified Bottle necks Identified
Initial assessments weak, with experience Initial assessments weak, with experience
assessments matured assessments matured
More intensive monitoring required from More intensive monitoring required from
both state & district levels both state & district levels
Essential vacancies of Medical Officers, Essential vacancies of Medical Officers,
Nursing Staff and Nursing Staff and ANMs ANMs need to be filled need to be filled
Some facilities, Some facilities, esp esp PHCs PHCs, require extensive , require extensive
infrastructure improvement infrastructure improvement
QAP could be done in only Govt. owned QAP could be done in only Govt. owned
facilities, majority of facilities, majority of SCs SCs remain outside remain outside
the ambit the ambit
Action plan implementation weak Action plan implementation weak
Hooghly Facility grading SC Hooghly Facility grading SC
Hooghly District: Gradation of Sub-Centres (N=66)
Grade A
56%
Grade B
42%
Grade C
2%
Grade A Grade B Grade C
Categorisation 2nd Assessment visits
Grade A
59%
Grade B
38%
Grade C
3%
Hooghly Facility grading PHC Hooghly Facility grading PHC
HooghlyDistrict: Gradationof PHCs(N=22)
GradeA
9%
GradeD
5%
GradeB
36%
GradeC
50%
GradeA GradeB GradeC GradeD
Categorisation 2nd Assessment visit
Grade B
45%
Grade C
50%
Grade D
5%
Hooghly Facility grading BPHC Hooghly Facility grading BPHC
HooghlyDistrict: Gradationof BPHCs(N=9)
GradeB
67%
GradeC
33%
Grade A
11%
Grade B
78%
Grade C
11%
Hooghly Facility grading RH Hooghly Facility grading RH
Hoogly District: Gradation of Rural Hospitals (N=8)
Grade B
25%
Grade A
62%
Grade C
13%
Grade A
49%
Grade B
38%
Grade C
13%
2 Assessment visits Feb to Apr ssess e s s eb o p
08 08
Chart showing the changes during the two
assessments
1
3
2 7
5
6
15
49
2
0
3
5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
RH BPHC PHC SC
Type of Institutions
%

C
h
a
n
g
e
s
Deteriorated
Same
Improved
Did the QAP have an impact? A Case Did the QAP have an impact? A Case
Study March to April 08 1 Study March to April 08 1
Objectives Objectives
To find out the appropriate changes at facility To find out the appropriate changes at facility
level that have occurred as an effect of QAP level that have occurred as an effect of QAP
To find out the immediate consequences of To find out the immediate consequences of
changes changes
To share the findings for making appropriate To share the findings for making appropriate
future plans for scaling up future plans for scaling up
Facility selection Facility selection
5 sub centres, 1 PHC, 1 BPHC and 1 RH 5 sub centres, 1 PHC, 1 BPHC and 1 RH
Tools and Methodology Tools and Methodology
Primary Data interviews with staff, clients & Primary Data interviews with staff, clients &
PRI members, observation of work practices PRI members, observation of work practices
Secondary data DQAG forms and reports, Secondary data DQAG forms and reports,
facility reports facility reports
Findings QAP Impact Assessment Study.. 1 Findings QAP Impact Assessment Study.. 1
Access to services Access to services
Increased antenatal Increased antenatal
estimation of estimation of
haemoglobin haemoglobin
( (Panisheola and Kharial
SC) with concomitant with concomitant
increase in increase in
consumption of IFA consumption of IFA
Display of timings Display of timings
have empowered have empowered
clients to demand clients to demand
services to be services to be
delivered on time delivered on time
Speaking Walls Kanaipur BPHC
Findings QAP Impact Assessment Study..2 Findings QAP Impact Assessment Study..2
Equipment and Supplies Equipment and Supplies
All facilities have an emergency tray All facilities have an emergency tray
All basic equipment like thermometers, All basic equipment like thermometers,
stethoscopes, BP apparatus, covered tray, stethoscopes, BP apparatus, covered tray,
fetoscopes fetoscopes and and haemoglobinometer haemoglobinometer
available and functioning available and functioning
Sterilisation equipment in all BPHCs and Sterilisation equipment in all BPHCs and
RH validated regularly during use RH validated regularly during use
Better housekeeping Better housekeeping
RKS and untied funds utilisation more RKS and untied funds utilisation more
oriented towards service delivery oriented towards service delivery
Findings QAP Impact Assessment Study Findings QAP Impact Assessment Study 3 3
Professional Standards and Technical Competence Professional Standards and Technical Competence
Overall improvement due to availability of SOPs, guidelines Overall improvement due to availability of SOPs, guidelines
and manuals and technical discussions with DQAG members and manuals and technical discussions with DQAG members
All All ANMs ANMs had detailed knowledge of ECP, OCP, Kangaroo had detailed knowledge of ECP, OCP, Kangaroo
technique, IUD technique, IUD
Technical CME integral part of meetings Technical CME integral part of meetings
Doubt clearance and Doubt clearance and reasons behind reasons behind activities part of DQAG activities part of DQAG
themes themes
Activities are more organised due to improved house keeping Activities are more organised due to improved house keeping
Physical Infrastructure Physical Infrastructure
Improvement of functional toilet facilities Improvement of functional toilet facilities
( (Panisheola SC, Purba Thakurani Chowk SC)
, repair & up keep. The direct benefits are , repair & up keep. The direct benefits are
Collection of urine for testing, IUD insertions Collection of urine for testing, IUD insertions
easier, staff & clients remain for longer times easier, staff & clients remain for longer times
Improved Improved signages signages
Privacy for patients is consciously ensured Privacy for patients is consciously ensured
Needle cutters being used in all facilities Needle cutters being used in all facilities
Essential repairs identified and carried out Essential repairs identified and carried out
broken panes replaced broken panes replaced
Lighting improved Lighting improved
Some Photographs Some Photographs- - Sub Centres Sub Centres
Kharial Sub Centre
Panisheola SC
Balibela SC
Bhadur SC
Some Photographs Some Photographs- - RHs RHs &BPHC &BPHC
Kanaipur BPHC
PA System Singur RH
Haripal RH
Kanaipur BPHC
Findings QAP Impact Assessment Study Findings QAP Impact Assessment Study .5 .5
Continuity of Care Continuity of Care
RKS and untied funds expenditure provides RKS and untied funds expenditure provides
assistance to keep services undisrupted assistance to keep services undisrupted
Service Environment Service Environment
Uninterrupted availability of equipment and Uninterrupted availability of equipment and
materials materials
Better housekeeping each equipment in its own Better housekeeping each equipment in its own
place place
Functional toilets Functional toilets
Validated sterilisation facilities during sterilisation of Validated sterilisation facilities during sterilisation of
equipment equipment
Use of gloves Use of gloves
Better ambience Better ambience
Privacy issues being looked into Privacy issues being looked into
Informed Decision Making Informed Decision Making
More knowledgeable staff more More knowledgeable staff more
confident in giving information confident in giving information
One window One window counselling provides better counselling provides better
information, saves time information, saves time
More choices for contraceptive services More choices for contraceptive services
actually available actually available
Better relevant communication at Better relevant communication at
service delivery service delivery
Summing Up Summing Up
Processes of ANC check up improved Processes of ANC check up improved
Knowledge level improved with regards to IUD, New Knowledge level improved with regards to IUD, New
Born Care and Family Planning Born Care and Family Planning
Improved housekeeping Improved housekeeping
Improved infection control & waste management Improved infection control & waste management
Improvement in record maintenance Improvement in record maintenance
SOP material used for reference wherever it is SOP material used for reference wherever it is
available available
Conscious hygiene maintenance Conscious hygiene maintenance
PRI aware on expenditure of untied funds for quality PRI aware on expenditure of untied funds for quality
improvement improvement
Improvement in supply of equipments and material Improvement in supply of equipments and material
and its maintenance and its maintenance
Signage and Charters in place Signage and Charters in place
Emphasis on follow up of plans e.g. Toilets Emphasis on follow up of plans e.g. Toilets
A tool for monitoring visits by supervisory officers. A tool for monitoring visits by supervisory officers.
