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

FOREWORD
MoHFW

ACKNOWLEDGEMENT

To be written by Director MH

INTRODUCTION TO THE MANUAL

Introduction to the Quality Assurance Programme 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/sterilization camps and outreach services. Assessing and 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 mechanism. Operational Manual This Quality Assurance (QA) process manual is designed for the district level health officials, who will constitute the District Quality Assurance Group. Inputs for this process manual have largely emerged out of UNFPAs technical report entitled Planning Population and Development Projects (1999) that focuses on decentralization and quality of care. The FRONTIERS Programme of the Population Council in partnership with USAID and UNFPA adopted the UNFPA approach for QA piloting in few selected districts of Gujarat and Maharashtra. Likewise the experiences of other QA projects such as the COPE approach of EngenderHealth in Uttar Pradesh and Uttarakhand and the Child Immunization QA approach of PATH in Andhra Pradesh have been reviewed. This manual organised in four chapters and an annexure is, therefore, an assimilation of experiences of these different approaches and has evolved as an integrated operational guide for implementation of the QA intervention in RCH programme. Chapter 1 provides a background and discusses the concept of quality assurance. Chapter 2 outlines the scope of quality assessment in the District Quality Assurance Programme and briefly explains different components, elements and sub-elements. Chapter 3 deals with institutional arrangements and methodology. It explains how the District Quality Assurance Group (DQAG) should be formed and lists the roles and responsibilities of the members. This chapter through the process of quality assessment also helps to guide the QAG members in their function. Chapter 4 describes the definitions of each of the elements and sub-elements and procedures to be followed for completing the assessment checklists. The instruments (checklists, formats of output and reporting) to be used for quality assessment of services at different levels of the health care facilities by the District Quality Assurance Group members are provided in the Annexure as assessment checklists, assessment output formats-results, action plan and reporting. Finally, the agenda for orientation training for DQAG and different stakeholders is also provided in the Annexure. QA Pilot Project: This manual has been revised based on the experience of site assessment visits by DQAG teams of six states, using the draft QA operational manual, checklists and formats during the QA pilot project from January 2006-December 2007. Their feedback on improving the manual has been incorporated to make the manual, checklists and formats more user-friendly and appropriate. Instruction to users: It is recommended that before proceeding with the assessment using the assessment checklists, the users of this manual (DQAG members) first read it in its chronological sequence to understand and become familiarised with the purpose, and the instructions and procedures to follow, while conducting the assessment. Thus preparing the user and enabling him/her to fill the checklists and output formats correctly.

TABLE OF CONTENTS

Chapter
i Forward

Topic

Page
2

ii

Acknowledgements

iii

Introduction to the Manual

iv

Table of Contents

List of Acronyms

6 -7

Background

8 - 10

Defining Quality of Care and Scope of Quality Assessment in District Health Management

11 - 19

Institutional Arrangement for Initiation and QA Assessment Methodology

20 - 31

Definitions and Procedures for Completing Checklists

32 - 73

Annexures Annexure 1: Assessment and summary Forms Annexure 2: Agenda 5 Annexure 3: Presentations Annexure 4: Suggested readings / references

74 135 75 116 117 118 119 - 133 134 - 135

LIST OF ACRONYMS
ADHO A.D. ANC ANM AT BP BPHC CDHO CHC CMO COPE DDO DGO DHS DNS DPHN DPMU DQAG DTO ECP EmOC BEmOC CEmOC FP FHW FRU FW FWTC GOI HA Hb HCL HIV HLD ICPD IEC ILR IPC IPD Additional District Health Officer Auto Disabled Antenatal Care Auxiliary Nurse Midwife Abdominal Tubectomy Blood Pressure Block Primary Health Center Chief District Health Officer Community Health Center Chief Medical Officer Client-Oriented Provider-Efficient Drawing and Disbursing Officer Diploma in Obstetrics and Gynaecology District Health Society Dextrose and Normal Saline District Public Health Nurse District Program Management Unit District Quality Assurance Group District Tuberculosis Officer Emergency Contraceptive Pills Emergency Obstetric Care Basic Emergency Obstetric Care Comprehensive Emergency Obstetric Care Family Planning Female Health Worker First Referral Unit Family Welfare Family Welfare Training Center Government of India Health Assistant Haemoglobin Hydrochloric Acid Human Immuno-deficiency Virus High Level Disinfection International Conference on Population and Development Information Education and Communication Ice-lining Refrigerator Inter-personal Communication Integrated Population and Development

IPHS IUD JSY LAM LHV LMP MD MS MOH MIS ML MO I/C MoHFW MS MTP MVA NGO NFHS NRHM NSV OCP OPD OT PHC PNC POL QA QAC QAG QI QOC RCH RCHO RH RKS RPR RTI SOPs STI UNFPA USAID VCT VHND

Indian Public Health Standards Intra-uterine Device Janani Suraksha Yojana Lactational Amenorrhea Method Lady Health Visitor Last Menstrual Period Doctor of Medicine Master of Surgery Ministry of Health Management and Information System Minilaparotomy Medical Officer In-charge Ministry of Health and Family Welfare Medical Superintendent Medical Termination of Pregnancy Manual Vacuum Aspiration Non-governmental Organization National Family Health Survey National Rural Health Mission No-scalpel Vasectomy Oral Contraceptive Pill Out-Patient Department Operation Theatre Primary Health Center Postnatal Care Petrol, Oil and Lubricants Quality Assurance Quality Assurance Committee Quality Assurance Group Quality Improvement Quality of Care Reproductive and Child Health Reproductive and Child Health Officer Reproductive Health Rogi Kalyan Samiti Rapid Plasma Reagin Reproductive Tract Infection Standard Operating Procedures Sexually Transmitted Infections United Nations Population Fund United States Agency for International Development Voluntary Counseling and Testing Village Health and Nutrition Day

Chapter

Background

Consensus on the importance of quality of care in population programmes emerged in the International Conference on Population and Development (ICPD) held in Cairo in 1994. Provision of a package of quality reproductive health services and addressing unmet reproductive health needs of couples and individuals became the central theme. Quality of care (QOC) was perceived as an integral and major component of peoples reproductive rights. This was considered as a landmark development wherein there was a paradigm shift from a demographic approach to responding to the reproductive health needs of the clients. The Population Council devised a framework for QOC for family planning services, which outlined the fundamental elements of care while capturing both technical and interpersonal, dimensions (Bruce 1987, 1990, Jain 1989). The Client-Oriented, Provider-Efficient (COPE) framework of quality assessment and improvement evolved by EngenderHealth gave further impetus to efforts for operationalizing QOC in programme settings (COPE 2003). Quality assessment and improvement activities have burgeoned in the recent years, stimulated by the diversified rationale, experiences and perspectives. Most interventions are driven by the fact that provision of services should reflect on the providers management and clients perspectives. There is also increasing recognition of insistence on adhering to service delivery protocols by the providers so as to achieve desired health outcomes from services. Inevitably, there is also emphasis on measuring service quality on a continuing basis. Quality management models from industry, demands from providers professional associations, focus on clients perspectives and satisfaction, and emphasis on achieving efficiency in programme settings are the basis of this manual. Incorporation of user perspectives and inter-personal discussion of service quality provision in monitoring of family planning programmes were lobbied by advocates of QOC in the decade of eighties. In India too, some attention has been paid to monitoring service quality in the RCH 1 project using tools and checklists. However, information from the states and districts indicate that routine supervisory visits did not provide adequate opportunities to monitor service quality and invariably these visits were rushed in nature. The National Population Policy document of 2000 noted that health care centers were over-burdened and struggled to provide services with limited personnel and equipment. Absence of supportive supervision, lack of training in inter-personal communication, and lack of motivation to work in rural areas together impeded citizens' access to reproductive and child health services, and contributed to poor quality of services and an apparent insensitivity to client's needs.

The Present Setting The Monitoring & Evaluation Strategy of Ministry of Health and Family Welfare (MOHFW) for the National Rural Health Mission (NRHM) and Reproductive and Child Health Programme II (RCH II) envisages assessing the quality of RCH services as an important element. The technical strategies in NRHM/RCH II are designed to increase access and improve service quality for specific evidence based interventions. The NRHM has proposed Indian Public Health Standards (IPHS) for health facilities at different levels of the system. Taking into consideration the IPHS guidelines and the RCH II Quality Protocols, it becomes imperative to evolve a system based on which quality improvement can be measured as an internalised ongoing activity. Although large-scale population surveys such as RCH and NFHS provide estimates on service utilization, these datasets are of very limited use for providing information on quality of service-delivery especially adherence to service quality standards, in the context of inputs, processes and client satisfaction and are not designed to provide estimates on different quality indicators. Therefore, it becomes critical to put in place, a mechanism to enable programme managers to assess the quality of services on a routine basis and track those elements that need quality improvements. Programme focus on measurement of service quality and consequent improvement by addressing gaps will help in achieving programme objectives and also lead to client satisfaction. The MOHFW intends to undertake a process of evolving a methodological framework for accessing maternal health, child health and family planning services being provided by the public health system in RCH II programme. Since quality assessment and improvement is in nascent stage, it was decided to adopt a simplistic approach and confine it to a few select indicators of the reproductive and child health programme so that the health system is able to absorb and internalise QA activities as part of the routine activities. In this context, a half-day brainstorming meeting was organized by MoHFW with experts and development partners to understand the quality assessment approaches experimented with in different states of the country; and discuss the feasibility of introducing QA in NRHM/RCH-II programme. Three agencies, namely, Population Council (Gujarat & Maharastra), EngenderHealth (Uttar Pradesh & Uttarakhand) and PATH (Andhra Pradesh) with prior experience of implementing different QA aspects of RCH services were invited to make presentations and share their experiences. Despite some commonalities in the QA approach, the three agencies had attempted in assessing merely one to two components of RCH, and hence the need for a comprehensive approach was acknowledged. Quality Assurance intervention in RCH services is an attempt to move forward by initiating and operationalizing programmatic interventions, initially in pilot settings. It proposes to develop and institutionalise the use of the field based, practical and feasible indicators in quality assessment and to transform existing supervision practices into a more standardized and structured process. Any sustainable change in terms of institutionalisation of Quality Assurance (QA) will come from within the system and not from outside. It is hoped that interventions from demand side (for example, community and individuals demanding better services) will also put pressure on the system to deliver quality services which will in turn give impetus for investing in QA. The FRONTIERS Programme of the Population Council, with technical and financial support from USAID and UNFPA, piloted implementation of QA for reproductive health in UNFPAs Integrated Population and Development (IPD) project districts of Gujarat and Maharastra along the lines of the UNFPA Quality Framework. The pilot phase was successful and by the end of it QA was internalised by the Department of Health in Gujarat. Presently, the Government of Gujarat has scaled up the activities to cover the entire state with technical

support from the FRONTIERS Programme. An Operational Manual developed by FRONTIERS Programme and UNFPA has been finalized and is being used. In view of the fact that most of the RH components have already been covered, it has been decided to largely adopt the standards set out in the manual and prepare an adjunct version of this manual that would include child health component and cover not only the CHCs/PHCs and RCH camps but include subcenters and outreach sessions. In this endeavour, UNFPA on behalf of MOHFW, GOI, coordinated with three agencies- Population Council, EngenderHealth and PATH to create an integrated operational manual for RCH components. To ensure use of standard definitions and the processes, the present manual will adopt the ones followed earlier in Gujarat. This manual tries to explain the process of QA in simple practical terms and is directly addressing the needs of district health officials who have been given the task of ensuring quality of reproductive and child health services provided at subcenters and primary health care facilities. Subsequent chapters deal with the implementation of the QA programme for RCH services at Subcenters, PHCs and CHCs and in camp settings.

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Chapter
Defining Quality of Care and Scope of Quality Assessment in District Health Management 1

Quality of Care: Quality of Care as applied to a public health system is defined as attributes of a service programme that reflect adherence to professional standards, in a congenial service environment and satisfaction on the part of the user (UNFPA technical report 1999) Quality Assurance Quality assurance (QA) can be defined as mechanism/process that contributes to defining, designing, assessing, monitoring, and improving the quality of healthcare. These activities can be performed as part of the accreditation of facilities, supervision of health workers, or other efforts to improve the performance of health workers and the quality of health services. Hence QA applies broadly to an entire cycle of assessment which extends beyond problem identification, to verification of the problem, identification of what is correctable, initiation of interventions/improvements, and continual review to assure that identified problems have been adequately corrected, quality of services improved and no further problems have been engendered in the process. The Quality Assurance Programme is made up of two main components: Quality Assessment Quality Improvement

Continuous assessment of the quality of services provided by facilities is fundamental to any QA programme. Assessment requires not only monitoring service utilization but also the processes undertaken in delivery of RH service package. It is assumed that both health providers and managers will pay more attention to the processes that are regularly monitored. It is known that unless monitored and supported, people often resort to the simplest or easiest ways of getting outcomes. At times these outcomes do not necessarily correspond to ultimate and intermediate goals of health systems and hence do not lead to client satisfaction. When assessment of quality is built into the routine monitoring of services, there will be more likelihood of attention being devoted to the processes in delivery of services.
1

This chapter has been largely adapted from District Quality Assurance Programme for Reproductive Health Services: An Operational Manual. Manual developed by FRONTIERS Programme of Population Council and UNFPA for Department of Health and Family Welfare, Government of Gujarat. May 2006.

11

Quality Assurance approach is one way to improve quality through systematic monitoring and improvements in delivery of services.