West Bengal Hospital Standards ver 1
West Bengal Hospital Standards
37 Standard Elements
Sub divided into 4 sections
Hospital Management- 6 Standard Elements
Clinical Services- 19 Standard Elements
Support Services- 5 Standard Elements
Cross Departmental Issues- 7 Standard Elements
Support Documents
Technical Document- Elaborating the
requirements of the Standard Elements
Checklists for 11 Quality Circles
The Break up of the Check lists
Quality
Circle
Docume
nt
Equipme
nt
Persone
l
Infrastruct
ure
Policie
s
Practic
e
Signag
e
Trainin
g Total
MATERNI
TY 68 23 12 20 38 101 28 23 313
SURGE
RY 57 58 9 17 33 118 27 20 339
MEDICIN
E 33 17 3 7 23 66 27 12 188
NURSIN
G 81 40 10 31 24 113 12 43 354
OPD 15 25 6 31 28 74 23 4 206
DoHFW decided to introduce QAP in secondary hospitals as
part of HSDI
State Working Group set up in March 2007 to formulate the
QAP process
QAP state level workshop held in June 2007 followed by
fortnightly brain storming sessions
Review of different international and national standards, QA
processes done
Resource persons sent for international and national
exposures on QA methodologies
West Bengal Hospital Standards (draft) developed and
presented to Department in Feb 08
Integrated as activity of Planning & Development Branch
QAP in Secondary Level Hospitals
Challenges with selling the Idea
Why speaking of quality in Govt. healthcare?
Quantity vs Quality
Overburdening of Staff
Expensive
Admission of Not Quality Services Provided
Now
Will it be sustainable
The modifications made- were they
compromises?
The QAP Process.. 1
Sensitisation of key stake holders in hospitals
(Off site)- Introduction to QA Programme
Superintendent
Nursing Superintendent
Non Doctor Administrator- Asst Superintendent/
Ward Master
Sensitisation of key stake holders from all
functional areas (On site)- Introduction to QAP
and Self Assessments
Doctors & Pharmacists
Nursing Supervisors
Technicians- Diagnostics, Imaging, Physiotherapy
Office Staff and Store Keepers
The QAP Process 2
Formation of Quality Circles (QC) - 3 members each:
1 doctor, 1 nursing staff and 1 technical person
OPD, Casualty & Minor OT
Surgical & Allied Departments like Eye, ENT
Medicine & Allied Departments like Paediatrics
Maternity and Allied Departments like Neonatology
Nursing Services- 2 Quality Circles
Diagnostic Services including Lab and Imaging
Safety, Infection Control and Waste Management
Facility Management andProcurement
Records
Contract Management
The QAP Process 3
Sensitisation of Convenors of QCs (on site)- Use of
checklists for self assessments and preparation of
action plans and identification of areas of
improvement for next 3 months
Documentation of Baseline indicators for
improvement
Training of Convenors of QCs on simple quality
tools like cause & effect diagrams, Pareto Charts,
work flow analysis, spaghetti diagrams to detect
problems and work out probable solutions
Training of Hospital staff on Infection Control,
Waste Management, Safety, Disaster Management
and Fire Safety
The QAP Process 4
Assessment of Action Plan by QA Group and
improvement strategies discussed
Annual Action Plan formulated
Repeat self Assessment after 9 months of 1
st
Self
Assessment
Peer Assessment
Accreditation/ Certification
The Present Status
Pilot in 3 Hospitals- all with > 90% bed occupancy
1 District Hospital with QA Working Group member
1 District Hospital with no QA experience
1 Sub Divisional Hospital
Sensitisation Meeting for key stake holders done
in April 2008
QC formed in May 2008, sensitisation of self
assessment done
Action plans for next 3 months and determination
of baseline indicators in progress
Assessment of 1
st
phase implementation in Sept 08
2
nd
Assessment by Dec 08
Scale up decision- July 2008
The Learning
Keep on harping that QAP is not being enforced from the
top- make it part of the system
Identify champions in the system and utilise them in
initial period. After some time QA becomes infectious
Overcome initial scepticism with intense hand holding-
authorities at higher levels should show personal
involvement
Keep focus on documentation- only policies and SOPs
that get written get practiced
Keep documents simple- no document should cover
more than 1 side of an A4 paper in 10 size font
Address training needs of all staff- keep them short,
simple & focussed to needs
The Learnings 2
Develop a monitoring and evaluation plan right
from the beginning
Develop measurable indicators for monitoring
Be patient- the start of the programme requires all
to put in extra effort. Hurrying up may be counter
productive. However, ask the facilities to prepare
their timelines and monitor that they are being
stuck to
Facilitation should be on site as far as practicable
Ensure physical comfort in all activities
Scale up with caution, QA requires intense hand-
holding
Thank You
Annexure 5
Secondary Level Hospital Quality
Improvement & Management State
Experiences
Dr Preeti Kudesia
Senior Public Health Specialist
Health, Nutrition & Population
The World Bank
June 4 - 7, 2008
NIHFW-WBI, Shimla Workshop
Overview of Bank support to Health Sector
in India
HIV/AIDS III
(ongoing)
TB II (ongoing)
VBDC (under
preparation)
Leprosy (2001-04)
Cataract Blindness
(1994-2002)
F & D control
Disease surveillance
Andhra Pradesh-secondary
and primary
Karnataka (KHSDP
completed; KHSDRP ongoing)
Punjab
West Bengal
Orissa
Maharashtra
Uttar Pradesh (ongoing)
Uttarakhand (ongoing)
Rajasthan (ongoing)
Tamil Nadu (ongoing)
RCH II (ongoing)
RCH I (1997-
2001)
IPPs I-IX (1980-
95)
Nutrition (1980-06)
Cross-Cutting
Programs
State Health Systems
Strengthening Program
Central Programs
Objectives and interventions of State
Health Systems Projects
Since 1996 State Health Systems Projects
providing interventions at District Hospital and
Sub-district level (secondary level of health
care) with broad objectives to:
Improve efficiency and quality of services
Enhance access to and ensure equitable
services for disadvantaged populations
Quality Improvement Aspects
Rationalization of service norms
infrastructure, equipment, manpower
Monitoring and Performance evaluation
Housekeeping/ hotel functions
Behavior change of service providers
Quality enhancement of processes
Certification & Accreditation
Rationalization of service norms
A four pronged approach
Services provided: Services (including manpower) to be provided
at each level - Rajasthan Health Systems Development Project
Equipment requirements: Equipment norms - Tamil Nadu Health
Systems Project
Drugs and supplies: Essential drug list - Rajasthan State Health
Systems Project
It was agreed with the state governments that these norms will be
met by adopting various strategies, eg: procurement, repair,
contractual recruitment of staff
Manpower Norms
Norms developed for each state for each level of facility
Placement/Recruitment to fulfill norms
Retention of staff
Motivation of staff
Skill up-gradation and training
Doctors: skill upgradation, equipment and procedure based training
Nurses training: AP,Punjab, Rajasthan
Technicians: RHSDP - general training by CSIO/ equipment based training
from manufacturers at time of delivery
Presentation by Dr. Preeti Kudesia
Manpower norms: A case study of
CEmONCs from Tamil Nadu
The critical issue of manpower was put on high priority by GoTN to
enable Govt. hospitals (FRUs) to function as Comprehensive
Emergency Obstetric & Neonatal Centers (CEmONCs).
A GIS mapping of CEmONCs was done and a sample of 83 were
selected to ensure access within one hour of travel (subsequently 30
minutes of travel)
An in-depth analysis of existing and required manpower for
CEmONCs was done based on established norms
Specialists posted in peripheral and primary level positions where
their skills were not being utilized were identified and relocated
Shortfall in specialist services post relocation was calculated and
doctor and nursing staff was recruited on contractual basis
Remuneration of specialists raised by 150%
41 CEmONCs have been assessed based on a set of parameters
and certified as fully functional CEmONCs.
Equipment Requirement, Repair and
Maintenance
Inventories developed of existing equipment
Equipment that was fully functional
Equipment that needed repairs and maintenance
Equipment that needed to be condemned
Decisions taken regarding equipment maintenance: RajasthanAn options paper
prepared for most effective equipment management and repair system for the
state
One-time repair of all faulty equipment
New equipment purchased according to the norms developed for each level of
facility
Challenge: Setting up sustainable system for equipment maintenance
Budgetary allocation for equipment maintenance
Innovation: Karanataka: Six Centers streamlined processes and to
obtain ISO Certification for Equipment Repair and Maintenance
Centers.
Housekeeping & Hotel Functions
An important function raised in most patient satisfaction surveys
Cleaning
Laundry
Diet
Security
Lessons Learnt
Outsourcing through PPPs
Model contract development
Contract management
Supervision
Government commitment to resources (Experience from KHSDP:
financially more viable to contract out housekeeping/hotel functions)
Free services to disadvantaged populations
Barriers to seeking healthcare from government services
Lack of
Information Access: Campaigns (VCD, IEC, Counselors)
Physical Access: Renovation/Up-gradation, emergency transport
services, outreach camps
Social Access: Targeted approach to BPL, SC, ST populations
Financial Access: User fees exempt, free drugs and diagnostics for
poor (RMRS from RHSDP)
Drug supplies
Drug logistics
Inventory
Supply chain management
Tamil Nadu Medical Services Corporation (TNMSC)
Monitoring & Performance Evaluation
Hospital Information Systems
Hospital activity indicators and performance indicators: Indicators from
Rajasthan Health Systems Development Project
Maharashtra Health Systems Projectperformance indicators and external
validation of data
West Bengal State Health Systems Development Project Quality Assurance
and grading of hospitals with data from all levels of facilities
Andhra Pradesh Health Systems Project Grading up to PHC level
Punjab Health Systems Project Use of data for management purposes
Quality indicators
Benchmarking
Grading/rating
Behavior Change of Service Providers
Attitude of service providers a major barrier for populations to
access healthcare at government facilities
Training for 3 cadres of service providers (doctors,
nurses/technicians, class IV) to
Improve client orientation, service behavior and communication skills so as to
improve quality of service delivery
Increase sense of team spirit amongst service providers
Increase sense of organizational belonging and ownership among providers
Strategies: Training of BCC trainers: Tamil Nadu Health Systems Project
Facility-wise training and TOT: Rajasthan Health Systems Project
Facility-wise training: Uttaranchal Health Systems Project
An overview to mechanism of stimulating Behavior Change amongst service providers
The Maharashtra Example
Quality Enhancement of Processes
Drug inventory and Rational Use of Drugs
Standard Treatment Protocols/Guidelines
Guidelines for action in emergency, OT, Labor room, OPD
Equipment Maintenance
Audits (case sheets, death reviews, prescription audits)
Patient Flow Management (time spent at different sites, overcrowding)
Hospital timings and rationalization of duty hours
Healthcare Waste Management
Hospital Systems Improvement Teams
To improve the quality of health care offered at all health care
facilities and health systems performance through
A continuous internal process of problem identification
Solution finding
Implementation of best solutions and
Working with staff, funds, information, supplies, transport,
communications, management etc in an integrated manner
The HSIT process
HSIT: An innovative pilot initiative in Rajasthan Health Systems Development
Project to stimulate quality improvement at each facility level with complete
ownership of all cadres of service providers
Quality is never an accident; it is always the result of high Quality is never an accident; it is always the result of high
intentions, sincere effort, intelligent direction and skilful ex intentions, sincere effort, intelligent direction and skilful execution ecution
Thank you!
Annexure 6
Quality Management Initiatives in
Himachal Pradesh
Dr. Monika Krengel
Shimla, June 2008
HSSHP - Programme Setup
Jan 2000 Dec 2007, 3 Phases
Basic Health Project Himachal Pradesh (BHPHP) until
2004
From 2004 onwards integration into the GTZ Indo-
German Health Programme (IGHPHP), Delhi, in 2005
changed into GTZ Health Sector Support (HSSHP)
Cooperation with two other GTZ projects: West Bengal
and Maharashtra.
Only the HP project focussed on secondary healthcare
support, following a request of the HP health department
Enabling Environment for Introducing QM in
2002
1. Himachal Health Vision 2020 envisions Continuous Quality
Improvement
2. Sectoral reforms in the Health Sector with focus on
Decentralisation and Hospital Autonomy
3. Creation of Hospital Welfare Societies and introduction of User
Charges in Himachal (2002)
4. Decision of the Department to strengthen Secondary Health
Care and to use Quality Management for Service Improvement
General Problems
Accessibility poor road connectivity
Availability of health services - very few private health
facilities
Limited range of services and shortage of specialists
High spending by patients on travel and medicines (over
prescription)
Absence of planning and innovations, shortage of
adequate equipment and infrastructure, low level of
maintenance, etc.