The objective of the proposed Quality Assurance mechanism at district level is to facilitate the continuous monitoring of quality of reproductive health services at subcenters, CHCs/PHCs and RCH camps and consequently improve service quality by focusing on and addressing the gaps identified during the assessment process. In order to do this, it is proposed to set up a District QA group within the public health system consisting of district programme managers who will conduct periodic assessment visits using specific tools and based on the gaps identified will help the service providers, address specific service quality elements and subelements. Details of the activities of the QA group have been discussed in the subsequent chapters on institutional arrangements. This manual provides the tools to ensure that quality assessment is standardized and reduce subjectivity to the extent possible. These tools are also amenable to scoring and on the basis of service quality assessment for the facility a composite score can be arrived at. This summary assessment will allow the CHC/PHC In-charge and District Health Officer and his/her staff to identify and begin the process of change required to improve quality of services. Thus quality assessment through refocusing and restructuring routine monitoring visits using standardised tools will help in identification of existing gaps in service quality. This will also lead to initiating a series of actions to address the gaps and hence improvements in the quality. Subsequent visits will ensure that actions initiated have resulted in improvements in the facility score. How do We Measure the Quality of Health Services? There are three dimensions of quality requiring measurement using a systems approach Inputs, processes and outputs. InputsIt includes all programme efforts that facilitate the readiness of the facilities to provide services when a client visits the clinic. Inputs include physical infrastructure, staffing, supplies, equipment, etc. Availability of inputs will be critical for delivery of services as per the service delivery guidelines and protocols. ProcessesRefers to the actual process of care giving and services received. Processes include technical and interpersonal dimensions and a range of elements. All the actions by staff members of the CHC/PHC, subcenter and RCH/sterilization camps for ensuring quality services to the clients have been covered. Process observations- The days of visit to the facility are used in this manual to assess whether the providers are maintaining standards of care as specified in service guidelines. Visit dates will need to be scheduled to be reasonably sure that on the date of visit a particular set of clients is present- e.g. RCH camp days for family planning services observation, ANC check up for antenatal care observations and outreach child immunization sessions. Outputs - Outputs can be seen from the perspectives of clients, providers and managers. Outputs from service delivery will result in better reproductive health outcomes leading to achievements of the programme goals. One of the more difficult dimensions of quality is to measure output in a clinic setting especially during the monitoring visits. For example clients who availed of a particular RCH service from a facility may or may not come for a follow-up visit on the day of QA teams visit. It is therefore not feasible for the QA team to form an opinion on the service quality received and record their degree of satisfaction with services

12

during the monitoring visit. The other practical approach is to do an exit interview of the clients on the day of visit and review records, specifically for follow-up services provided by the facility. Standards of Care used for defining quality indicators in this manual are those that are widely accepted and recognized by the Government of India. A reference list of standards of care used in different settings is annexed at the end of this manual. Each state may also have a list of additional guidelines, which are used when no formal GOI guidelines are currently available for the particular service delivery interventions. Scope of Quality Assessment in District Health Management The Elements of Quality The following is extracted from the UNFPAs technical report entitled Planning Population and Development Projects (1999) with focus on decentralization and quality of care. The framework for addressing quality of care issues is particularly relevant for services provided through the primary health care system. The Reproductive Health Quality Framework comprises of 9 elements drawn from the agreed definition of Quality of Care (QOC) as applied to the public health system. For definition of QOC, please refer to the beginning of this chapter. Each element has been defined and then described in more specific terms by sub-elements, which have been given below in the form of queries or questions. Elements of Quality: The nine elements can be categorised into generic and specific elements. Four elements can be grouped as specific elements, as they are specific for a particular RCH service while there are five elements those can be applied to any RCH services and are therefore generic. The proposed QA intervention conveys most of these elements and sub-elements. Generic Elements (Common to all RCH services) a) Service environment b) Client provider interaction c) Informed decision making d) Integration of services e) Womens participation in management a. Service environment

This is defined as organisation of services for the clients convenience and for maintaining standards. The QA checklists ask questions that specifically address this aspect of qualityfor example questions about a separate labour room, privacy etc. Sub-elements 1. 2. 3. 4. Are there adequate physical space and specifications for procedures? Are water and electric supply connections available as per requirement? Are adequate sheltered waiting areas, drinking water and clean toilets available? What are the standards of hygiene and cleanliness? Is the waste disposal system adequate and proper? 5. Does the facility have provision for ensuring privacy and confidentiality? Are the provisions followed? 6. Are the waiting times for consultancy, tests and procedures reasonably short?

13

7. Are policy and provisions in place for maintenance of facilities? Does regular periodic maintenance of building and amenities take place? b. Client-provider interaction

This is defined as the nature of providerclient relationship and information exchanged between them. The assessment of client-provider interaction cannot be directly observed in most cases as it violates the rights for privacy and confidentiality of the client and also the presence of an observer will most likely alert the provider towards changing behaviour when observed. The methods used in the QA Checklists to assess client-provider interaction are indirect and are limited to clients self report in a short questionnaire about their satisfaction with services and questions asked to clients. Sub-elements 1. Are providers friendly and courteous? Do they actively listen to clients? Do they invite doubts and questions? 2. Do providers give complete information on each serviceeligibility, dosages, possible side effects, how to manage them or where to go for care, follow up schedule, etc? 3. Do providers understand clients language or dialect? Do they give instructions using simple, easily understood words (without medical jargon)? 4. Do providers use models, pictures, samples and other communication and job aids while explaining clinical or non-clinical contraceptive methods? c. Informed decision making

This is defined as availability of relevant information and service procedures that facilitate informed choice by client. Sub-elements 1. Do the clients receive adequate counselling on methods and procedures involved in provision of services? 2. Do communication efforts address social and economic determinants of health related behaviour? 3. Is a clients decision biased by incomplete information on available options, or inhibited due to fear of denial of some or all service(s)? 4. Are those who switch or discontinue contraceptive methods encouraged to make another choice? 5. Are there adequate procedures in place for informed consent before major clinical procedures? Is informed consent followed in practice? For example the QAG member reviews filled in case sheets of clients who underwent a sterilization operation for completeness of information and verifies through exit interviews of clients who availed the services. d. Integration of services

This is defined as linkage of services and health institutions in order to provide comprehensive RCH care in a convenient manner. Sub-elements 1. Are clients with two or more RCH needs (e.g. contraception & RTI) served at the same time or in the same institutions?

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2. Is adequate upward referral system across primary, secondary and tertiary institutions available? Are referred clients reverted to peripheral institutions after specialised care? 3. Is there adequate linkage between government, private, voluntary and corporate sector health institutions? 4. Are referral protocols established? 5. Is a system established for co-ordination, interaction between different health sectors? e. Womens participation in management

This is defined as accountability of RH programmes to its clients, especially women, by involving them in planning, implementation and monitoring RH services. Sub-elements 1. What is the number and role of women managers and supervisors within the system? 2. Are there career development opportunities for women employees? 3. Are there mechanisms for involvement of community/womens group representatives in programme planning? Service Specific Elements (Specific to each RCH service) a) Access to services b) Equipment and supplies c) Professional standards and technical competence d) Continuity of care a. Access to services This is defined as availability and accessibility of RH care to clients, especially to underserved segments of the population (age, religion, men, women-old and young etc.) and marginalized groups (tribes, migrants, slum dwellers etc.). Sub-elements 1. What is the location, distance and timings of the health institution? Do any of these elements pose as barriers to accessing services? For example, one of the questions used to asses this is, are the services and timings mentioned on a wellmarked board? 2. Are service providers available on a routine basis, and in the event of an emergency? For example the question asked regarding availability of nursing personnel at CHC for 24 hours. 3. Are services affordable? What are the costs of medication, fees, travel, lost wages, etc? Since most of the services are free in the facilities the question, testing this aspect of access is to see whether the cost of transportation to a higher-level facility for referral is shown on a well-marked board. b. Equipment and supplies Quality of care in terms of equipment and supplies has been defined as the functional status and quality of equipment and consumables supplied. Not all sub elements are part of the QAG assessment. Sub-elements 1. Are equipments of standard specifications available? Are they in working order? Are they regularly maintained as required? For example All beds in the CHC/PHC that are being used should have rubber covered mattress and clean sheets.

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2. Are sufficient supplies (of drugs, contraceptives, vaccines, antiseptics, linen etc.) available? These should be well within expiry date. For example - The QA Checklist asks questions on supplies worded to ensure current supplies for at least 20 clients on date of visit. 3. Is there a need based procurement system and inventory control in place? Is the indent-delivery interval appropriate? Is the logistics management information system established and operational? 4. Is the warehousing and storage space adequate? Are they protected from weather, pests and pilferage? 5. Is there adequate transportation arrangement for delivery of equipment and supplies? 6. Are policy and provisions in place for maintenance of equipment and storage facilities? c. Professional standards and technical competence This is defined as the availability of norms and service guidelines for procedures with administrative sanction for the same and provider competence for their observance. All the national ealth services guidelines need to be provided by the District Medical Officer to all the health facilities. These guidelines should be available in the facilities with easy access to all concerned for reference, including interested staff. Sub-elements 1. Are service guidelines available at the point of use? 2. Are service guidelines observed for clinical and asepsis procedures? 3. Are providers competenceclinical, communication and managerial skills adequate for the prescribed roles? Are regular training courses organised for skill enhancement? 4. Are service standards established? Are administrative sanction and provisions (staff norms, budget for supplies) for observing guidelines in place? 5. How are training needs identified? Are the strategy training, certification norms, refresher courses, record keeping and personnel MIS adequate? For example, the QA Checklists first 4-5 questions are specifically related to this for RH services. d. Continuity of care It is defined as continuity of services and records over a clients reproductive life cycle. Sub-elements 1. Is the Management and Information System (MIS) designed to track elements over different reproductive stages? 2. Is MIS data available and records well maintained? The QA checklist has questions that check whether the details of programmes are maintained. 3. Is the client follow-up regular and effective? 4. Are providers able to manage themselves or need to refer problems of side effects, complications, relapses or recurrences? Scope of Quality Assessment in the District Quality Assurance Programme In this QA intervention, the Reproductive and Child Health services to be assessed are limited to those provided at the facilities such as CHC and PHCs, subcenters, RCH/sterilization camps and include subcenter outreach services.

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RCH Service Areas A. Family planning services including provision of clinical and non-clinical contraceptives ANC, safe delivery, Basic Emergency Obstetric Care (BEmOC) including essential newborn care Reproductive tract infections including sexually transmitted infection (RTI/STI) prevention and management including VCT for HIV at designated facilities. Child Immunization

Elements of Quality Assessed 1. 2. 3. 4. Service environment Access Equipment and supplies Professional standards and technical competence 5. Continuity of care 6. Client provider interaction 7. Informed decision making 8. Privacy 9. Confidentiality 10. Informed consent 11. Proper disposal of wastes

B.

C.

D.

A.

Family Planning:

Assess quality of service provision for all modern family planning methods available at PHCs and CHCs. Family Planning Services Components a. Method specific counselling of men and women for FP method b. Provision of Oral Contraceptive Pills (OCPs) c. Provision of Condoms d. Cu-T 380 insertion e. Tubal Ligation: Laparoscopy/mini-lap f. Emergency contraception g. Vasectomy: Traditional/No-scalpel vasectomy h. Management of contraceptive side-effects i. Follow-up services j. Record keeping Elements of Quality Assessed 1. Facility infrastructure 2. Equipment inventories including functionality 3. Supplies inventories 4. Staff availability, training 5. Staffing knowledge and skills 6. Availability of standards 7. Tracking follow-ups 8. Communication aids for IPC 9. Confidentiality 10. Privacy 11. Informed consent 12. Proper disposal of wastes

B. Safe Motherhood Services and Newborn Care Assess all components of antenatal care, safe delivery, basic emergency obstetric care services, postpartum care and essential newborn care provided at the facility. Assess the necessary stabilization of client before transportation, and arrangements for transfer of woman to the nearest Comprehensive Emergency Obstetric Care (CEmOC) facility in the district. Maternal and Newborn Care Services a. b. c. d. Antenatal care Management of normal labour Postpartum care Essential newborn care Elements of Quality Assessed

1. Facility Infrastructure: Consultation rooms, laboratory, labour Room, ward, OT 2. Transport availability and functionality arrangements

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e. Basic emergency obstetric care f. Referral of obstetric and newborn complications

3. Communications: Functional telephone 4. Equipment inventories including functionality 5. Service equipment 6. Supplies inventories, including EmOC drugs 7. Staffing- training 8. Staffing knowledge and skills 9. Availability of protocols 10. Privacy and confidentiality 11. Proper disposal of wastes

C.

Management of Reproductive Tract Infections and Sexually Transmitted Infections.

Assess the RTI and STI case management services. Currently these services at the CHC/PHC are being provided on the basis of laboratory diagnosis. The CHC and PHC are expected to be staffed with trained MO, nursing staff and a laboratory technician and have reagents and supplies and equipment to conduct simple tests to detect common RTI/STI pathogens and drugs for their treatment.

RTI/STI Services (Common RTIs/STIs only) For all common RTI/STIs a. History taking, clinical examination b. Lab investigations c. Treatment d. Partner management e. Counselling f. Follow-ups and referrals 1. 2. 3. 4. 5. 6.

Elements of Quality Assessed

Facility infrastructure including laboratory Equipment Supplies inventories Staffing- availability Staffing knowledge and skills, training Records maintenance for partner management and follow-ups 7. Availability of treatment protocols 8. Privacy 9. Confidentiality 10. Informed Consent 11. Proper disposal of wastes

.D.

Child Immunization Services

This element, as far as possible has to be assessed on an immunization day when the immunization session is being conducted at the sub-center or at an outreach facility. However, this may not be feasible every time at the CHC/PHC level when the facility is being visited on non-immunization days. If the facility is offering immunization services on all working days and there is a child availing of the immunization service during the visit, then the steps suggested in the checklist should be followed. In case, it is not so, the QAG member should review the maintenance of cold-chain equipment, logbook, vaccines and examine the stock register and MIS records.

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Child Immunization Services a. Immunization session schedule planned and conducted b. Functioning of cold-chain equipment c. Adherence to vaccine quality norms d. Infection prevention and safe-injection practices e. Stock situation of vaccines 1. 2. 3. 4. 5.

Elements of Quality Assessed Facility infrastructure Equipment and instruments Cold-chain maintenance Supplies inventories AD syringe use and disposal and safe injection practices 6. Staffingknowledge and skills 7. Log-book maintenance and updating of immunization cards 8. Availability of protocols

In sum, the above classification of elements and sub-elements have been reorganized in the data collection checklists and crosscutting areas that are common to all the three RCH components, which have been categorized in general facility readiness category, followed by questions on specific RCH components at facilities and camps.

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Chapter
Institutional Arrangements for Initiation and QA Assessment Methodology2

Institutional Arrangements

In order to rollout QA interventions at the district level, concurrence and continuous support of the state is essential and critical. This is because several programmatic inputs and decisions and those having financial implications may have to be decided at the state level. For instance, there could be activities such as technical capacity building of providers, making available necessary equipment and instruments, ensuring demand generation through statelevel multi-media activities etc. that are mainly driven by state. Unless the state initiates such activities, it becomes difficult for the district to carry forward certain specific interventions. This is true in case of capacity building programmes that are more state centric and follow a cascade approach. The task of doing this has become simpler because the National Rural Health Mission (NRHM) has adopted a decentralized approach and envisaged clear-cut responsibilities for the state and district health missions. It has suggested setting up of district committees consisting of various stakeholders including community representatives for ensuring smooth functioning of the missions. In addition, Rogi Kalyan Samitis (RKSs) and citizens charter have been recommended for transparency in functioning and providing quality services and improvement in quality has been accorded priority. The QA pilot in six states has been implemented within the confines of NRHM. Formation of the District Quality Assurance Group (DQAG) It is proposed that Director Family Welfare, State Government would identify a focal point in the state programme management structure to steer quality assurance interventions. Further, the state would issue a letter to concerned District Health Officers to set up the District Quality Assurance Group. The DQAG would not be an independent structure but would be an extension of the Quality Assurance Committee (QAC) set up as per the directives of the Supreme Court to ensure quality of sterilization services. The DQAG when constituted will be housed along with District Programme Management Unit (DPMU) and would report to the District Health Mission/Society constituted under the National Rural Health Mission (NRHM). Thereafter, the line of reporting would follow the guidelines articulated in NRHM. The State QA Nodal Officer nominated for QA piloting activities will liaise between the District and State Health Missions and facilitate QA implementation. The core constitution of the DQAG would include present members of QAC and additional three-four members from the supervisory level and senior district programme officers. The DQAG in its constitution will ensure the presence of a woman representative in the group. The Chairperson of the District QAG will be the Chief Health Officer of the district. The member secretary of the District QAG would be the District Quality Assurance in-charge or a person designated by the Chief Health Officer such as Additional CMO/Deputy CMO or
2

This chapter on Institutional Arrangements has been largely adapted from District Quality Assurance Programme for Reproductive Health Services: An Operational Manual. Manual developed by FRONTIERS Programme of Population Council and UNFPA for Department of Health and Family Welfare, Government of Gujarat. May 2006

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RCHO etc. It is desirable that the focal point or designated person is drawn from the ranks of senior district level officers in the health system. In case there is an active NGO working on health issues in the district, a representative may also be invited to join the DQAG. The Government order would include the provision of office space, utilization of office equipment and vehicle with driver if available. In many states, the health department is hiring vehicles on contract basis in the RCH II programme and same modalities can be used for ensuring availability of a vehicle during scheduled visits of the DQAG. Resources available with District Health Mission/DHS under NRHM/RCH II programmes could be used to ensure mobility support and the QA element can be included in the district and state health plans as well. Alternately, need for a designated vehicle may be explored depending on the number of visits to be made. Available supervisory vehicles can also be optimally used for these visits but it all depends on the district vehicle pool. The Chief District Health Officer should explore the possibility of assigning some office space with necessary equipment, furniture, stationery and computers; assistance in computerizing and maintaining the QAG summary reports and records for bi-annual follow-up at the next QA visits. Structure of DQAG State Health Mission
State QA Nodal Officer

District Health Mission

DQAG

Chief Medical Officer (Chairperson)

Nodal Officer

Dy. CMO/ADHO /RCHO

DQAG Teams

Eight-Ten Members

Terms of Reference of the District Quality Assurance Group Planning QAG visits to facilities and communicates visit schedule to members of the Quality Assurance Group in advance Making necessary preparations for visit transport, at least three members per visit, adequate supplies of QA forms Visiting facilities and uses the QA Checklists to conduct the assessment. Debriefing the Medical Officer In-charge of the facility Compiling findings obtained during district level visits Distributing the District Summary Report and discusses these at the monthly meeting with Medical Officers Communicating the findings back to the facilities with guidance on what actions need to be taken

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Forwarding the minutes of the monthly QAG meeting and actions to be taken to the concerned officials Keeping records of follow-up and actions taken so that these can be reviewed on subsequent visits to the facility.