Strong centralisation and little decision making powers of
hospitals shortage of budged
Goals and Objectives of HSSHP
Decentralised health systems are supported
Establishment of Hospital Societies 2000-2003
Strategic Planning Workshops 2001-2005
Leading to the introduction of Quality Management in
2002
Health Management Information System (HMIS) is strengthened
2001-2007
Community involvement in health is increased 2001-2005
Human Resource Development Systems and Strategy initiated
Asset/Material Management Systems are demonstrated
Rational Use of Drugs (RUD) 2001-2005
Biomedical Waste Management (BMWM) 20032006
Repair and Maintenance of Equipment 2001-2006
Objectives and Activities
Main Areas of Activities
Quality Management 2002-2007;
143 Workshops, 2855 participants
Health Management Information
System(HMIS)2001-2007, 82
Workshops, 2018 participants
Rational Use of Drugs(RUD) 2001-
2005, 68 Workshops, 1310
participants
Community Involvement in Health
2001-2005; 66 Workshops; 1633
participants
Strategic Planning 2001-2005; 61
Workshops; 1060 participants
Repair and Maintenance of
Equipment 2001-2004; 20
Biomedical Waste Management
(BMWM) 2003-2005; 13
Presentation Quality Management Initiative in Hospital Management in
Himachal Pradesh
Scope of the QM Initiative in HP
Task
Introduction of Quality Management in 49 Government Hospitals in HP
Activities/Tools
Implementation of a QM structure (Core Group, QM representatives, Quality Circles)
in 29 hospitals
Development, testing and adaption of Standards for Government Hospitals in HP
(following the model of HAP - British Hospital Accreditation Programme)
Development of a low cost QM implementation process, based on Self Assessments
and Peer Reviews - including manuals for introduction courses, in-house
sensitisation for staff, thematic workshops, etc.
Outcome/Products
3rd version of the HP Hospital Standards printed (2007), QM Information Handbook,
Assessor Manual and Thematic Manuals, e.g. on Health & Safety, Standard
Operating Procedures, developed and printed
36 Self Assessments in 3 batches and 13 Peer Reviews completed and analysed
A very extensive product documentation (tool-box) is available
Steps of Introducing QM in HP
2002-2004: Basic Assessment, formation of Quality Circles, Quality Core
Group and Quality Representatives in 6 Pilot Hospitals
2004 onwards:
1. Development and testing of Standards, using the Standards of the
British Hospital Accreditation Programme as a model for adaption, in
13 Hospitals (1
st
batch QM hospitals).
2. Establishment of Directorate Quality Core Group (DQCG) and attempt
to establish an Inter-sectoral Quality Group.
3. Surveyor training and conduction of Self Assessments against the
Standards, followed by gap analysis and action planning in 26
Hospitals in 2005-2006 (1
st
and 2
nd
batch QM hospitals).
4. Training of Peer Reviewers and conduction of external Peer Reviews
in 13 hospitals (1
st
batch).
5. Conducted case studies in 6 pilot hospitals (2006).
6. Re-establishment of State Quality Core Group (SQCG) in 2006.
7. Further revision of Hospital Standards (Version 3) in 2007
QM Process in HP
Sensitisation of all Staff
Formation of QM Structure
Self Assessment against HP Standards
Gap Identification and Action Planning
Peer Review
Accreditation
Development of Standards
Training
of
Surveyors
External Assessment
Training
of
Peer
Reviewers
Formation
of
Accreditation
Body
Thematic Workshops
for the development
of guidelines / SoPs
Initial Action Planning and implementation
Introduction to QM for Key Persons
Formulation
of State
Quality
Policy Quality Core Group (SMO,
Quality Representative,
Doctor, Matron, Technician)
QC QC QC QC
State/Directorate Quality
Core Group
Department Level
Hospital Level
State Level Quality
Committee
State Level
Inter - sectoral QG
QM Structure and Levels of Responsibility
Tasks of the Hospital Quality Core Group
(QCG)
Formulation of Hospitals QM Strategy and Policy
Sensitization of Staff and awareness raising for quality
improvement
Annual action planning and review of activities
Identification of training needs and development of
training plans
Support and supervision of Quality Circles and activities
Reporting of QM progress to the Directorate
Tasks of the Quality Representative
(QR)
Mediator between staff, QC and QCG
Report to QCG on the performance of the QC and
progress of QM improvement plans
Monitoring, evaluation and documentation of QM
activities, including follow up of the Annual Action Plan
Tasks of Quality Circles (QC)
Identify problems or areas for improvement
Analyse problems or processes
Identify solutions
Prepare Action Plans
Implement Improvement measures
No quality programme can succeed without setting standards!
The project and members of the Directorate studied and compared
Standards and QM systems used by other countries, e.g. EFQM (European
Foundation for QM), ISO, JCI (Joint Commission/US), British Hospital
Accreditation Program (HAP)
Outcome: Basic contents and principles of all standards are very much the
same: e.g. focus on patient satisfaction, on processes (instead of
infrastructure), and on leadership and communication.
The HAP Standards were selected as a model, because they were
- designed for small and middle scale hospitals,
- easily understandable, detailed and not leaving much scope for
interpretation
- The British and the Indian Health System have some similarities
- HAP allowed the Govt. of HP to use their standards as a model
Hospital Standards: Departments/Institutions
responsible
DHS, 360
Civil Def ence (Incl.
Fire), 17
Hospital, 1303
District
Administration, 4
PWD, 94
Food & Civil
Supplies, 5
PCB, 8
Nursing Council,
13
Telephone Dept., 1
Results Self Assessments
The 1
st
Self Assessment (2005) showed
a general compliance of 40% (range 21
to 70%),
the 2
nd
Self Assessment (2006) 54%
(range 22 to 83%) - 2 hospitals went
below their previous compliance (most
likely their first Self Assessment was not
realistic).
Government of Himachal Pradesh, India
Department of Health and Family Welfare
The HAP Standards were reviewed and customized to local
requirements through intensive group work at hospital (5 regional
groups) and directorate level, following the RUMBA approach. Is the
Standard
Relevant
Understandable
Measurable
Behavioral (culturally acceptable and practical) and
Achievable (within the next 5 years)
Review and integration of local/national laws and regulations, e.g.
Consumer Protection Act, Regulation of BIS, was done and new
relevant criteria were added.
It took about 6 months to draft the first version (June to Dec. 2004),
and another 9 months (Jan to Sep 2005) for testing and drafting of the
second version.
The third version of the HP Hospital Standards was reviewed by
members of the SQCG and printed in 2007
Structure of HP Hospital Standards - Version 2
Total number of 1813 criteria, divided into 4 Sections:
Management
Clinical Services
Support Services
Cross-Departmental Issues
SECTIONS OF THE STANDARDS
Management
12%
Clinical Services
44%
Support Services
15%
Cross
Departmental
Issues
29%
Results Self Assessment
Overall Response
Yes
55%
?