The specific roles and responsibilities of the Member Secretary will be Planning the DQAG visit schedule Ensuring that all the QAG members are informed about their responsibilities and days of DQAG visits Ensuring that the DQAG visits are reported and recorded within one week of visit Analysing the QA Forms and preparing the District QA summary reports based on the findings of the facilities visited each month Communicating the date and time of the monthly DQAG meeting at the District Headquarters, keeping records of the minutes of the meeting, and sending them to the requesting parties Assisting the DHO in presentation of the DQAG findings and follow-up during meetings with the facility Medical Officers In-charge. Submitting the DQAG district summary reports at the direction of the DHO.

Other district level health department officials who are to be part of the DQAG are the CMO, ADHO-FW, RCHO, DTO (I/C), and DPHN/Tutor FWTC, besides other members of the DQAG selected by DHO based on local supervision roles. For example, in certain districts, a block is assigned to the supervisor and, therefore, the supervisor of the block whose CHC/PHC is being assessed should accompany QA team on field visits. Membership of the District Quality Assurance Group The Chairperson of the DQAG i.e. DHO/CMHO/CMO should have the autonomy to decide on the members of this group. The DHO/CMHO will also nominate one of the members as Member Secretary (ADHO/Dy. CMO). QA Orientation Workshops Prior to launch of QA program in the district, and the training of DQAG members, the states will organise two half-day orientation workshops, one for the state officials at state headquarters and another for the district officials at district headquarters. In addition to these, a one-day orientation workshop for Medical Officers of participating facilities will be organised at district level to make them aware of the indicators on which their facility will be assessed during QA visits. This will be done prior to starting QA visits to selected facilities, and after DQAG has been trained. The following is recommended for each level of orientation State Level Orientation: Agenda: (a) Welcome of participants and opening remarks by Principal Secretary/Secretary, Health or a person of similar level (b) Overview of Quality Assurance Program by State Nodal Officer A Director level person (c) Formation of Quality Assurance Group at District level and roles and responsibilities of key state and district officials in QA activities by Representative of field agency (d) Discussion followed by the closing remarks.

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Note: The presentations given in Annexure 3 should be used to give an overview of QA program and explain the constitution of DQAG and roles of key players Participants: Recommended invitees: (a) (b) (c) Directors of all Departments of State Health Directorate. Director of RCH, NRHM, FW, IEC should attend the orientation Regional Deputy Director under whose jurisdiction the selected district falls CDHO, RCHO and Head of District Medical Hospital/college of the selected district.

District Level Orientation: Agenda: (a) Welcome of participants and opening remarks by Head of District Health Mission/DHS or DDO or District Magistrate (b) Overview of Quality Assurance Program by District Nodal Officer, who is also Member Secretary of DQAG (c) Formation of Quality Assurance Group at District level and roles and responsibilities of key state and district officials in QA activities by representative of field agency (d) Discussion followed by the closing remarks. Note: The presentations given in Annexure 3 should be used to give an overview of QA program and explain the constitution of DQAG and roles of key players Participants: Recommended invitees are: (a) All members of DHS/District Health Mission, Head of District Hospital/Medical College, District Development Office, All ADHO/Dy. CMOs, DPHN, District Immunization Officer, Chief Surgeon of District Hospital, IEC officer and members of the existing QAC set for sterilization. The State Nodal Officer and Regional Director who will facilitate the orientation workshop.

(b)

One-day Orientation Workshop on QA for Medical Officers In-charge/ MS CHC and PHC service providers The MOs In-charge of each CHC and PHC should receive orientation about this intervention and they are also expected to then orient their staff about the QA programme. This will ensure that each facility is prepared for the visit and medical officers and staff members know the objectives of the visit from the district QA group.. It will also lead to a more collegial QA visit and will reduce the time spent in explanations. The CDHO along with the other DQAG members should conduct these orientation meetings. All the participants will be given a copy of the operational manual in order to understand the QA visit, the scoring and the debriefing procedure. The design of the proposed one-day orientation for Medical Officers InCharge/MS of CHC and PHC is given below: Agenda: (a) Welcome of participants and opening remarks by CDHO (b) Overview of Quality Assurance Program by District Nodal Officer, who is also Member Secretary of DQAG (c) Formation of Quality Assurance Group at District level and roles and responsibilities of key state and district officials in QA activities by representative of Field agency

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(d) (e)

Briefing of CHC/PHC, Subcenter and RCH/sterilization camp checklists Discussion followed by closing remarks.

Participants: Medical Officers In-charge of PHCs and Medical Superintendents of CHCs. Note: Presentations given in Annexure 3 should be used It is essential to orient all MOs of CHCs and PHCs about the QA programme. A copy of the QA CHECKLISTS should be shared during the briefing so that they are familiarized, and at the same time instructed to orient other staff members specifically the supervisory staff members and Subcenter ANMs during monthly meetings at facility level.

Training of DQAG Members a four day workshop for the District QAG members Four-day training for members of the District Quality Assurance Group should be held in each district to train the members in the QA programme. The training will help in better comprehension of the roles and responsibilities, the use of the QA checklists for assessment at the CHC/PHC and subcenter, including outreach and RCH/sterilization camps. The training will also help the DQAG members understand the requirements for recording reporting, meetings at the district level and the actions that need to be taken at each level, the facility, district and state level. The presence of Regional Director/Zone Officers during the orientation is essential as it will help in arriving at a shared understanding about work and follow up actions. The Gujarat experience shows that it also helps in keeping the training better organized and focussed. The presence of senior officers during the training also communicates the commitment and ownership of the system about the QA process The training should be made participatory by encouraging questions from the participants and discussions to help address issues raised by the participants. This will make them feel engaged in the training process and clarify their doubts related to the QA process, filling the forms and interpreting and analysing the results. During the briefing on various checklists and formats, the participants may be allowed to practice filling and interpreting the checklists in a mock situation or exercise. Field visits to the different types of facilities and their assessment on the formats should be an integral part of the DQAG Training. This should follow the review of the formats. Hand on practice should be given and any difficulty in understanding the formats or filling the formats or any query related to indicators should be explained. Facilitator should demonstrate the whole process. . Compilation of REPORT FORMATS will be demonstrated and hands-on practice to be given to district data entry person for compilation of QA reports at district level will be done. Discussions on how improvements can be made and conducting a mock QAG review meeting can be part of this training. A draft design of the four days training programme for District QAG members can be found in the Annexure 2.

QA Methodology The quality assessment involves coverage of CHC/PHC, subcenters and outreach sessions (both inclusive) and RCH/sterilization camps. In an average sized district of 10-15 lakhs population, there would be about 10-15 CHCs/BPHCs, 30-35 sector PHCs, and 200

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subcenters. In addition to rendering services through static facilities, nearly 250 RCH/sterilization camps are organized annually in different blocks of the district.

Sampling Frame of a Bi-annual Cycle Estimated number of facilities Sample Coverage

CHC/BPHC (10-15) Sector PHC (35) Sub Center-250 RCH Camps-250

CHC/BPHC (10-15) Sector PHC (12)

Sub Center24 (approx10%) RCH Camps25 (10%)

Given this break-up of the number of facilities and camps organized in a district, it is envisaged to cover all the CHCs and BPHCs, one sector PHC from each CHC/BPHC area selected randomly and two subcenters on the basis of performance-one good and one poorly performing center. Thus one visit cycle lasting about six months will enable coverage of all CHCs/BPHCs (about 12) an equal number of sector PHCs and 24 subcenters. In addition, one RCH/sterilization camp that is being conducted in each of the selected CHC/BPHCs will be covered in one cycle, resulting in a total of 24 RCH/sterilization camps in a year. On a monthly basis, two CHC/BPHCs, two PHCs, four subcenters and two RCH camps will have to be covered by the district DQAG members. In order to cover these facilities, a minimum of three-four QA teams, each consisting of two members will be required. Each team will have to spend about two to three days a month in carrying out their QA work component. The subcenter visit must coincide with an immunization day (Wednesday of every week) while the other visits can vary. Since two activities, those of assessing the subcenter and of observing the outreach session are involved, they have to be fixed in such a way that they do not affect the work of the ANM. (The outreach session can be covered in the first half of the day and subcenter facility assessment in the latter half of the day). In undertaking all these tasks, the assessment team will be spending just one day per two weeks on QA without affecting their routine chores in field work. The above calculation is based on an assumption but the district will have to calculate on an actual basis, develop its plan and decide the number of teams required for undertaking the assessment. However, the minimum recommended is three teams consisting of two members each. So, it will be good to train about 10 persons in QA assessment so that if one team member is not available, there is a backup available.

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Planning the schedule of visits An itinerary of visits should be prepared for every quarter-stating the name of facilities or camps, date of visit and QAG members conducting the assessment visit. This should be prepared at least two weeks ahead of initiating bi-annual visits. The Bi-annual QAG work plan should contain: Visit schedule Dates of district QAG meetings Dates for monthly meetings with MOs regarding action to be taken and follow-up. Only MO I/C from facilities covered during the previous month are to be invited. Dates of Regional/Zone bi-annual meetings where regional and state level interventions required will be discussed and follow up actions will be listed

Immediate Pre-Visit Activities The member secretary should ensure that all members of the team are available and ready on the day of visit. The QAG member secretary should: Ensure that the Medical Officer In-charge of the facility has been informed at least one week in advance of the visit Make certain that the MO is available on the date of visit Arrangement of vehicle and driver and POL provision has been made Ensure adequate QA Forms and additional stationery for the visit.

The team leader should be identified prior to the visit and is responsible to the QA member secretary and CDHO for reporting on the visit. Reaching the Facility It is suggested that the team members should travel together in the designated vehicle. This will allow time for preliminary discussions; understanding of specific tasks of each member and bring about clarity in the assignment to be undertaken. Above all, a sense of team approach will be inculcated. The Quality Assessment visit should proceed according to a time schedule, and the QAG visit will be successful only if both members of the team understand and closely follow the procedures for filling in the QA Checklist. On the day of the QAG visit to a CHC/PHC, it is of utmost importance that the Medical Officer In-charge of the facility is present when the team arrives. The QAG visit needs to make the best use of the time it has for assessment which should not be conducted in the absence of the Medical Officer In-charge. In case the district has selected a CHC/PHC without a MO In-charge, clarify with the CMHO who is the officiating MO In-charge and only after getting CMHOs confirmation should a visit be made. In such cases, the same procedures should be followed. Sometimes, new MOs tend to abdicate authority to a senior nursing/paramedical staff. This should not be encouraged. Take this opportunity to assist the new/young Medical Officer to understand his/her supervisory role. Team members should all stay together for the initial introductory session with the MO and only then go on to separate rooms in order to administer the checklist. Following are examples of problems one may experience in gathering relevant information: Medical Officer is not available. The MOs availability and willingness to be interviewed will depend largely on the initial preparations made. It is to be ensured beforehand that all MOs are fully aware of the importance of the QA visit and have been given adequate

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advance notice about the date of visit. In unavoidable situations where MO I/C/MS is not available, the QA team should not assess the facility and should not proceed to visit the next facility. This facility will be visited again after fixing a new date with the MO I/C/MS of the PHC/CHC. However a revisit to a facility assessed before can be made to follow the action plan developed during the previous visit. QA Checklist could not be completed. About 4 hours have been assigned for the task. It is very important that the team complete the QA Checklist during the visit itself. If it is not done, a revisit needs to be planned again at an early date. Item on QA form was not verifiable: The MO or other respondent may be called away during the visit or he/she may not have the keys to rooms/cupboards/stock registers, to check utilization, availability or functionality at the time of visit. In such cases, the word of the MO should be considered final and should be believed. The Medical Officer acknowledging that the information collected in person or ascertained is correct, to the best of his/her knowledge, signs the final report on the Forms. It should however be indicated with a small asterix (*) that the particular item was not checked but only scored based on MOs response. Try to ensure that these particular items are physically verified in the next QAG visit. Too much rush in OPD: Visiting team must ensure that there is minimal disruption of routine patient care activities in OPD and other work stations. Reschedule activities that require minimum assistance and continue with specific activities when the staff members are relatively free.

Administering the QA Checklists The Quality Assessment instruments cover key indicators to assess whether necessary services are available at the facility and whether the services being provided are meeting quality standards. Furthermore, the assessment does not include a comprehensive or exhaustive list of all supplies, equipment, and records etc. that a facility is supposed to have for provision of reproductive and child health services. Instead it includes a list of selected priority INDICATORS of all the elements and sub-elements of quality that are considered critical. National and state level administrators, service providers, experts and programme managers decided the methodology of arriving at these critical elements through a consensus process. The importance of using the Checklists is to answer the question Is this facility today providing quality reproductive health services that meet the standard? This helps us to ascertain if facility is providing services as per agreed standards/protocols or not. In all, six checklists have been designed to cover CHCs/PHCs, subcenters and RCH/sterilization camps respectively. The first four checklists are related to assessment of facilities, camps, and client satisfaction while the remaining two are related to analysis of findings in terms of identification of problematic areas and actionable solutions followed by a summary of assessment results.