3%
No
34%
NoResponse
8%
Results Self Assessments
Comparison of hospital compliance with standards, 2005 and 2006
0
10
20
30
40
50
60
70
80
90
100
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Achievements and Lessons Learnt
Efficient knowledge transfer, through emphasis on
high coverage in reaching professionals; see large
amount of trainings and workshops and successive
inclusion of all districts (examples),
a group of about 20-30 key professionals who actively
used concepts and material developed in their
environment and developed tools on their own, like
in-house training modules for staff, standard
operating procedures, draft publications on safety
issues, first aid and so on (even starting websites),
good documentation and dissemination of all
trainings, workshops and tools
Challenges
The only challenge is how to achieve
sustainability.
Some Achievements and Benefits
Himachal Pradesh is the first State in India that developed and applied
Hospital Standards for the Public Sector, that provide a monitoring tool
for performance and improvement.
Compliance with the Standards is already quite satisfactory (40 % in the
first Self Assessment, improved to 53 % in the second Self-Assessment.
A team approach for problem solving and quality improvement has been
initiated in all QM hospitals, through Quality Circles.
Action planning and monitoring with an emphasis on Quality
Improvement takes place for the first time in those hospitals.
Rationalization of facilities/manpower and improved resource utilization
has started.
Innovative models for local good practices are implemented: e.g.
improvement and monitoring of patient satisfaction and communication,
medical records, signage, bio-medical waste management, health and
safety, repair and maintenance of medical equipment.
More scope for staff initiative and education and for exchange of best
practices.
Achievements and Lessons Learnt
The Quality of healthcare in the QM Hospitals has visibly and
measurably improved, following the approach to focus on
promotion of competition between hospitals and introduction of
low-cost incentives and learning through the exchange of best
practices,
easy reachable, visible and mandatory changes, like
improvement of sanitation, signage, patient information and
safety,
strengthening of communication skills and means.
Most hospitals accepted QM as an opportunity to strengthen
their position towards the Centre, Court (consumer protection
act) and Politicians
A tour through the hospitals
Some Pictures before Start of QM Activities in QM Hospitals
Signages
Display of Site Plan
Plantation and
beautification of
surroundings
Quality Improvement Activities in the QM Hospitals
Some Pictures before Start of QM Activities in QM Hospitals
Cleanliness
Waste Management
Record Keeping
Development of
display of check lists
Patient Information
Health & Safety
Display of hospital vision
statement and patient
Responsibilities
Display of Patient Rights
Display of SoPs
Display of Hospital
Profile/statistics
Patient oriented services:
Privacy
Display of organizational
chart
Thank You
Patient Focused Services:
Information on doctors on duty and
price list of various services/tests
Display and monitoring of
standards for waiting time in OPD,
X-ray, Lab
Newspaper facility for patients
Improved vertical and lateral
Communication
Regular Staff Meetings
Improved ambulance
services
Annexure 7
QUALITY
Quality for me is :-
1.Achievement of Standards / Targets fixed
2.Doing the right thing in right way at right time.
3.Generating resources.
4.Minimizing Conflicts.
STANDARDS OF MY HOSPITAL
1. Registration----------15 minutes.
2. Examination by Medical Officer---30
minutes
3. Lab.Report.----------2 Hrs.
4. X-Ray Report--------2 Hrs.
5. Treatment to be started to admitted Pt.-
Immediately.
ACHIEVEMENT OF STANDARDS
Employed receptionist from Rogi Kalyan Samiti.
Job Responsibilities of Receptionist :-
1. Registration.
2. To guide the clients.
3. To help the patients who have no attendants.
4. To Keep watch on serious patients and to direct such
patients to go directly to emergency management room
and to inform the Medical Officer on duty through
intercom provided by GTZ.
5. To keep watch on unwanted elements / unwanted events
and to inform BMO immediately about it.
EXAMINATION BY MEDICAL OFFICER -30 Minutes
Provided separate
chambers to individual
Medical Officers.
Ensured Punctuality .
Waiting room
provided between
OPD 1 & 2 with
facilities of water and
fan.
LAB. REPORT-2 Hrs.
Purchased Auto analyzer.
Employed one attendant for help
X-Ray-Report-2 Hrs.
Purchased new X-Ray Machine.
Employed one Helper through RKS.
Presentation by Dr. Raghu, Block Medical Ofcer
IDENTIFICATION OF CONFLICT AREAS :-
For Emergency Cases.
1.Non availability of Staff
Immediately :-
Solution :-Night Watch
man room near gate
2. Non availability of
stretcher / Wheel Chair.
Solution :- Fixed place for
stretcher / Wheel Chair
QUALITY CORE GROUP :-
Block Medical Officer.
Senior Medical Officer.
Chief Pharmacist.
Ward Sister
Meeting held on every last working day of
the month.
Donation box and suggestion box opened
on the same day
QUALITY CIRCLES :-
1.Quality Circle OPD :-
SMO In-charge.
Pharmacist
Lab. Technician.
X-Ray Technician
Meeting on every Ist Monday every month at 3.30 PM
Q.C.Contd.
2.Quality Circle Indoor :-
Medical officer in-charge indoor.
Ward Sister.
Trained Dai.
Sweeper
Meeting on every I st. Tuesday of the month.
QualityCircles-Contd.
3.Quality Circle-Bio
Medical Waste :-
-Medical Officer entrusted
the job of Bio Medical
Waste.
-All Supervisors
-Ward Sister
-All Sweepers
Meeting-Every Ist
Wednesday of every
month
POLICIES & PROCEDURES
1. OUT PATIENT DEPARTMENT :-
-Reception / RegistrationReceptionist to be available here.
-Sufficient waiting area with facilities of news desk/drinking
water and fans.
-One Doctor made responsible for OPD.
-Staff Duty Roster available one month advance.
-Patient choice regarding examination by particular Doctor.
-Rights and responsibilities of clients clearly written in Hindi
and English.
-Privacy Maintained.
OPD POLICIES CONTD.
Toilet facility available
near OPD.
Waiting room available .
Wheel Chair / Stretchers
available near OPD.
Facility of separate queues
facility for males, females
and senior citizens at
registration and Pharmacy
POLICIES & PROCEDURES CONTD.
2. INDOOR :-
-Ward Sister is responsible for
looking after the wards.
-Next Senior staff nurse given the
responsibility to look after the
wards during the absence of
ward sister.
-Every new admission provided
clean bed sheet.
-Bed Sheets are changed on every
third day.
POLICIES & PROCEDURES CONTS--INDOOR
Each ward has :-
Bed Head Light
T.V. Facility.
News Paper facility.
Under bed light facility.
Working Clock
Calendar of current year.
Exhaust fan facility.
Changing room facility.