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ASSESSMENT CHECKLISTS Form 1: CHC / PHC quality assessment checklist Form 1A: CHC / PHC quality assessment results summary of major assessment findings at facility Form 1B: CHC / PHC quality assessment results -findings, interpretation and areas of improvement - action plan Form 2: Subcenter quality assessment checklist Form 2A: Subcenter quality assessment results - Summary of major assessment findings at facility Form 2B: Subcenter quality assessment results - Findings, interpretation and areas of improvement -action plan Form 3: RCH /sterilization camp quality assessment checklist Form 3A: RCH camp quality assessment results - Summary of major assessment findings at facility Form 3B: RCH camp quality assessment results- Findings, interpretation and areas of improvement -action plan form Form 1C: monthly QA summary report of CHC / PHC prepared by member secretary actions to be taken at CHC / PHC level Based on all visits made Form 1D: monthly QA summary report of CHC / PHC prepared by member secretary actions to be taken at district level - Based on all visits Form 1E: monthly QA summary report of CHC / PHC prepared by member secretary actions to be taken at state level - Based on all visits made Form 2C: monthly QA summary report of subcenters prepared by member secretary based on all visits made Actions to be taken at sub centre/ CHC / PHC level Form 2D: monthly QA summary report of subcenters prepared by member secretary based on all visits made Actions to be taken at district level Form 2E: monthly QA summary report of subcenters prepared by member secretary based on all visits made - Actions to be taken at state level Form 3C: monthly QA summary report of RCH camps prepared by member secretary Based on all visits made Form 4: client satisfaction with services

Broadly, the first three checklists consist of assessing facility readiness and different elements and sub-elements of RCH components. Since facility readiness crosscuts all the programmatic areas of RCH, all the elements and sub-elements related to this, have been grouped together in one part. It contains availability of: trained providers, infrastructure, essential protocols and job aids, equipment and instruments, replenishable supplies and observance of infection prevention practices; while the other parts have specific questions pertaining to programme areas of family planning, maternal health and child health/immunization. The fourth checklist is on client satisfaction and is common to both facilities and camps. Depending on the services availed of by the clients, relevant questions will be posed. The rankings from the facility checklist (Form 1 in case of CHC/PHC) will be translated to Form 1A. After this exercise is complete, each of the elements that have low ranks will be taken up for discussion. Problems, root causes of the problems and workable solutions person responsible to take/follow actions and a time frame will be discussed and noted in Form 1B. If it is feasible to resolve the problem at the facility or local level the officer in charge will be asked by when it would be done. However, in case, it is not possible at that level, the level at which it can be resolved will be discussed and noted.

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Further, for the purpose of convenience and practicability, it is proposed that one team member should cover the first part on facility readiness, while the other member covers the second part on RCH programme components. After completion of the checklists assigned to a particular QAG member, they then return to the facility In-charges office to score and discuss the assessment scores. Participation of other members of the facility should be encouraged in order to include their ownership in the problem solving exercise and the staff should take responsibility for future actions. It is advised to form a Quality Improvement (QI) committee at the site to follow up the action plan which may include the key staff including pharmacist, staff nurse, lab technician, LHV, HQ ANM, data analyst, cleaner etc. (In case of a subcenter, it will be the ANM alone but involvement of LHV/MPW-male should be encouraged). It is advisable to develop the action plan with the help of the Medical Officer In-charge and key staff of the site by identifying root causes of problems, probable solutions, and tenable actions, person/persons responsible for the action and a time frame in which problem is expected to be solved (Form 5A1 & 5A2). This is helpful in institutionalizing the quality improvement at the site, and the site will have the ownership of the QA process.

REMEMBER: QA does not replace any other reporting required to be made.

Instructions for Filling the QA Checklists: Introduction/Cover Page: Each checklist has an initial page to provide details about the identity of the facility, distance from district headquarters, person conducting the assessment and service provider present, along with team for completing the assessment. Step 1 Briefing the facility In-charge (Applicable for CHC/PHC and RCH/Sterilization Camp Setting) Introduce yourselves and explain that QA team members will require time with various staff members in order to fill out the assessment forms. For this, all staff involved in general and clinical OPD family planning services, maternity services and RTI/STI related services will be called on to assist and accompany individual team members for the assessment. These include the MO, HA (F), HA (Male), lab. technician and persons looking after stores and the RCH monthly report compilation. If a client being attended to by any staff in any of the rooms in the facility (e.g. OPD, labour room and OT) ensure that the QA team members do not enter or observe procedures requiring privacy without explaining the reasons for their presence? Always ensure that the clients right to privacy and confidentiality is maintained. Step 2 Complete filling all QA Checklists As mentioned earlier, one of the team members accompanied by a staff member of the facility commences on the facility readiness part of the checklist while the other team member, after preliminary discussions with the officer In-charge, initiates the RCH part of the exercise.

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Step 3 Filling in the various columns in the Forms: USE BLUE PEN AND FILL Response: These are a list of minimum standards of carehence in most cases they will require a Yes/No response. In cases where a number is requested please ask for it and verify from records. Score: The scores given for a Yes response are weighted 3, 2, and 1, according to the weighting mentioned next to the response options. At the end of each element, summary score boxes have been provided. Sum all the scores of the sub-elements and place the aggregated score in the respective boxes after the assessment. Copy the scores of each of the elements into Form 5A1 (in case of CHC/PHC).

-A high score is given to those considered absolutely essential (3) -A middle score is given to those which are necessary (2) -A lower score is given to those that are less important or are one of many components necessary for providing a particular service (1).
ACTION PLAN MEETING AT SITE - DEBRIEFING Discuss with MO I/C and other relevant staff the assessment results (specifically the results where the scores have been satisfactory) of each of the sub-elements (Form 5A1 in case of CHC/PHC) in terms of problems, root causes, solutions, responsibility of action to be taken and by when. If the officer In-charge wishes to involve other staff members in the debriefing, they could be invited. Discuss in detail the shortfalls in quality and explore what can be done to improve it. These columns should be filled in after the team has informed the facility Incharge why less than a full points have been assigned to an item, and they have agreed upon the solutions and ways of improving it. This should be carefully filled because the Quality Assurance GroupsCHC/PHC level solution will be shared at district level and further deliberated upon. The results of a visit to a subcenter should be shared with PHC MO I/C and other site staff so that the problems of the assessed subcenter are included in the PHC action plan. DQAG team members will organize the debriefing session in the following manner Present the findings Review sub-elements with lower scores Discuss each lower scored sub-elements with facility staff to identify the root cause Discuss and decide possible solutions and level of actions, who will initiate the action and by when it will be taken Take MO I/Cs consent on output forms and take his/her signatures Give copies of output forms to facility in-charge Reinforce the positive and thank staff

The action plan developed should be filled in forms 1B, 2B and 3B

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Step 4 Checking completed QA Forms and Debriefing with Medical Officer It is the responsibility of the QAG team members to review each form with the MO at the facility itself when the verification is completed. This review should be done before they leave the CHC/PHC so that they can be sure that every appropriate question was asked, that all answers are clear and reasons for not meeting standards have been discussed and improvement suggestions are mentioned.

Ensure that all actions that need to be taken at CHC/PHC and district level within the next six months are clearly stated.
Only mention key issues that must be dealt with immediately to ensure quality services and refer to repeated problems or drawbacks by mentioning the section and item numbers. After re-checking the completed checklists the QA team leader should initial the top of the checklists to certify that the questionnaire has been re-checked, before thanking the MO and leaving the facility. Immediate Post-Visit Activities Documentation on return to district HQ At the end of QAG field visit day, the team leader will check the completeness of all the forms, ensure that they are attached together and return them to the DQAG member secretary at district HQ. The next day the QA member secretary will give them to the data assistant for data entry in user-friendly QA software. This software will help in tabulating information from the QA checklists, generating output tables and graphs and help in maintaining QA database. Assessment Results Forms of the QA teams, for instance forms 1A & 1B at CHC/PHC level and similar forms for other levels (Form 2A & 2B at subcenter and Form 3A & 3B at RCH/sterilization camps) should be placed before the DQAG within a week of visit to the facilities to make certain district level action on key problems are initiated at the earliest. Since it is difficult for the DQAG to meet frequently, two meetings in a month-one in the first half and the other towards the end on fixed days are proposed. The first meeting should be held upon completion of visit to a CHC/PHC, two sector PHCs, four subcenters and an RCH/sterilization camp. During the DQAG meeting, the findings of the assessment have to be shared and discussed. It is necessary to put forth the local-level actions contemplated and actions at district and state levels should be discussed. The necessary steps and communication to the state level will have to be initiated. Based on the discussions during the DQAG meetings, the member secretary will prepare the monthly consolidated summary report. This will illustrate the common and facility specific recommendations for district and higher level actions. These reports will be separately prepared for each type of facilities visited in the previous month. The formats of these reports are given in Annexure two as form 1D, 2D and 3D. The consolidated monthly QA reports will be tabled in the monthly meeting of DHS/District Health Mission, where decisions on the recommendations will be taken and minutes will be forwarded to all concerned officials.

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Chapter
Definitions and Procedures for Completing Checklists

Introduction

To collect effectively the information needed in the QA checklists the DQAG team must understand why the items have been included and how to ask each question, what information the question is attempting to collect and how to record the reasons behind why the standard has not been achieved. The DQAG team member must also know how to correctly record answers given by the respondent, how to tally the scores for each section and how to follow special instructions in the summary report. This part of the QA manual is designed to familiarize the DQAG members with the checklists. This chapter has 3 sections. Section-1 contains definitions and procedures for sub-elements given in CHC/PHC checklist. Similarly sections 2 and 3 are devoted to subcenter and RCH/sterilization camp checklists respectively. Asking the Questions The QA checklists have 5 columns. Column 1 shows the question numbers with section identification (A, B, C etc.), Column 2 contains the sub-elements with instructions on how to complete the questions. Columns 3, 4 and 5 record the response in pre-coded category against each question. The QA checklists are not confidential, so it is acceptable if other members of the facility help with the exercise of verification such as showing a commodityor looking at old registers and calculating attendance/utilization however it is of utmost importance that the QA forms be filled in blue pen by a QA team member and not by a facility staff member. The signatures on the first page of each checklist clearly indicate that this is the responsibility of the QA team member signing on that cover page. It is important that you as a DQAG Member should understand each question exactly as it is written in the QA checklists so that these checklists are standardized across CHC/PHC/subcenters/RCH/sterilization camps as well as across states. In cases where a particular item is clearly not relevant for the facility visited, write NOT APPLICABLE. When ascertaining functionality of an instrument, be sure that the respondent shows you it is functioning. At times you may have to explain the question in order to be sure the respondent understands it. In cases where there is a substitute for the particular item being used or an alternative procedure is mentioned, do not give a full score but mention the alternate equipment/procedure exactly as it is reported in the side margins. Quality standards are set with specific instruments and proceduresa substitute may be below standard and needs to be discussed at the district QA meeting. In some cases, you may have to ask additional questions (called probing), to obtain a complete answer from a respondent. If you do this, you must be careful that your probes do not change the meaning of the question and that they do not suggest an answer to the

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respondent. Probing requires both tact and skill, and it will be one of the most challenging aspects of your work as a QA team member. Recording the Response In the QA checklists, all QA team members will use pens with blue ink to complete the checklist. The person at district deputed to compile all the formats will use a red ink pen. The following is a systematic list of instructions for each item on the checklists and has to be adhered to. FORM - 1: CHC/PHC QUALITY ASSESSMENT CHECKLIST Form 1-A: Providers Availability The purpose of questions in this section is to assess the availability of staff to provide different types of services and to assess their training needs. On the day of QA visit; ask the MO Incharge or other staff to answer the following questions. QA.1 At least one Medical Officer trained in handling Basic Emergency Obstetric Care (PHC)/Comprehensive Emergency Obstetric (CHC) and RTI/STIs This question should be asked for all medical officers who are appointed at the facility. The PHC MO should be trained in Basic Emergency Obstetric Care (BEmOC) and CHC MO should be trained in providing Comprehensive Emergency Obstetric Care (CEmOC). If any of them is trained in handling BEmOC/CEmOC and RTI/STIs then circle Both EmOC and RTI/STIs, if any MO is either trained in handling EmOC or RTI/STI then circle accordingly in response column 2, and if no MO is trained in handling EmOC and no MO is trained in treating RTI/STI then circle No additional training. You may also find that one medical officer is trained in EmOC and another is trained in RTI/STIs. In this case, since both the services are available at the facility, circle Both EmOC and RTI/STIs QA.2 A Medical Officer empanelled in at least one method of sterilization operation. This question is asked for all the medical officer(s) posted at CHC/PHC. If any medical officer is empanelled in at least one method of conducting male/female sterilization operations then circle Yes otherwise circle No. QA.3 A trained and registered medical officer available to conduct MTP This question will be asked to all the facilities as they have now been certified to provide MTP services. If a medical officer is trained and registered to conduct MTPs then circle Yes otherwise circle No. QA.4. An HS (LHV) and/or HW (F) trained for RTI/STI screening with per speculum examination This question relates to in-service training only, since RTI/STI management is not a part of ANM curriculum nor for promotional training. The training usually relates to, IUD insertion as well as to RTI/STI management. This question can be asked to MO In-charge or HS/HW/ANM only. If any HS/HW is available and trained for RTI/STI screening with per speculum examination then circle Available and trained, if the HS/HW is available but not trained then circle Available but not trained, and if the staff is not available then circle Not available. QAG members can recommend points like HS/HW should be posted and trained for per speculum examination at the facility in their report.

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QA.5 Lab Technician is trained in conducting RTI/STI tests The aim of this question is to know whether a lab technician is available and trained in RTI/STI tests. If the lab technician is available and trained/oriented in RTI/STI tests then circle response column 1, if the lab tech is available but not trained then circle response column 2, and if the lab technician is not available on all clinic days or post is vacant then circle response column 3. QA.6 (ONLY FOR CHCs) Lab Technician is trained in blood storage protocols and crossmatching. CHCs should be equipped with the blood transfusion facility as it may be required by women (e.g. women undergoing caesarean section). To maintain a functional blood storage facility, the lab technician posted at CHC should be trained in blood storage protocols and cross matching of blood samples. If the CHC lab technician is available and trained in both blood storage protocol and cross matching then circle response column 1, if the lab tech is available but not trained then circle response column 2, and if the lab technician is not available on all clinic days or post is vacant then circle response column 3. Make sure that Lab tech is trained in both the types of services. QA.7 At least one staff nurse/LHV/ANM available round the clock at facility in eight hour duty shifts If one nurse/LHV/ANM is available on duty at any given time in 24 hours throughout the week then the answer will be Yes otherwise circle No. QA.8 (ONLY for CHCs: (a)Trained MO for C-section (b) Anaesthetist/trained MO available on call This question is only applicable for CHCs and need to be assessed separately for round the clock availability of trained provider to conduct C-section and provide anaesthesia. (a) If a medical officer trained in conducting C-sections is available on call round the clock then circle Yes otherwise circle No. (b) If the anaesthetist (qualified post-graduate or MO trained in obstetric anaesthesia) available on-call for 24 hours then answer will be Yes otherwise circle No. Form 1B: Infrastructure Four indicators are included in the checklist to assess the infrastructure of the facility. These are 1. Cleanliness of facility 2. Essential amenities for comfort of clients 3. Facilities 4. Information and communication services All the questions in this section should be assessed after observing the services. Please do not record your response by asking the CHC/PHC staff. Cleanliness of facility: The purpose of these questions is to assess cleanliness, and maintenance of the CHC/PHC building. Response should be based on actual observation. Circle should be on appropriate answer.

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QB.1 General cleanliness of the facility (a) Surroundings are clean with no water logging or spread of hospital waste; (b) Clean floors and no seepage from the wall and ceiling; (c) clean dustbins in all rooms, waiting area and corridor Check general cleanliness of the campus, floors, ceiling/roof and other facility service points. Check also the condition of all wings of the building. The condition should be satisfactory with whitewash/painting and no seepage. No water logging in the campus. If the surroundings are clean as per the sub-elements, circle the score in the Yes column in the appropriate row, otherwise circle the score in the No column. QB.2 No windows/panes broken The purpose of this question is to assess the status of privacy to clients during examination, labour/delivery and surgical operations. If no windows are broken then circle the response in the Yes column otherwise, circle the score in the No column. In some facilities you may find that although windows are not broken but they cannot be shut properly and do not ensure privacy. In such cases, circle the score in the No column. QB.3 No dust in OT and on window panes of OT To look at the dust in OT and window panes of OT, rub your finger or a piece of paper on the windowsill or table/bed. If there is no dust in OT table/bed and windowsills then circle Yes otherwise circle No. QB.4 Proper arrangements for segregation of waste generated at the facility The purpose of this question is to know whether CHC/PHC have arrangements to segregate waste so that biological or contaminated (medical) waste is segregated from the general waste. If the CHC/PHC have arrangements for segregation of different types of waste, the response will be in the Yes column and if there is no arrangements for segregation of different types of waste then the response will be in the No column. Essential amenities for comfort of clients QB.5 Waiting area has benches in the covered/shaded area The purpose of asking this question is to look at the clients comfort in the clinic. Is this facility providing clients with a comfortable waiting area (not too hot, clean place to sit)? If the waiting area has benches in a covered area (e.g. veranda) then the answer will be in the Yes column and if there is no waiting area, or if there are no benches, then circle in the relevant No column. QB.6 Drinking water available for clients If potable drinking water is available for clients then circle the appropriate response. QB.7 All occupied beds have mattresses, rubber cover and clean bed sheet If all occupied beds have mattresses, rubber covers and clean bed sheets then circle the score in the Yes column otherwise circle in the No column. Make sure all the three things are available and if any of these is missing the circle will be in the No column.

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QB.8 At least one separate toilet with running water for women The purpose of this question is to know whether clients can use the toilet at the facility and whether there is at least one separate toilet for women at the CHC/PHC. The reason for needing a womens toilet is because of the routine need for a toilet during ANC examination (for urine testing) and also during labour and delivery (where an empty bladder is essential to assess and prevent obstructed labour or fistulae). Water is essential because without water supply it is not possible to keep the toilet clean. If at least one toilet is marked only for women with functional water arrangements, then circle in the Yes column. If either the toilet is not marked only for women or there is no functional water arrangement then circle in the No column. QB.9 A separate labour/delivery room with curtains on doors and windows for privacy If the facility has separate labour/delivery room with curtains on doors and windows, then circle in the Yes column otherwise circle in the No column. In case a separate labour room is not available then circle in the No column. If facility has separate labour/delivery room but there are no curtains to ensure privacy then also circle in the No column. Facilities QB.10 A functional OT/procedure room with facility (a) to conduct sterilization operations This question will be assessed both in PHCs and CHCs. The OT should have all the facilities to conduct sterilization operations and should meet the state norms for OT. The OT should be thoroughly scrubbed, mopped and disinfected with 0.5% chlorine solution and detergent daily even on a non-working day. OT should have equipment as per standards like operating table, step up stool, spot light, instrument trolley, emergency equipment and drugs, IV stand, waste basket, storage cabinet, buckets, basins for decontamination, covered water proof container for used linen and puncture proof box for disposal of needles and other sharps. The doors of OT should remain closed and ensure that all personnel enter the surgical area through a clothes-changing room. OT should not have ceiling fan. If the CHC/PHC has an OT equipped to conduct sterilization operations then circle the score in the Yes column otherwise circle in the No column. (b) and (c) (ONLY FOR CHCs) to provide anaesthesia and conduct a caesarean section Under the state norms, a CHC should be equipped with handling the comprehensive emergency obstetric cases (CEmOC) and be able to conduct caesarean sections. The purpose of this question is to assess the availability of a functional OT with the facility to provide anaesthesia and conduct a caesarean section. Assess separately the ability of the facility to provide anaesthesia and conduct a caesarean section,and record the appropriate response. QB.11 Functional electricity generator with POL or solar system connected to procedure rooms and OT The purpose of this question is to assess the availability of power back up in case of power failure during service delivery, especially the surgical interventions. During QA visit, ask someone to start the generator/solar system is available for alternate source of electricity to check its functionality, and in case of generator, check that its fuel tank contains at least 10 litres of diesel. If both a functioning generator and POL are available or solar system is functioning and connected to procedure rooms and OT then circle in the Yes column, if

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generator is not in working condition or POL not available or if it is not connected to procedure rooms and OT then circle in the No column. Information and Communication Services at the Facility: QB.12 Citizens Charter in local language displayed at the prominent place This charter seeks to provide a framework which enables users to know what services are available in this facility, the quality of services they are entitled to, and the means through which complaints regarding denial or poor quality of services will be redressed. Information will include general information, timings of the services, emergency services, facilities available, users charges if any, complaints and grievances and responsibilities of the user. If such a Charter is prominently displayed and easily visible , then circle the response in the Yes column. If the Charter is not displayed, or displayed at a place where it is not easily visible, circle in the No column. QB.13 Sign board in local language showing different service stations This question will indicate whether the community is getting information about the locations of the services provided at the facility. This information should be provided by sign boards. Circle in the No column if all the service stations are not properly marked. QB.14 Functional phone available for incoming and outgoing calls

The aim of this question is to find out whether clients are being provided with a phone facility to keep in contact with relatives and friends, and also to keep in touch with FRU and other health facilities during an emergency. If the functioning phone is available for incoming and outgoing calls at the facility, then circle in the Yes column otherwise circle in the No column. QB.15 A functional CHC/PHC vehicle (with driver) or outsourced vehicle available on call 24 hrs for referrals The purpose of this question is to know whether CHC/PHC has a functional emergency transportation system to manage EmOC and other referrals at any time. This information would be obtained from the MO I/C. If both the driver and vehicle are available at the facility or on call for 24 hours at the CHC/PHC, then circle in the Yes Column. If only driver is available but vehicle is not functioning or available and if neither driver nor functioning vehicle is available then circle in the No column. The use of a private or out-sourced vehicle will get same scores only when there is 24-hour availability of such vehicle. Form 1 C: Essential Protocols and Guidelines In this section, we would like to know whether the facility is providing services to the clients according to the established protocols and guidelines. According to the government norms all protocols and guidelines should be available in the clinic rooms or at an appropriate place with easy access to those who want to refer to them. Instructions: On the day of visit please physically verify the availability of job aids in the facility or in an appropriate place. The protocols or guidelines that should be observed should give details of procedures to be followed in routine service delivery. QC.1 QC.2 QC.3 QC.4 RTI/STI management protocols available IUD insertion/removal guidelines available MTP guidelines available Normal delivery SBA including essential newborn care guidelines available

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QC.5 Village Health and Nutrition Day (VHND) guidelines available QC.6 Guidelines mentioning standards for sterilization available QC.7 Waste disposal guidelines available QC8 Blood storage guidelines available (CHC) QC.9 EmOC and new born care guidelines available The guidelines to organise immunization sessions include the injection safety protocol, coldchain management and guidelines for surveillance Sometimes it is possible that protocols, guidelines, charts were provided to the facility but providers kept them at home or have locked them in a cupboard which cannot be accessed by other staff, who may need them. Ensure that guidelines are kept at the service station or at a place where staff can access them easily. Please see the protocols and guidelines during the assessment visitif this is not done the response should be No. Also if all the guidelines are not available then answer should be No. Mention the guidelines which are missing in the margin of the checklist so that it can be discussed and added in the action plan. Form 1 D: Infection Prevention Practices The questions in this section are to assess the infection prevention measures being practiced in the facility. This is not only important for the clients who are seeking the services from the facility but equally important for providers to provide the services in an infection free environment and also for the safety of the facility staff responsible for managing wastes. Instructions: These questions will be assessed through observation. QD.1 Providers washed hands with soap and water as indicated and wiped with personall towel/air dried The providers should wash hands every time immediately after arriving at work, before and after examining a client, before putting on and after removing gloves, after touching any instrument, object or waste that might be contaminated with blood or other body fluids, or after touching mucous membranes and before leaving work at the end of the day. The providers should not use common towels; they should wipe off the water with a personal towel or airdry the hands by shaking them. If the providers washed hands with soap and water as indicated and used personal towel or air-dried then circle the score in Yes column otherwise circle the score in No column. QD.2 Providers wore gloves when required The providers should wear the gloves and change them between cases as and when they require. This is especially important in case of surgical interventions and when removing the sharp waste from containers. When observing the providers, make sure that they wore gloves and changed them before they took a new client. If both the practices are being followed then circle the score in the Yes column otherwise circle the No column. QD.3 Waste disposed of as per guidelines If CHC/PHC has arrangements for segregation and disposal by either burning or burying contaminated medical wastes the response will be Yes and if there is no arrangement to either burn or bury contaminated wastes then the response will be No. Form 1- E: Availability of Equipment and Supplies The purpose of questions in this section is to know the availability of equipment and supplies, whether they are in working condition and whether they are in use. In the routinely provided

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RCH kits most of the essential equipment has been supplied; however, it is important to find out if specific instruments are available and drugs/consumables are in adequate supply. QA team members will check and confirm the availability and condition of the equipment and instruments. The emphasis is on functionality of the whole unit in conformity with set standardsfor example, in order to take blood pressure of a pregnant woman it is essential to have a BP apparatus and stethoscope in working order. On the day of visit please check and confirm availability of the following items which are mentioned below. If all equipment and supplies are available and in working condition then circle the score in the Yes column and if equipment and supplies are available but are not in working condition or not available then circle on the score in the No column. Record the appropriate response in response column. QE.1 BP apparatus and stethoscope in working order Both need to be available in order to get systolic and diastolic BP. This is essential. QE.2 Weighing scales in working order (a) Adult (b) Infant

Place an object weighing approximately 2 kgs to check the functionality and accuracy of both the types of weighing scales. If weighing scales are in working condition but not showing accurate weight, ask the MO In-charge to get them corrected. If both (adult and infant) weighing scales are present and functional, circle the score in their respective Yes column otherwise circle the score in the No column. QE.3 Autoclave/boiler in working order and being used (check log book) Check pressure meter of autoclave to see whether it is working or not. Request the staff member to show something recently sterilized. Ask staff to switch on the boiler and feel the warmth. Check the autoclave log book, if it is maintained. QE.4 Complete delivery kit with scissors/blades, cord ties/clamps and two cord clamping forceps Make sure that all the above items from each category are available in one tray and in the delivery room. All these items should either be sterile or HLD. Sometimes instruments are scattered or available elsewhere in the facility. In such case, circle the score in the No column and suggest to the MO to arrange them in the delivery room. QE.5 Sterile/HLDManual Vacuum Aspiration (MVA) syringe with sterile cannulae (4-10 mm) for managing incomplete abortion This question will provide information on availability of sterilized/HLD manual vacuum aspiration (MVA) syringe and sterilized cannulae (4-10 mm) at the facility. All this equipment is used in cases of spontaneous incomplete abortions and for clients seeking first trimester MTP services. Score in the Yes column should be circled only when all this equipment is available and sterilized before use. If available but not sterilized, circle the score in the No column. QE.6 Sterile Ovum forceps and curette available The instruments are either autoclaved and kept in sterilized drum with date of sterilization or high level disinfected by boiling for 20 minutes and stored dry in a covered HLD tray. If stored in a boiler submerged in water circle the score in the No column.

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QE.7 Paediatric resuscitation kit available-paediatric self-inflating Ambu bag, newborn mucus extractor or bulb syringe. When both the instruments-paediatric self-inflating Ambu bag with masks and newborn mucus extractor or bulb syringe are available in the paediatric resuscitation kit, circle the score in the Yes column, and if any of them or both are not available, circle the score in the No column. QE.8 Sufficient number of syringes and needles (50 in PHC and 100 in CHC) with needle cutter/puncture proof boxes for disposal of sharps Physically verify that at least 50 pieces of syringes and needles are available at PHC and at least 100 pieces of both are available in CHC, along with needle cutter or puncture proof boxes. If any of these are not available, or available, but not functioning circle the score in the No column.

QE.9 Infection prevention supplies available in procedure rooms (a) Surgical and utility gloves (b) Surgical attire (c) Bleaching powder, plastic buckets, mugs, soap, mops. In the procedure rooms assess whether all the infection prevention supplies are available. These accessories are essential to maintain asepsis and prevent infections. Separately verify for each of the item category. If any item is not available, then circle the score in the No column in the response row against that category. It is recommended to keep bleaching powder in small air tight packets of 150 or 300 gms. to retain its potency longer. QE.10 Sterile/HLD suturing tray containing scissors/blade, needle holder, sterile needles and sterile self dissolving suture thread/chromic cat-gut If the sterile/HLD suturing tray contains all equipment like (a) scissors/blade, (b) needle holder, (c) sterile needles and d) sterile self dissolving suture thread/chromic cat-gut then circle on the score in the Yes column and if any one of these items are missing in the tray then the response will be to circle the score in the No column. The instruments are either autoclaved and kept in sterilized drum with date of sterilization or high level disinfected by boiling for 20 minutes and stored dry in a covered HLD tray. If stored in a boiler submerged in water circle the score in the No column. QE.11 IV stand, sterile IV needles/venflos /scalp vein needle and adhesive tape available In the facility, check the availability of IV stand, sterile IV needles/venflos/ scalp vein needle and skin adhesive tape in the emergency room, pre and post -operative rooms and OT. Circle the score in the Yes column if all the items are available, if any of them are missing, then circle the response in the No column. QE.12 Oxygen cylinder with tubing, wrench and disposable masks in working order If facility has all of themoxygen cylinder, wrench and disposable masks in working order then circle the score in the Yes column. If any of them is missing or not functioning, then circle the score in the No column.

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QE.13 At least three suction apparatus in working order At least three suction machines should be present at PHC/CHC- one in the emergency room, one in the OT and one in the post-procedure/post-operative room. Check the suction machines for negative pressure by putting outer tube in water and confirm water is sucked in when it is on. Circle the appropriate response. QE.14 Emergency tray with emergency injections available All emergency injections e.g. Adrenaline, Chlorpheneramine maleate, cortisone, bronchodilators, atropine, vasopressors, oxytocin etc. should be available and kept in a tray with sterilized/HLD syringes. Other injections like anti-snake venom can be added to the list, as per local needs. At least 5 ampoules/vials of these drugs should be available in the tray. A separate anaphylaxis tray/reaction tray with Adrenaline, Chlorpheneramine maleate, cortisone, bronchodilators, atropine and vasopressors with two syringes with needles should be made available at all places where injectables are being given. Laboratory Equipment and Supplies: On the day of visit please check and confirm availability of the following equipment and supplies. Circle the appropriate score in response column. QE.15 Microscope up to 40*10 X magnification in working order

Check that the microscope is functioning and is being used in the lab. QE.16 Sahlis Haemoglobin meter in working condition to be used for measuring Hb with fresh N/10 HCL solution

Check that all items mentioned above are present and Hb is being tested for the clients. QE.17 Gram staining, crystal violet, iodine solution, acetone-ethanol and safranin stain available:

QAG team will circle the score in the Yes column only when all the above-mentioned chemicals are available at the facility. If any one of these chemicals is not available then the response will be to circle the No column. QE.18 RPR kits for syphilis available QE.19 Urine albumin/ acetic acid and lamp for heat test or uristix available QE.20 Sugar uristix/(Benedicts solution and lamp for heat test) available QE.21 CHC ONLY - Kits for ABO/Rh blood grouping and cross matching available Instructions: For QE18-21, check the availability of all the items mentioned in the different categories for at least 20 clients. If all the items and chemicals are available to enable the test to be completed, circle the respective scores in the Yes column otherwise even if one item is missing or non-functional because of which the test can not be performed correctly and completely, circle the score in the No response. Essential Drugs for RTI/STIs Instruction: Do not stock check. On the day of the visit, please check and confirm availability of all the following drugs or alternate medicines of the same group for at least 20 clients.