Refrigerator facility
MEDICINE BANK :-
Medicine bank has been established in the
hospital . Medicines collected in this bank
are given to poor / needy patients.
SUGGESTION BOX:-
Exit inter view scheme has been started to
get the feedback from the clients. Exit
interview forms are put at suitable places
and the clients are to fill these forms and put
into the suggestion box. Suggestion box is
opened on the last working day of the
month and action taken is conveyed within
fortnight.
SPECIMEN OF EXIT INTERVIEW FORM
1. Behavior of Doctors..
2. Behavior of staff nurses..
3. Cleanliness.
4. Beds & Bed Sheets
5. Condition of toilets.
6. X-Ray
7. Lab. Facilities..
Specimen of Exit interview Contd. :-
8 Hospital stay(days)
9. Time between admission and starting of
treatment.
10. Any medicine provided from hospital
11. Total Expenditure on tests & Medicines.
12.Any suggestions to make the hospital services
better.
13.Staff member whose services you feel are the
best.
FUNDS GENERATION :-
Five shops constructed
through Rogi Kalyan
Samiti. Rs.1,11,000/-
income per month
from these shops.
Improvement of Surrounding area Surrounding area
This area was full of
Bhang Plants
Surrounding area Surrounding Area Contd.
SURROUNDING AREA CONTD.
This area was used for toilet and parking by local
people
The same area Being converted into a Garden Contd.
Contd. Contd.
Garden developed
Bed Condition
Bed Condition Contd. Same beds after repair
Condition of furniture Same furniture after repair
Repair work
Repair work Contd.
Tiling work Tiling work complete.
FRU NAGROTA BAGWAN THANKS
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Annexure 9
Group work 2- Curriculum Development
Terms of reference and results
CurriculumDraft (original document) with comments fromparticipants, contents and methods listed
GROUP 1 Empowering Consumers
Key competencies/
learning objectives
(including level)
What course contents could help
themto attain the competency?
What learning methods would enable
the learning process?
Consumer education and
awareness (need to
strengthen the education of
patients in the session)
Global perspective on patient rights
and responsibilities
Ice breaking session, classroom
exercises, reading materials
Lectures and interactive discussions
Consumer perspective on quality of
care
Need assessment based on evidence
and data
Reference material and eld studies
(ten
commandments)
Developing relationship
between service provider
and patients
Effective and efcient communication
skills
Exercise on communication skills
Role plays
Consumers perspective on QoC
(rewards and recognitions)
Matrix performance measurement and
exit Poll
Peer review
Consumer driven culture towards and
thinking (initiatives and projects)
Success stories (i.e. case studies)
Short lms and interactive discussion
Complaint redress
mechanism
Citizen charter as a tool to redressal Charts, diagrams, pictorials
Brainstorming and classroomexercise
Existing regulations on health care Lectures with emphasis on landmark
judgments
Case studies
Key competencies/
learning objectives
(including level)
What course contents could help
themto attain the competency?
What learning methods would enable
By the end of the session the participants should be able to:
1. Consumer education and awareness: recall global best practice, list out various dimensions on quality of
care frompatients perspective, develop capacity to conduct research on patient feed-back
2. Developing relationship between service providers and patients: develop positive thinking towards patients,
core skills on communication, measuring effective communication
3. Complaint redressal mechanism: skill of bringing efciency in resolution on patient feedback,
institutionalizing the redresses mechanism, develop skills on conicts resolution
GROUP WORK 2 - Curriculum development
GROUP 2 Institutional Development
Key competencies/
learning objectives
(including level)
What course contents could help themto attain
competency?
What learning methods
would enable the
learning process?
Communication Sensitisation to communication: role need gaps Case study
Lectures
Learning communication skills Film
Role play
To be able to
understand the need
etc.
for institutional
development
Types of communication: internal-interpersonal, external
Modes of communication: active, passive (drafting
circulars etc.
Conducting meeting: agenda, check list
Information ow and feedback: role, mechanism
Standards
To be able to apply
the standards to
achieve quality
To be able to
perform
Standards mean
infrastructure, human
resources, logistics
Standards: need & role Review of standards
Group work
Set of standards
Available, adapt and adopt
Case studies WB/ HP
Standards and accountability: performance, reward
assessment tools and techniques, MIS
Visits (to organisation
who are implementing
the standards)
GROUP 3 Management (Strategic management for quality)
Key competencies/
learning objectives
(including level)
What course contents could help them
to attain the competency?
What learning methods would
enable the learning process?
Sensitisation on QM
Explain the signicance
and need for quality
culture
To identify and discuss
issues for implementing
quality
What is quality
Dimensions of quality
Rationalisation of resources
available for quality
Resources manpower, nancial
infrastructure
Group work and presentation
(TORs) using data
Policies, guidelines and processes for
decision making
Identication and
interpretation of quality
indicators
Existing indicators in health sector Lecture/ demonstration
Tools for assessing quality Assignment home work
Supervision and monitoring What is supportive supervision and
monitoring
What are the linkages to quality
improvement
Identication of supervision and
monitoring practices in the existing
systemand modify for quality
Feedback and follow-up action for quality
Lecture and discussion
Brain storming
Evaluation Methods of evaluation
Discuss existing evaluation
processes for quality
Problems and solutions
Lecture/ discussion
GROUP 4 Evidence Based Practice
Key competencies/
learning objectives
(including level)
What course contents could help themto attain
the competency?
What learning methods
would enable the
learning process?
Methods of acquiring data
Identication of data needs
Identication of data sources
Monitoring of data sources
Data security and
intellectual protection
Denition of areas fromwhich data are to be
acquired: facilities, research Lecture studies,
internal and external clients, community, media
Lecture
Preparation of data pathways and formulation of
tools (forms)- use of email, telephones, personal
communication should also include training
institutions and how data is generated and used
by them(linkages between training and policy)
Data should be used as a resource generation
mechanisms
Data is being generated, they dont know why
D&T
ICD 11 classication disease load, enables the
facilities to identify their needs
Which are the critical areas that can convert into
good practices
This is an area of international debate, evidence
into practice and linkage with policy and strategy
Group work
Analysing Data and
preparing action plans:
Enumerate various tools for
analysing data
Use of results of data
analysis in making action
plans
Identication of trigger
events
Able to effectively use
feedback pathways
Use of data analysis tools (like pareto charts, sh
bone diagram)
Identication of trigger events
Lecture
Methods of prioritisation of activities and
preparation of action plans and feedback
mechanisms
Group work Group work,
case studies
Hospital standards -
including STP
Able to enumerate the
various national standards,
STPs available
for hospitals and public
health programmes
Able to formulate strategies
to apply the STPs and other
standards as
monitoring
Introduction to standards and standard treatment
protocols
Examples of standards, discussion on essential
requirements
Implementation Methodology
Lecture
Need to integrate standards and HMIS and identify
the linkages and roles in each
Case Studies, eld
visits
Group work 2- Curriculum development
GROUP 5 Leadership and Human Resource Development
Key competencies/
learning objectives
(including level)
What course contents could help themto attain the
competency?