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Drugs for RTI/STIs QE.22 Tab. Norfloxacin 400 mg QE.23 Tab. Azythromicin 1gm QE.24 Tab. Metronidazole 400 mg QE.25 Tab. Fluconazole/Clotrimazole Vaginal tabs Essential supplies for active management of infections/complications in pregnancy/puerperium and child health care: Check availability for at least 20 clients QE.26 Inj. Ampicilin/amoxyciline 250/500 mgs QE.27 Inj Gentamycin 20 and 80 mgs QE.28 Cap Nifidipine QE.29 Inj. Oxytocin QE.30 Inj. Magnesium sulphate QE.31 Normal saline I/V/Ringer lactate/DNS 20 bottles QE.32 ONLY FOR FRUs: One unit of blood for Rh positive groups (A, B, AB & O) available QE.33 Inj. Lignocaine for local anaesthesia QE.34 Inj. Adrenaline QE.35 Inj. Atropine QE.36 Injection Tetnus Toxoid (TT) QE.37 Tab Misoprostol QE.38 Inj Dexamethasone (any cortisone injection) QE.39 Inj. Chlorpheneramine maleate QE.40 Tab Cotrimoxazole QE.41 ORS Packets For Disinfection QE.42 Glutaraldehyde concentrates Check for the availability of the Gluteraldehyde concentrate and diluent solution. Check the date of reconstituting the solution in the container for use as per the manufacturers instructions for the solution to be active. If it is within the limit period and clean (without blood or tissues in the container), circle the score in the Yes column. QE.43 Packets of bleach powder/concentrated hypochlorite solution It is suggested to keep bleach powder in small airtight packets of 150/300 gms. The bleach powder/concentrated hypochlorite solution need to be available at the facility to make 0.5% Chlorine solution QE.44 Povidone Iodine/Alcohol/Spirit /cetrimide These antiseptics are used for disinfection and should be available at the facility. Confirm availability of at least one. Form I F: Family Planning Quality Assessment The quality of family planning services that are being provided through CHC/PHC will be assessed in terms of the following 3 indicators 1. Sufficient FP supplies 2. Maintenance of FP records 3. Counselling of clients FP Supplies Instruction: Do not do a FP materials stock check just check availability for at least 20 clients at the service delivery point

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QF.1 QF.2 QF.3 QF.4

Condomsat least 200 pieces OCPsat least 20 cycles IUDsat least 20 packets available ECPsat least 20 packets

If the above contraceptives (QF 1- QF 4) are available in the mentioned number, circle the score in the respective row in the Yes column. FP Records In this section check and review the availability and maintenance of FP records at the facility, to see if facility is providing these services as well as continuously updating their records. One of the QA team members will take this responsibility and ask the Medical Officer or senior paramedic to provide the FP records which are being maintained. Instruction: On the day of visit please check and review whether the following records of FP services given in the past 3 months are being maintained. QF.5 FW Records show OCP usage and new acceptance in last 3 months This information should be with LHV/Staff nurse. Please check and ask whether OCP users and new accepters have received supply from the facility only. QF.6 Last three months records show (a) M/F sterilizations conducted at the facility (b) Sterilization cases followed-up This information is also available with LHV/ANM/FHW. In case where CHC/PHC conduct RCH/sterilization camps, make sure the sterilization records are separately maintained for facility and RCH/sterilization camps. QF.7 FW Records show ECP uptake in last 3 months This information should be with LHV/Staff nurse. QF.8 FW records show (a) IUD inserted during last 3 months and (b) IUDs removed (needs reasons for removal) This information should also be available with the LHV/ANM/staff nurse. Assess that records for IUD insertions and removals are maintained and regularly updated. Please check whether the IUD insertions and removals were managed at the facility. The statistics should not include the referred cases where IUD services were provided elsewhere. Record your response separately for each of these aspects. In case of IUD removals, the records should have information regarding the reasons for removal. If this is not present then the information for IUD removal is incomplete and should be circled in the score of No column. FP Counselling During the QA visit if there are FP clients, observe at least one client during the counselling. Before observing the counselling session, please take the consent of the client for being present during the session to respect the clients privacy and confidentiality. Observe the client-provider interaction, if client was told about how the method works, what are the possible side effects and complications and whether informed choice was provided. If it is not possible to observe a FP counselling session or there is no client for FP, leave the response blank. Record your response separately for each of the aspects for QF 9- QF 11 in the appropriate score.

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QF.9 Provider informed the client about different FP methods QF.10 Client counselled on how each method works and how it should be used QF.11 Client counselled on side effects, how to manage them and where to go for care of side effects/complications FORM IG: Maternal Health Quality Assessment The quality of maternal and newborn health services will be assessed based on the following four elements. 1. Screening of ANC clients 2. Counselling of ANC clients 3. Assessment of labour and delivery records 4. Newborn care Under the maternal health quality assessment, some indicators of maternity services that are being provided by the facility will be measured and assessed to check whether providers are maintaining the standards. The questions in this section will be completed both by observations and review of records. It is recommended that the QA team should plan their visit to CHC/PHC on ANC clinic day. QA team will review the labour and delivery records of last three completed months to assess the service usage and continuity of services. Screening of ANC clients Instruction: On the ANC day visit to the facility, observe new ANC clients to assess the quality of antenatal screening. Take the consent of the clients prior to observing the ANC screening session. For questions QG.1 to QG.6, if you find that providers are practicing as per the question for then circle response column 1, if providers are practicing partially then circle response column 2 and if they are not/hardly practicing according to the question then circle response column 3. QG.1 Detection of pregnancy and screening (physical, per-abdomen foetal assessment by history and calculation of due date) For detection of pregnancy the providers should be doing physical and per-abdominal examination, foetal assessment by history taking and calculating the due date from the date of last menstrual period (LMP). All the findings should be noted down in the ANC register. Observe the ANC cases and circle the appropriate category in response column. QG.2 Screened for signs of anaemia (pallor on tongue, conjunctiva, nails) and measurement of Blood Pressure and weight For assessment of anaemia providers should check pallor on tongue, conjunctiva and nails. They should be doing all three (Anaemia check, Blood Pressure and weight taking) for all the ANC women. Observe that providers are following the standards. The findings should be noted down in the ANC register. Circle the appropriate category based on the observations. QG.3 Lab tests for Hb, urine for albumin and sugar done Circle the appropriate category based on your observations on providers prescribing the lab tests to all new ANC clients for Hb and urine. ANC Counselling Instruction: Observe at least 5 ANC clients to assess the quality of ANC counselling. Take the consent of the client prior to observing the counselling session.

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QG.4 Counselling of ANC women on nutrition and rest QG.5 Counselling on the recognition of danger signs during pregnancy, delivery and postpartum period QG.6 Counselling on breastfeeding and LAM Observe the providers counselling the women on nutrition, rest, recognition of warning signs during pregnancy, during labour and delivery and during postpartum period for her and her baby, and what to do if such danger signs appear, where to go to seek help and care. Also observe whether the provider is counselling the client regarding initiation of early breastfeeding within half an hour of birth, and for continuing with exclusive breast feeding for her and the babys health. Does the provider counsel regarding LAM ? Circle the appropriate category against each counselling question if all are being performed. Labour and Delivery Records Instructions: On the day of visit please review records in order to ascertain use of services in the past three months (rounded to the nearest month end). QG.7 Copies of partograph available and used in last five deliveries Check availability of blank copies of partograph. Check delivery register and filled partograph for last five deliveries conducted at the facility. If properly filled partographs are available then circle the score in the Yes column. If partographs are not available or not filled properly circle the score in the No column. QG.8 Last three months records show women with obstetric complications are managed in the facility QG.9 Records show the deliveries that took place between 8 PM and 8 AM in last three months This question would record whether the facility is providing delivery services at night i.e. between 8:00 pm to 8:00 am and whether providers are staying in the campus/nearby and are available on call at night. QG.10 IUD register shows that women were screened for RTI/STI prior to insertion in last three months The purpose of this question is to assess whether the facility is following the norms of screening the women for RTI/STIs prior to IUD insertion. QG.11 This question will be assessed only at CHCs. Last three months records show that women given blood transfusion during pregnancy, delivery and post delivery period This question will assess the blood transfusion facility at CHC to women during pregnancy, delivery and post delivery period QG.12 Records/vehicle logbook shows that women needing EmOC transported by facility vehicle to referral unit in last three months This information can be obtained from referral slips/referral register. The details are available in the referral slip/referral register like name of the patient, age, sex, name of disease,

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purpose of referral, place of referral, date and time. This information can also be obtained from vehicle log book. QG. 13 Indoor records show delivery clients stayed in the facility and kept under observation To provide care to the mother and newborn in the immediate post partum period and first few days after delivery, in order to reduce maternal and newborn deaths during this crucial period, it is recommended that women after delivery are kept for care in the institution for at least 48 hours after delivery. If the women are kept for 48 hours in the facility as a policy, circle the score in the column with More than 48 hours. If women stay from 24-48 hours, circle the score with 24-48 hours if even some women stay for less than 24 hours, circle the score of less than 24 hours and if even one woman is discharged immediately, circle the score of discharged immediately. As a quality institutional delivery service, the policy of the institution should be to keep the woman and her newborn for 48 hours at the hospital. QG. 14 JSY records maintained and updated up to the previous month Check the JSY register to see if all the clients who delivered at the facility received the complete payment before discharge or not. If all received complete payment before discharge, circle the score in the Yes column otherwise circle the score in the No column. Newborn Care The objective of this section is to assess the quality of newborn care at CHC/PHC. On the day of visit, QA team member will find out if there is any mother and baby admitted. If they find a case, the QA team member will check and verify for the questions given below. Newborn baby should receive services according to the essential newborn care guidelines. QG.15 Newborn baby corner in the labour room with baby warming facilities QA team member should visit the labour room and physically verify about the newborn baby corner. The newborn baby corner should have an earmarked area assigned for new born baby resuscitation, equipped with a baby tray with clean towels, baby suction machine or Newborn mucus extractor -Delees sucker or bulb syringe, a radiant baby warmer or a 200 watt bulb fixed at a height of 18 inches above the baby corner and baby Ambu bag with masks for newborns. If it is available then circle the score in the Yescolumn else circle the score in the No column. QG.16 Babys cord has no medicine or bandage and kept clean and dry Physically verify babys cord. According to the essential newborn care guidelines, the babys cord should have no medicine or bandage and should be clean and dry. However, traditionally, family members apply oil on the babys cord in the absence of a provider. The provider should inform the family not to apply any oil as it could lead to sepsis/infection. Circle the appropriate score. QG .17 Breastfeeding initiated within half hour and nothing other than breast milk has been given to the baby This question can be asked to mother or the attending staff nurse/ANM/HW (F). After delivery, breastfeeding should be initiated within half an hour and nothing other than breast milk should be given to the baby. This helps the baby to receive nutrients that help build immunity. There are many benefits of the breast milk; if breast milk is given immediately then baby gets protection from many diseases and under weight baby starts gaining weight. It

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also helps the placenta to be expelled soon thereby, reducing the chances of retained placenta and postpartum haemorrhage. QG.18 Newborn properly covered and kept warm Please physically verify if the newborn is admitted for care in the facility during the QA visit. If the newborn is properly covered (check if the babys head is also covered) and kept warm then circle the score in the Yes column else circle the score in the No column. QG.19 Polio0 dose and BCG administered Ask the ANM or attending nurse about Polio-0 dose and BCG administration to the newborn. Check the immunization card of the baby for the entries. Circle your observation in the appropriate column. QG.20 Records show that newborns managed in the facility for birth asphyxia in last three months. The purpose of this question is to assess whether the CHC/PHC has the facility to keep the low birth weight babies or babies with birth asphyxia under observation for at least 24 hours, and whether the center continues to provide such services. Ask the doctor/staff nurse to show you the indoor diary and case sheets. FORM 1H: Child Health Immunization Quality Assessment The quality of child health services is measured by assessing the immunization services in the facility. The immunization services are assessed in terms of service delivery, vaccination logistics and supplies and observations on cold-chain management. The QA team should visit on the immunization day and observe at least five cases to assess the quality of services. Immunization Service Delivery Instructions: Visit the facility for assessment on an immunization day. For Micro Plan check previous months record. For QH.2 to QH.7 OBSERVE at least five cases during immunization. If you find that providers are practicing as per the question for 4-5 clients then circle score in the All column, if providers are practicing for 2-3 cases then circle the score in the Some column and if they are not/hardly (0-1 case) practicing according to the question then circle the score in the None column. For QH 2 and QH 5, if your observations are as per recommended schedule or standards, circle the score in the yes column else circle the score in the No column. QH.1 MICRO PLAN - Whether immunization sessions conducted as planned Check for availability of Micro Plan at CHC/PHC and check the number of sessions conducted during the last month in records available. If the conducted sessions are more than 70% without deviation, circle Yes, and if less then 70% circle No. QH.2 Measles vaccines is being administered between 9-12 months of age The purpose of this question is to know whether the providers are administering the measles vaccine at the right age, that is, between 9-12 months of age. Observe the administration of measles vaccines and mark in the appropriate response column.

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QH.3 Sterile needle not touched by hand or swab during injection process Observe closely during the session and mark the appropriate column. QH.4 Needle cutter/puncture proof box used for disposal of used syringes Observe that needle cutter/puncture proof box is available at the site of injection and used each time for disposal of used syringes. QH.5 Vaccine carrier kept closed during immunization session If the vaccine carrier is being opened only while taking out the vaccine vials and found closed during other, times circle the score in the Yes column, and if the lid of vaccine carrier is found open, circle the score in the No column. QH.6 Post-immunization counselling regarding side effects, how to manage side effects and follow-up visits While observing the immunization session, observe for post-immunization counselling of the person who has brought the child. Observe, if the provider is discussing side effects, how to manage them or where to go for care if required and follow-up visits, then, circle the score in the All column. QH.7 Immunization card updated/completed for each child after administering the vaccine Observe updating of cards & counterfoils after each child's vaccination. Mark in the appropriate response column based on the observations. Vaccination Logistics and Supplies Instructions: Please physically verify the ILR and storage QH.8 No stock out of Measles vaccine Check in the vaccine carrier for measles stocks, if available along with diluents then circle the score in the Yes column. If vaccine is not available circle the score in the No column. QH.9 No stock out of AD syringes Check for availability of AD syringes with provider and if available as per plan, circle the score in the Yes column. If provider does not have stocks as per plans, circle the score in the No column. QH.10 No stock out of vitamin-A solution

Check for availability of Vitamin-A with service provider. If available and being administered, circle the score in the Yes column; if provider does not have stocks as per plans, circle the score in the No column. QH.11 No vaccines stored are beyond expiry date Check in vaccine carrier and ILR for any vial beyond expiry date. If all are within the expiry dates, circle the score in the Yes column; if the date on vials has expired, circle the score in the No column and discard those vials immediately.