What learning
methods would enable
Overview & concepts of
QM in healthcare
Denition, elements, current practices national and
international experiences, QM tools/ methods,
development of standards (related to HRD), criteria,
indicators, SOPs, guidelines, assessment methods, data
collection, monitoring and analysis, problemsolving
skills, accreditation, statutory requirements
Principles of adult
learning
Lecture, eld visits,
group discussion, role
play, case study,
problemsolving
Human resource
development for quality
management in
healthcare
Workforce planning for QM in healthcare, job description
role, task, responsibility. Performance appraisal and
supportive supervision and monitoring, Motivation/
incentives, conict management, teambuilding &
effective communication, HR Management and
constraints (transfer, promotions, appointments),
Induction, Continuous professional development
programs, ethics, HR statutory requirements
(registration, licensing, credentialing)
Lecture, eld visits,
group discussion, role
play, case study,
problemsolving
Force-eld analysis, sh
bone analysis
Is this more Human resource management focus rather
than human resource development?
Annexure- 10
An Introduction to National Institute of Health and Family Welfare (NIHFW)
The NIHFWis an autonomous body registered under the Societies Act, which gives it the freedomto make its
own rules and to also charge for the courses delivered. However, policies and decisions are also guided by rules
and regulations, approved by the governing body, of which the Minister of Health and Family Welfare,
Government of India is the Chairman, the Secretary (Health and Family Welfare) is the Vice Chairman and
Director of the institution, is the member secretary.
The institution has its own vision and mission. The Programme Advisory Committee (PAC) supports and monitors
the teaching, research and training activities, and also gives guidance for improvement of the programmes,
which are reviewed on a regular basis.
The institute was established in 1977 by amalgamation of two erstwhile institutions namely, National Institute
of Health Administration and Education (NIHAE) and the National Institute of Family Planning (NIFP). The
objective of the institute is to promote Health and Family Welfare programmes in the country through
education, training, research, evaluation, consultancy and specialised services.
The institute provides advisory and consultancy services to the central government, state governments and other
national and international agencies, and conducts training and research in the eld of public health.
It also imparts postgraduate teaching in the eld of community health administration, including hospital
administration. The institute with the support of European Commission, established a professional development
course on public health, management and health sector reforms for district medical ofcers and at present, this
course is being imparted in cooperation with 15 State Institutes of Health and Family Welfare and private
institutions. Hospital and health management are also the key areas of the one year post graduate certicate
distance learning courses conducted by the institute. The institute recently established a Public Health Research
and Education Consortium- network and partnership. 167 medical colleges, 34 training institutions of health
and family welfare, 168 nursing colleges and schools; and 125 NGOs are the partners. It provides a very good
platformfor exchanging information and providing opportunities to introduce quality management in the
curriculumof other institutions as well.
Recently, NIHFW, in partnership with UNFPA has also undertaken Rapid Appraisal of Health Interventions (RAHI)
under NRHM. During the rst phase, technical and nancial support was given to 12 partner institutions in
NRHM states and in the second phase, 12 more partner institutions are involved.
Annexure-11
List of participants- (Workshop)
S. No. Name Designation & Address E-Mail ID/ Phone No.
1. Prof. Deoki Nandan Director
National Institute of Health & Family
Welfare, New Mehrauli Road, Munirka,
New Delhi-110067
director@nihfw.org
dnandan51@yahoo.com
Tel- 011-26714380,
011-26100057
Fax: 011-26101623
Mobile: 09971104666
2. Ms. Monika Krengel Senior Health Consultant
EPOS Health Consultant GmbH
Hindenburgring 18
61348 Bad Horburg, Germany
Monika.Krengel@epos.de
Tel: +496172-930379
Fax: 496172-930372
3. Ms. Sylvia Sax Consultant
University of Heidelberg
Deptt. Of Tropical Hygeine & Public
Health, INF 324 Heidelberg,
Germany-69120
sylvia.sax@urz.uni-heidelberg.de
Tel-+496221562930
Fax: +496221562918
4. Dr. Inder Preet Kaur Deputy Commissioner (Trg.)
Department of Health & Family Welfare,
Government of India, 206 D Wing,
Nirman Bhawan,
New Delhi-110011
ip.kaur@nic.in
Fax: 011-23061540
Tel (O)-011-23061540
Mobile: 09868032356
5. Dr. Dinesh Baswal Assistant Commissioner (Trg.)
Department of Health & Family Welfare,
Government of India, 505 A Wing,
Nirman Bhawan,
New Delhi-110011
dinesh.baswal@nic.in
dinesh126@hotmail.com
Tel-(O)-011-23062930
Fax: 011-23062930
Tel (H)-011-25251648
6. Dr. Suparna Pachouri Consultant (Health Financing)
New Delhi-110067
mimisuper@sify.com
Tel-011- 26165959ext-108
Mob: 09873480039
7. Dr. S.K. Sikdar Assistant Commissioner (RSS) Ministry
of Health & Family Welfare
Nirman Bhawan,
New Delhi-110011
sk.sikdar@nic.in
sikdarsk@rediffmail.com
Tel: 011-23062427
Fax: 011-23062427
(M)- 09911422499
8. Ms. Alexandra
Humme
Capacity Development Specialist
World Bank Institute, World Bank
Ofce, 70, Lodhi Estate, New Delhi
91-1141479 - 367
ahumme@worldbank.org
9. Ms. Sheeja Nair Consultant
World Bank, World Bank Ofce,
70, Lodhi Estate,
New Delhi
snair1@worldbank.org
Mob: 09810622754
10. Dr. Preeti Kudesia Senior Public Health Specialist,
World Bank, World Bank Ofce,
70, Lodhi Estate, New Delhi
pkudesia@worldbank.org
Tel (O)-011-41479101
11. Mr. Amit Paliwal Senior Technical Specialist
German Technical Cooperation (GTZ),
B-5/ 1, Safdarjung Enclave, 3rd
Floor,New Delhi-110 029
amit.paliwal@gtz.de
Tel-011-46036684
Fax: 011-46036677
12. Mr. S. Mallikarjuna Senior Expert Quality Management
B-5/ 1, Safdarjung Enclave,3rd Floor,
New Delhi-110 029
mallik.manu@gmail.com
Mobile: 9958100270
13. Ms. J ahanavi Das Technical Specialist
B-5/ 1, Safdarjung Enclave, 3rd Floor,
New Delhi-110 029
jahnavi.das@gtz.de
(O)-011-46036695
Fax: 011-46036688
14. Dr. J ivanananda
Pandit
Senior Technical Expert
Swasthya Bhawan Campus
Block GN, Sector V,
Kolkata-700091
jnpandit@gtz.de
pandit_home@sify.com
Fax: 033-23574697
Mob: 09830579822
15. Dr. B.S Garg, Director
Dr. Sushila Nayar School of Public
Health & Director-Professor and Head,
Department of Community Medicine,
Mahatma Gandhi Institute of Medical
Sciences, Sewagram, Wardha442102
Maharashtra
bsgarg_ngp@bsnl.in,
bsgarg123@rediffmail.com
Tel: 91-7152-284230
Fax: 91-7152-284320
16. Dr. P.H Rao Professor & Chairperson, Health Studies
Area, Administrative Staff College of
India, Bella Vista, Khairatabad,
Hyderabad 500082
Andhra Pradesh
Phone (O): 040-66534279
Phone (R): 040 23378158
Cell: 09440625240
Fax: 040-23312954
www.asci.org.in, drphrao@asci.org.in
17. Dr. Uday Mohan Prof. & Head, Deptt. of Preventive &
Social Medicine,
C.S.M Medical University,
Lucknow - 226 003, Uttar Pradesh
drudaymohan@yahoo.co.in
(O)- 0522-2257343
(Fax)-0522-2257674
(M) - 0941540896
18. Dr. Akhilesh
Bhargava
Director
State Institute of Health & Family
Welfare, J halana Institutional Area,
Near Doordarshan Kendra, J halana,
J aipur- 302004, Rajasthan
sihfwraj@yahoo.co.in,
abdoctor19531@rediffmail.com
Tel fax-0141-2706534
(H) -0141-3243030
19. Dr.Ashok Bhardawaj Medical Teacher, Deptt. of Community
Medicine, I.G. Medical College, Shimla,
Himachal Pradesh
ashoknonu@gmail.com
(O)-0177-2652983
(H)-0177-2657122
Fax: 0177-2652983
20. Dr. N.A. Khan,
Surgeon Captain
(Retd.)