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Cold Chain Management Instructions: Check yourself the ILR. Conduct spot shake test for frozen vaccines. QH.12 Temperature record card maintained and recently updated Check for the temperature records. If all the rows/columns filled and dates of defrost mentioned say Yes, if all the entries are same during entire month say No. QH.13 No frozen T series vaccine in ILR at the facility (Frozen T series vaccine are invalid for use) Check for all T series and Hepatitis-B vials and observe closely for any signs of frozen vials. If all the vials are in liquid state, circle the score in the Yes column; if ice/floccules are seen in these vials, circle the score in the No column. Form 1-I: MISCELLANEOUS SERVICES QUALITY ASSESSMENT QI.1 Last three months records show RTI/STI tests done at the facility Check the lab records of the last three months, if tests for RTI/STI have been done, then circle the score in the Yes column, otherwise circle the No column. QI.2 Last three months records show that children under age five are managed for respiratory tract infections Check the treatment records/OPD/Indoor records of the last three months, if children have been managed for respiratory tract infections, then circle the score in the Yes column. QI.3 Last three months records show that children under age five are managed for diarrhoea. Check the treatment/OPD/Indoor records of the last three months, if children are being treated with ORS, then circle the score in the Yes column. QI. 4 IEC material displayed in waiting area on Maternal Care/FP/RTI/STI

Check the client/patient waiting area to see if the IEC material for maternal care, family planning and RTI/STI are displayed so that they are easily visible to the clients/patients. If they are easily visible, circle the score in the Yes Form 1- J: OUTPUT INDICATORS FOR QUALITY ASSESSMENT

Instructions: To assess this section, review records and calculate the data as required in the questions. Also write the total number of the information data required for the corresponding period in the last year. Compare the current data with that of the last year for the corresponding months by subtracting last years data from the current data. Also calculate the required percentage change of utilization of services and the score percentage of change. The formula to calculate the two percentages is given in the respective columns. QJ. 1 Total number of ANC women registered in the last three months Check the ANC register and write the total number of the women who were registered in the last three months in column 1. Check the ANC register for the last year for the same months and write the number of ANC registrations during that period in column 2. Note the

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difference in the two numbers as per the formula given in column 3. Calculate the percent change as per the formula and write in column 4. Finally write the score % as per the formula provided in column 5. QJ. 2 Total number of deliveries at this facility Tabulate and calculate the number of deliveries conducted at the facility in the same way as for ANC cases. QJ. 3 Total number of IUD acceptors in the last three months Fill the required information in the respective columns for IUD acceptors. DO not count the IUD removals for this section. QJ. 4 Total number of IUD acceptors screened for RTI/STI with a lab test in the last three months Of the IUD acceptors during the last three months note the total number of clients who were screened for RTI/STI with a lab test prior to inserting IUD. Complete the other columns for this information as explained in the instructions at the beginning of this section. QJ. 5 Total number of RTI/STI cases in the last three months Check the records and note the total cases of RTI/STI identified in the last three months. Complete the other columns for this information as explained in the instructions at the beginning of this section. QJ. 6 Total number of RTI/STI tests done This will help to record the total tests done for RTI/STI, including cases with positive as well as negative results. Complete the rest of the information for this question. QJ.7 Total number of low birth babies who stayed at facility for 24 hours observation Low birth babies tend to die easily during the neonatal period especially within the first week after birth. Hence they require special attention and care at the institution to be safe. PHCs/CHCs are provided with the equipment and training to MOs to care for low birth weight babies. The measure of number of such babies being cared for indicates the level of specialised newborn and infant care being provided at the facility. Complete the rest of the information by comparing with the previous years records. QJ. 8 Total number of children received Measles vaccine Measles vaccine has been considered as the indicator of adequate immunization services. Complete the information for this indicator as explained in the instructions at the beginning of this section.

FORM2: Sub center Quality Assessment Checklist The subcenter quality assessment checklist is divided into 9 sections. These are (a) general quality of care elements-facility readiness (b) essential protocols and job aids, (c) infection prevention practices, (d) availability of equipment and supplies, (e) family planning (f) Maternal health, (g) Child health/immunization, (h) miscellaneous services and (i) output indicators

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Form 2A: General Facility Readiness General quality of care elements are comprised of the location and condition of the subcenter, essential amenities for clients comfort, and information and communication facilities for clients. The questions pertaining to each of these indicators are described below. The QA team member must walk around the area and complete this section by observing the facilities. Location and Condition QA.1 Location of the subcenter The location of subcenter in the village is crucial in terms of clients having easy access to services. If the subcenter is located at the heart of the village then circle the response at the heart of the village (score 3); if it is located at village peripheries then circle response column at village peripheries (score 1) and if it is located outside village peripheries and far from village then circle response column outside the village peripheries (score 0). QA.2 Ownership of building Ask the ANM about ownership of building of the subcenter, if it is a government building then circle Owned (score 3), and if it is rented then circle Rented (score 1 . QA.3 ANM residing Ask the ANM where she resides on a regular basis. Circle In SC (score 3) if she resides at the subcenter; In village (score1) if she resides in the village of the subcenter and if she resides outside the village of the subcenter, circle Outside village (score 0) QA.4 Condition of building (a) whitewash; (b) seepage Walk around the subcenter area and observe whether the building is painted or whitewashed, that no plaster has peeled off from inner/outer walls and no seepage has occurred from the ceiling or walls or around the subcenter building. Circle the appropriate code in response column Yes (score 1) or No (score 2). QA.5 No windows/doors broken Walk around the facility and check all doors and windows. If no windows/doors are broken, and if they can be shut properly when required, then only circle Yes (score 1) otherwise circle No (score 0). QA. 6 Solid waste containers available If solid waste containers are available in the subcenter to dispose off the waste then circle Yes (score 1) otherwise circle No (score 0). Instruction: Write the total score of this section as mentioned in the checklist and in the instructions for each question above. Essential Amenities for Clients Comfort QA.7 Subcenter has lighting arrangement (a) running electricity connection; (b) power backup in the form of functional petromax/lantern/torch

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In the subcenter look for BOTH, the functional electricity and some source of power back-up in the form of functional petromax/lantern/torch. If both are available and functioning then circle the score in the Yes column and if any of them is not available or available but not functioning then circle the score in the No column. The functional electricity means that there is routine power supply to the subcenter and it has not been disconnected by electricity department for some reason (e.g. non-payment of dues). Please check whether electricity boards and bulb holders/tubes are properly fitted and in working condition. Some alternative arrangement of light is essential, as the women may need labour/delivery services in night. QA.8 Benches for sitting available and placed in shaded place (Same as question QB.5 of CHC/PHC Checklist) QA.9 Toilets with functional water arrangement The purpose of this question is to know whether the clients have access to a clean toilet in the subcenter. Since running water may not be possible in the village, look for functional water arrangement. This means that there should be a bucket and mug in toilet and some source of clean water nearby (e.g. hand pump). If the toilets for client have functional water arrangement then only circle the score in the Yes column otherwise circle the score in the No column. QA.10 Drinking water for clients available (Same as question QB.6 of CHC/PHC Checklist) QA.11 Curtains on windows to ensure privacy The purpose of this question is to assess the status of privacy to clients during examination, labour/delivery and IUD insertions. If there are curtains on windows then circle Yes otherwise No. In some cases you may find that curtains are not available but windows are dark painted or coloured paper pasted on them to ensure privacy. In such cases ensure that no windows are broken and they can be properly shut. If windows are painted/coloured paper pasted and they can be properly shut then also circle the score in the Yes column otherwise circle the score in the No column. Information and Communication QA.12 A signboard/wall painting exhibiting (a) available services in the subcenter; (b) days and timing of services From this question, we want to know whether the community is getting information about subcenter timings and what services are available for them. Look for a well marked signboard exhibiting clinic timings and all the services provided by this centerplaced at an appropriate place where all can see. QA.13 Information on Janani Suraksha Yojna (JSY) displayed

Under the Government of India directive of communicating about JSY in rural areas, a subcenter should display the details of JSY on a signboard or wall painting. If subcenter has displayed JSY information then circle the score in the Yes column otherwise circle the score in the No column.

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Form 2B: Essential Protocols and Job Aids In this section, we would like to know whether the facility is providing services to the clients according to the established protocols and guidelines. According to the government norms all protocols and guidelines should be available in the subcenter. Instructions: On the day of visit please physically verify the availability of job aids in the facility or in appropriate place. The protocols or guidelines that should be observed should give details of procedures to be followed in providing the services. QB.1 IUD insertion/removal guidelines available QB.2 IUD cards or register available and filled for follow-up QB.3 Normal delivery/SBA guidelines available QB.4 Newborn care guidelines available QB.5 Village Health and Nutrition Day (VHND) guidelines available The guidelines to organise immunization sessions in the village health and nutrition day include the injection safety protocol, cold-chain management and guidelines for surveillance Sometimes it is possible that protocols, guidelines, charts were provided to the facility but providers kept them at home or have locked them in a cupboard which cannot be accessed by the ANM when she needs to refer to them during clinic hours, supervisors or other officers coming for monitoring visits. The QA team must ensure that they see the protocols and guidelines themselvesif this is not done the response should be to circle the score in the No column. If materials are not available then answer should be to circle the score in the No column. Form 2C: Infection Prevention Practices The questions in this section are to assess the infection prevention measures being practiced in the subcenter. This is not only important for the clients who are seeking the services from the facility but equally important for the ANM to provide the services in a hygienic and infection free environment. Instructions: These questions will be assessed after observing the ANMs while she is providing the services. QC. 1 Needle cutter/puncture proof box available and used for disposal of used syringes The subcenter should have a functional needle cutter or puncture proof box to dispose of the used syringes. If it is available and functional then circle Yes, else circle No. QC.2 Waste disposed off as per guidelines (See QD.3 of CHC/PHC Checklist) Form 2D: Availability of Equipment and Supplies The purpose of questions in this section is to know the availability of equipment and supplies, if they are in working condition, and are in use. In the routinely provided RCH kits most essential equipment has been supplied. However, it is important to find out if specific instruments are available and drugs/consumables are in adequate supply. QA team members will check and confirm the availability and condition of the equipment and instruments. The emphasis is on the whole unit functioning according to set standardsfor example in order to take blood pressure of a pregnant woman it is essential to have a BP apparatus and stethoscope in working order.

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On the day of visit please check and confirm availability of the following items that are mentioned below. If all equipment and supplies are available and in working condition then circle the score in the Yes column and if equipment and supplies are available but are not in working condition or not available then circle the score in the No column. Record the appropriate response in response column. QD.1 BP apparatus and stethoscope in working order (See QE.1 of CHC/PHC Checklist) QD.2 Equipment available and functioning (a) Baby weighing scale (b) Baby Ambu bag (c) Delees mucus sucker available Place an object weighing approximately 2 kgs to check the functionality and accuracy of the weighing scale. Check the function and record your response separately for a, b and c in the response column. QD.3 Delivery kit with scissors/blades, cord ties/clamps (See instructions for QE.4 of CHC/PHC Checklist) QD.4 Sufficient number of sterilized/HLD syringes available Physically verify that at least 50 pieces of sterilized/HLD syringes are available at subcenter. QD.5 Infection prevention supplies available: (a) Soap (b) Gloves and masks (c) plastic buckets and mugs (d) working boiler or stove with K-oil available. In the subcenter assess whether all the infection prevention supplies are available. These accessories are essential to maintain the hygiene and prevent the infections. Separately verify for each item. If any of them are not available then circle the score in the No column in the response row against that item. QD.6 Labour table, step stool, mattress, mackintosh and Kellys pad available If the subcenter has all of themlabour table, step stool, mattress, mackintosh and Kellys pad in working order then circle the score in the Yes column. If any are missing or not functioning, then circle the score in the No column. QD.7 Copies of partograph for progress of labour available and being filled Confirm that blank partograph forms are available. Ask for filled partograph forms for deliveries conducted at the subcenter to confirm that partographs are being filled during deliveries. If properly filled partographs are available, then circle the score in the Yes column. If partographs are not available or not filled properly circle the score in the No column. Supplies Instruction: Do not do a FP materials stock check just check availability of numbers given with each question. QD.8 Condoms at least 50 pieces QD.9 OCP at least 5 cycles QD.10 IUDs at least 5 packets available QD.11 ECP at least 5 packets QD. 12 IFA tablets- at least for 10 clients QD. 13 TT injections-at least 10 injections

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QD. 14 Tab. Misoprostol-at least for 10 clients QD. 15 ORS packets-at least 20 packets Verify the availability of the above items and if they are in the required number, circle the score in the Yes column. For disinfections QD.16 Small packets of bleach powder/concentrated hypochlorite solution available (See instructions for QE 43 of CHC/PHC checklist) QD.14 Povidone Iodine/Alcohol/spirit available (See instructions for QE 44 of CHC/PHC checklist) Form 2 E: Family Planning Quality Assessment The quality of family planning services that are being provided through the subcenter will be assessed in terms of the following 3 indicators 1. Providers knowledge 2. Maintenance of FP records 3. Counselling of clients Providers Knowledge Instructions: Ask the ANM the following questions to ascertain her knowledge about different contraceptive methods. If she answers correctly, circle the relevant score for each sub element. QE.1 Whether ANM has correct IUD knowledge-Does the ANM know- (a) About longevity of an IUD? (b) About No-touch and withdrawal technique of insertion of IUD? (c) About IUD removal technique? (d) About side effects/warning signs? The purpose of this question is to assess the knowledge of ANM about IUDs. (a) Longevity of IUD: Ask the ANM for how long an IUD can work or what is the maximum time period for which an IUD can be effective? The currently available IUD 380 A is effective for 10 years. If she answers correctly then circle the score in the Yes column otherwise circle the score in the No column. (b) Withdrawal technique of insertion of IUD: Ask the ANM about the insertion of IUD. See specifically that she knows how to wash hands and wear the gloves, do part preparation, insert speculum, screen for RTI/STI, clean the cervix, sound uterus using no-touch technique, load the IUD in sterile package, set depth gauze to the measured depth of uterus, gently pass loaded inserter tube through the cervix to the full depth of the uterus, release the IUD by withdrawing the inserter tube over the plunger towards its handle, remove the plunger and gently push in on the inserter tube to ensure high fundal placement of IUD. (c) Removal technique: Ask the ANM about the removal of IUD. See specifically that she knows how to wash hands and wear the gloves, do part preparation, insert speculum, grasp strings with Bozeman forceps close to cervix and pull gently but firmly to remove IUD. Perform a pelvic examination to exclude pelvic infection. (d) Major side effects/warning signs: Ask the ANM about major warning signs caused by IUD. If she mentions at least 4 side effects/warning signs correctly then circle the score in the Yes column otherwise circle the score in the No column. Warning signs include: Late period or other signs of pregnancy, bleeding or spotting between periods or after intercourse that either continues beyond 3-6 months after insertion or that start a few months after insertion, severe pain in abdomen, pain during intercourse,

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unusual discharge from vagina, fever and/or chills, missing string, or a shorter or longer string, feeling the hard part of the IUD in vagina or in her cervix when checking for the strings. QE.2 Whether ANM has correct OCP knowledge-(a) What would the ANM suggest the woman if she has missed the OCPs for 2 consecutive days? (b) From which month can a breastfeeding mother take OCPs? The purpose of his question is to assess the knowledge of ANM about OCPs. (a) Ask the ANM what would she suggest the woman if she has missed the OCPs for 2 consecutive days. If she answers that discontinue the pill and use another method till the next menstrual period and start with a new strip of OCP from the first day of the next menstrual period, then circle the score in the Yes column otherwise circle the score in the No column. (b) Ask the ANM from which month a breastfeeding mother can take OCPs. If she says that after 6 months postpartum a woman can start OCPs safely, then circle the score in the Yes column otherwise circle the score in the No column. QE.3 Whether ANM has correct ECP knowledge-What is the maximum time limit after unprotected sex for starting ECPs? The purpose of this question is to assess the knowledge of the ANM about emergency contraceptive pills (ECPs). Ask the following questions to assess her knowledge. If she has correct knowledge then circle the score in the Yes column otherwise circle the score in the No column. Record your response separately for each question. Ask the ANM that what is the maximum time limit after unprotected sex a woman can start taking ECPs? She should say that a single dose ECP could be started within five days (120 hours of unprotected intercourse. FP Records In this section we will check and review the availability and maintenance of FP records at the subcenter, to see if the facility is providing these services as well as continuously updating their records. The QA team members will ask the ANM/HW (F) to provide FP records, which are being maintained. The response to the following questions will be only in Yes or No. Instruction: On the day of visit please check and review whether the following records of FP services given in the past 3 months are being maintained.