Ex Director
Academy of Hospital Administration,
C56/ 43 Institutional Area Sector 62,
Noida, Uttar Pradesh
ahaindia@ahaindia.org,
aha1987@sifymail.com
Tel-0120-3233083
(M)- 91-9310981002
21. Dr. Aniruddh
Mukherjee
Technical Ofcer
Strategic Planning & Sector Reform
Cell, Deptt. of Health & Family Welfare,
Govt. of WB
Block A1st Floor, Swasthya Bhawan,
Sector V, Salt Lake, Kolkata
toam-sprsc@ wbhealth.gov.in,
dr.am06@rediffmail.com
Tel-033-23330174
Fax: 033-23577391
(R) o33-23359621
22. Dr. C.A.K. Yesudian Professor and Dean
Research and Development,
Tata Institute of Social Sciences, Post
Box No. 8313, Sion-Trombay Road
Deonar, Mumbai 400088, Maharashtra
yesudian@tiss.ed
Tel (O)-022-25563290
(H) 022-25561949
Fax: 022-25562912
23. Dr. Sanjay Agarwal OSD, PPP, Govt of Delhi
Health & Family Welfare Department
Res:B604, Sagar Apartment, Sector 62,
Noida
drsanjayagarwal.yahoo.com
mob:09868392784
Tel (O) -011-23392017
24. Mr. Bejon Misra Executive Director
Consumer VOICE, D14 G.K.Encalve II,
New Delhi, INDIA.
www.consumer-voice.org,
(O) 011-24379077
Mobile: +91-9811044424
or 9311044424
Fax: 011-24379081
Consumer Helpline 1800-11-4000,
bejonmisra@hotmail.com
25. Dr. M. Bhattacharya Prof. & Head
Deptt. of C.H.A., Dean of studies,
New Delhi-110067
Tel: 011-26714378,
Fax: 26101623,
26165959 (Ext) 349
cha_nihfw@yahoo.co.in,
bhattacharya_madhulekha@yahoo.
com,
26. Dr. K. Kalaivani Nodal Ofcer, RCH and
Prof. & Head,
Deptt. of RBM, National Institute of
Health & Family Welfare, New Mehrauli
Road, Munirka, New Delhi-110067
91-11-26165959, 26166441
Ext. 333, 330
(F): 011-26101623
(M): 09891568830
kkalaivani@nihfw.org
kalaivanikrishnamurthy@gmail.com
27. Dr. T. Mathiyazhagan Prof. & Head
Deptt. of Communication, National
Institute of Health & Family Welfare,
New Mehrauli Road, Munirka,
New Delhi-110067
91-11-26165959, 26166441 Ext. 368
(Fax): 011-26101623
(R): 011-25250057
(M): 9911189449
tmathiyazhagan@nihfw.org
mathi_53@yahoo.co.in
28. Dr. J .K Das Prof. & Head
Deptt. of Epidemiology, National
Institute of Health & Family
Welfare,New Mehrauli Road, Munirka,
New Delhi-110067
91-11-26165959, 26166441 Ext. 307
jkdas_19@rediffmail.com
Fax: 011-26101623
29. Dr. A.M Khan Prof. & Head
Deptt. of Social Science, National
New Delhi-110067
91-11-26165959, 26166441 Ext.308
(Fax): 011-26101623
(M): 9811833786
amkhan@nihfw.org
m_khannihfw@yahoo.com
30. Dr. Sanjay Gupta Reader, Deptt. of C.H.A., National
New Delhi-110067
91-11-26165959, 26166441 Ext. 338
(F): 011-26101623
sgupta@nihfw.org
31. Dr. K. S. Nair Lecturer (Health Economics)
Deptt. of Planning & Evaluation,
New Delhi-110067
91-11-26165959, 26166441 Ext. 197
Mobile: 09891917211
ksnair.nihfw@nic.in
k_sreenair@yahoo.com
32. Dr.D.S.Chandel SMOI/ C
Civil Hospital Palampur
Distt. Kangra H.P.
dr.chandel26@yahoo.com
(o)1894-234101
(H) 1894230857
Mob: 09418105470
33. DR. A.R. Raghu BMO, CHCNagrota, Bagwan
Distt. Kangra
Himachal Pradesh.
09816043403
34. Dr. Surender
Kashyap
Principal, Indira Gandhi Medical
College, Shimla, H.P. 171001
surendukashyap@hotmail.
com
Tel: 01772804251
Fax: 0177 2658339
35. Dr. T Bir Reader, Department of Social Sciences
NIHFW, New Delhi 110067
9868912906
tbir@nihfw.org
tbir_india@indiatimes.com
36. Dr. Abhilash Sood Department of Community Medicine,
IGMCShimla, H.P.
abhilashsood@yahoo.co.in
09418076890
37. Dr. PremPoonam Deputy Director, Health Services
Directorate of Health Services Shimla,
H.P
0177- 2622444
4th-8th June, 2008, Shimla
vkjksX;e~ lq[klEink
Workshop for
Senior and Mid-level
NIHFW
Organised by: Supported by:
Worldwide.
Jointly Organised by
and
World Bank Institute with Technical Support of GTZ
Baba Gang Nath Marg, Munirka, New Delhi 110067
Email: director.nihfw@nic.in
Website: www.nihfw.org
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