QE.4. FW Records show OCP usage and new acceptance in last 3 months (See QF.6 of CHC/PHC Checklist) QE.5. FW records show (a)IUDs inserted during last three months; (b) IUDs removed (needs reasons for removal); (c) Sterilization cases followed-up (See instructions for QF.9 of CHC/PHC Checklist) QE. 6 Informed the client about different FP methods QE. 7 Client counselled on how each method works and how to use it QE. 8 Client counselled on side effects, how to manage them and complications For QE.6 QE.8 (See instructions for QF.9 to QF.11 of CHC/PHC Checklist)

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FORM 2F: Maternal Health Quality Assessment Screening of ANC clients Instruction: During QA visit, if you find a new ANC client in the subcenter, then observe at least one ANC client for QF.1 to QF.3. Take the consent of the client before observing the session. QF.1 Detection of pregnancy and screening (physical, per-abdomen, foetal assessment by history and calculation of due date) (See QG.1 of CHC/PHC Checklist) QF.2 Screened for signs of anaemia (pallor on tongue, conjunctiva, nails and measurement of Blood Pressure and weight (See QG.2 of CHC/PHC Checklist) QF.3 Tests for Hb and urine for albumin doner (See QG.3 of CHC/PHC Checklist)

ANC Counselling Instruction: During QA visit, if you find a new ANC client in the subcenter, then observe for QF.4 and QF.5. Take clients consent before observing the counselling session. If you do not get an ANC client, ask QF.6 to QF.8 to ANM to ascertain her knowledge and record your response. QF.4 Counselling on ANC to women on nutrition, birth preparedness and warning signs

Key elements of a birth and emergency (obstetric and neonatal) plan are - identifying the location of the closest appropriate care facility; identifying a skilled attendant; identifying a companion for the delivery; identifying planning for funds for birth-related and emergency expenses; arranging transport; having adequate supplies for the delivery, identifying a compatible blood donor in case of haemorrhage. Observe whether the ANM is discussing these points with the client. Observe whether the ANM is counselling the client on nutrition to take small frequent meals, eat the food readily available in the village with green leafy vegetables and dals. Also observe whether the ANM is counselling the woman on danger signs during pregnancy (severe swelling over face and limbs, blurring of vision, fits; bleeding of any amount; fever with or without chills, uncontrollable leaking of water without labour pains, burning during passing urine; severe weakness with breathlessness; sluggish/very fast/loss of foetal movements). Danger signs during labour are: excessive bleeding, prolonged labour (more than 12 hours), abnormal presentation, fever with or without chills, fits. If the ANM discusses all this with the client, then circle the score in the Yes column other wise circle the score in the No column QF.5 ANC woman encouraged for institutional deliveries Observe counselling sessions and ensure that ANM is telling the client the advantages of institutional delivery/why institutional delivery is important in terms of safety for mother and child, and where to go for institutional delivery to have skilled attendants at birth.

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QF.6

What ANM will tell client about recognizing complications during antenatal period?

Ask ANM the signs/symptoms, which are important in recognizing complications during ANC period and what should be done if such complications arise. The complications can be haemorrhage, swelling over face and feet (pre-eclampsia), abnormal lie of the foetus (malpresentation), pallor and breathlessness, weakness (severe anaemia), blurring of vision, severe headache (high Blood pressure/pre-eclampsia), convulsions (Eclampsia), premature contractions (premature labour), and previous CS (possibility of difficult labour and rupture uterus). QF.7 Does the ANM know when a client should come for ANC/PNC check-ups?

The ANM should tell the QA team member that a woman should visit the facility for ANC for first visit during first trimester at around 12 weeks. The second visit should be close to 26 weeks of pregnancy and the third and fourth in between 32 38 weeks. The first PNC visit is recommended within the 6 weeks of delivery. QF.8 Does the ANM know of how a woman can recognize onset of delivery/signs of labour?

Ask ANM the signs/symptoms by which a woman can recognize the onset of delivery? She will be able to say-the beginning of regular contractions with increasing pain, intensity, frequency and duration, the bag of waters may break with leaking of fluid, and the colour of the vaginal discharge-if bloody fluid mixed with mucus-show is present. If the ANM is able to answer these questions to the QA team members satisfaction, circle the score in the Yes column. Records: Instructions: On the day of visit please review records of the past three months (rounded to the nearest month end), to ascertain that these services are being provided regularly and are being used by the community. QF.9 Last three months records show women with labour are managed in the facility QF.10 Last three months records show women with obstetric complications identified and referred in a timely manner QF.11 Last three months records show that newborns with birth weight less than 2 Kgs referred to higher centers If these services are being provided and utilized on a regular basis, circle the score in the Yes column. Newborn and Child Care: The objective of this section is to assess the quality of newborn care at subcenter. The questions are designed to assess ANMs knowledge about newborn care. since on the day of visit the QA team member may not find a mother and baby admitted for care in the subcenter. Ask the ANM about newborn care. QF.12 The ANM knows about the components of essential newborn care

Ask ANM about components of essential newborn care like resuscitation, cord care, thermal protection, eye care, breast-feeding, immunization, examination and referral for complications. If she can enumerate at least five components then circle the score in the Yes column otherwise circle the score in the No column.

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QF.13 Does ANM know about the Kangaroo Care for maintenance of temperature of hypothermic newborn? Ask ANM if she knows the term kangaroo mother care. Kangaroo mother care is care of newborn carried early, continuous, and prolonged skin-to-skin contact between mother and the baby. It is a powerful, easy to use method to promote the health and well being of newborns born pre-term as well as full term. It is effective for thermal control, breast-feeding and bonding in all newborns. Circle the appropriate score based on the knowledge of the ANM. QF.14 Tab. Cotrimoxazole available and being used for managing Respiratory Tract Infections in children Check availability of Cotrimoxazole tablets and also check clinic register to confirm its use for managing Respiratory Tract Infections in children. Accordingly circle the appropriate response. QF.15 ORS packets being used for managing diarrhoeal diseases in children Check availability of ORS packets and also check clinic register to confirm its use for managing diarrhoeal diseases in children. Accordingly circle the appropriate response. If services being provided and utilized, circle the score in the Yes column. FORM 2G: Child Health/Immunization Quality Assessment Immunization Service Delivery Instructions: The QA team is advised to visit the subcenter on an immunization day. For Micro Plan check previous months record. For QG.2 to QG.7 OBSERVE the immunization session QG.1 MICRO PLAN - Whether immunization sessions conducted as planned Check for availability of Micro Plan at subcenter and check the number of sessions conducted during the last month in records available. If the conducted sessions are more than 70% of those planned, circle the score in the Yes column and if less then 70% circle the score in the No column. QG.2 Measles vaccines is being administered between 9-12 months of age The purpose of this question is to know whether the providers are administering the measles vaccine at the right age, that is, between 9-12 months of age. Observe the administration of measles vaccines and mark in the appropriate response column. QG.3 Sterile needle not touched by hand or swab during injection process Observe closely during the session and mark the appropriate column. QG.4 Needle cutter/puncture proof box used for disposal of used syringes If there is a needle cutter/puncture proof box at the subcenter close to where immunization is being conducted, circle the score in the Yes column otherwise circle the score in the No column.

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QG.5 Vaccine carrier kept closed during immunization session If the vaccine carrier is being opened only while taking out vaccine vials and found closed during other times, circle the score in the Yes column. If the lid of vaccine carrier is found open, circle the score in the No column. QG.6 Post-immunization counselling regarding side-effects and follow-up visits When observing the immunization session, observe for post-immunization counselling of the person who has brought the child. Observe, if the provider is discussing side effects, what to do and how to manage them, where to go if care is required and follow-up visits. Circle the appropriate response. QG.7 Immunization card or register updated/completed for each child after administering the vaccine Observe updating of cards & counterfoils after each child's vaccination. Mark in the appropriate response column based on the observations. Vaccination Supplies and Cold Chain Management Instructions: Please physically verify the vaccine carrier. Conduct spot shake test for frozen vaccines. QG.8 Availability of supplies in the subcenter (a )No stock out of A D syringes (b) No vaccine without lables Check in the vaccine carrier for measles stock, if available along with diluents then circle the score in the Yes column, if vaccine is not available, circle the score in the No column. Check for availability of A D syringes with the ANM and if available as per plan i.e. as per expected client load, circle the score in the Yes column. If the ANM does not have stocks of A D syringes as per plans then circle the score in the No column. QG.9 No vaccines beyond expiry date in the carrier Check in vaccine carrier for any vial beyond the expiry date. If all are within the expiry dates circle the score in the Yes column, if the date expired on vials, then circle the score in the No column and discard the vial immediately. QG.10 No frozen T series vaccine in vaccine carrier Check for all T series vials and observe closely for any signs of frozen vials, if all vials are in liquid state, circle the score in the Yes column, if ice/floccules are seen, circle the score in the No column. Community Mobilization Instructions: ASK the ANM/HW (F) about participation of Anganwadi workers and ASHA. CHECK records to ascertain that drop out cases were traced and vaccine provided. QG.11 Anganwadi workers participated in Village Health and Nutrition Day ( VHND) Check for presence of AWW in the session, and ask the ANM/HW (F) about the involvement of AWW in the session. If the AWW is available, and actively involved and has information

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about the number of participants expected for the session, circle the score in the Yes column, otherwise, circle the score in the No column. QG.12 ASHA participated in Village Health and Nutrition Day (VHND) Check for presence of ASHA worker in the session, and ask the ANM/HW (F) about the involvement of ASHA in these sessions. If the ASHA is available, observe her involvement. If she is actively involved, circle the score in the Yes column, if not, circle the score in the No column.. QG.13 Drop out cases were traced and vaccines provided Ask ANM/HW (F) about the system for tracing the dropouts and providing the vaccine whether she has some system and it is being used. If so circle the score in the Yes column, else circle the score in the No column. Form 2-H: Miscellaneous Services Quality Assessment QH. 1 Last three months records show RTI/STIs cases referred to nearest centre for tests /management Check the last three months clinic register/records to see whether RTI/STI cases were referred to nearest centre for lab tests and further management. Even if one case is referred, circle the score in the Yes column. QH. 2 Untied funds available and utilized Check the accounts register for availability and utilization of untied funds. If available and being utilized, circle the score in the Yes column. Form 2-I: Output Indicators for Quality Assessment Instructions: Check the records of the last three months and count the total number of cases obtained in response to the questions from QI. 1- QI 6 below. Compare the data with the corresponding period of the last year and calculate the change and percentage as indicated in the respective columns. For QI 1-QI 3, refer to the instructions of QJ 1-QJ 3 of CHC/PHC checklist. For QI 6, refer to instructions of QJ 8 of CHC/PHC checklist. QI. 1 Total number of ANC women registered in last 3 months QI. 2 Total number of deliveries at this facility QI. 3 Total number of IUD acceptors in last three months QI. 4 Total number of RTI/STI cases referred in the past three months QI. 5 Total number of low birth weight babies referred to higher facility in past three months QI. 6 Total number of children received measles vaccine. Complete the information for QI 4 and QI 5 in the similar way and record your observations and calculations in the relevant columns of the subcenter checklist.

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Form 3: RCH/STERILIZATION CAMP QUALITY ASSESSMENT CHECKLIST Reproductive and Child Health (RCH) camps, which are popular as Parivar Swasthya Sewa Divas (Family Health Day) organized at CHCs and PHCs, provide an opportunity to integrate the efforts of providers and increase access to reproductive health services. Each camp includes a gynaecological check-up, management of RTI/STI, childrens examination and immunization, and family planning counselling and services. Though sterilization camps have been part of the family planning programme for many years, these RCH/sterilization camps are different as they: o o o Provide assured services as per a pre-determined calendar Combine benefits of rural outreach and high quality services Provide an array of maternal, child health and family planning services under one roof

This integrated approach of providing maternal, child health, RTI/STI and family planning services is found to be more cost effective and also convenient for clients. However, depending on the availability of manpower and logistics, the district could decide the type of services to be offered in sterilization camps. Standards for Mobile Services in RCH/Sterilization Camps The concept of Reproductive and Child Health lays emphasis on making services available as close to the client as possible. Therefore, mobile sterilization services have gained importance. Every attempt should be made for such services to be on par with those that are available at the static centers. The quality often gets compromised due to large number of clients who need to be served in a short span of time in a RCH/sterilization camp. The poor quality of services translates into post-service complications among clients, which often results in low acceptance or rejection of services in future and clients dissatisfaction Mobile sterilization services should be offered in an institution (at the PHC or CHC) where minimum OT facilities are available for conducting female sterilization or a clean separate room is available for conducting male sterilization. Under no circumstances should mobile sterilization services be conducted in a school building, panchayat bhavan or any other such building. Every one responsible for organizing / providing services in RCH/sterilization camp should read carefully the MOH GOI SOPs for Sterilization Services and adhere to the standards given in the standards. Primary responsibility for organizing a RCH/sterilization camp will be with the MOIC / MS incharge of the Block PHC/CHC. Surgery will be done by the operating team coming from static sterilization centers either from the CHC, district or from the state. The Mobile operating team will be responsible for final selection of appropriate client, including speculum and vaginal examination (in case of female sterilization), verification of informed consent, assurance of quality of care including cleanliness and infection prevention, surgical procedure and postoperative recovery. Mobile sterilization services should preferably be conducted between 9 am and 4 pm so that the team can have at least 4 hours of operating time. This will ensure sufficient time for postoperative observation, and also allow the team and clients to reach their destinations by the end of the day.

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The following are some of the important areas where standards should be maintained in the mobile sterilization services. However, the standards given in The SOPs for Sterilization Services in Camps must be followed. Staffing The mobile team should have Empanelled surgeon (1), OT nurse (1), OT assistant (1) and preferably an anaesthetist. The local service site should provide Medical Officer (1), nurse/LHV/ANM (1), OT attendant (1), staff for registration of clients (1), staff maintaining proper client records (1) and other staff as per SOPs for sterilization camp. Counselling/Informed consent/Eligibility Criteria The standards must be adhered to. Clinical Assessment Pre-operative assessment of the patients medical status is extremely important to ensure that high-risk clients are not operated upon in this setting. Emergency Preparedness Staff Preparation: All staff of the mobile team and operating center must be skilled in administration of intravenous fluids and drugs, external cardiac massage and other resuscitative measures. Emergency equipment and supplies: All emergency equipment must be immediately available, prepared for use and in good functioning condition. Emergency drugs: The staffs need to be well informed about the availability of these drugs, their use, dose, strength, route of administration, signs of toxicity and treatment for overdose. Backup referral facility: Facility must be available to transfer clients to higher referral centers/district hospitals in case of any complications which cannot be managed during mobile sterilization services. Asepsis Standards in Mobile Sterilization Services: All the steps of infection prevention preparation should be observed. Client discharge after mobile services: The surgeon or member of the surgical team must see all operated clients at least once during the post operative period before he/she leaves the center. All operated clients must be examined before discharge. For assessment of RCH camp, confirm from the district authorities about the organization of a RCH camp and plan visit to the site accordingly. In RCH camps the team should observe whether providers are following the protocols and guidelines when providing the services. Instructions to complete the Form 3: On the day of visit request MO I/C and identified staff to respond to the identification details of the facility, questions of the checklist and fill the personnel assessment section. Identification State, District, Taluka/tehsil Please fill these clearly to help identify them later if required.

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Type of camp: 1. Sterilization Camp 2. RCH Camp Circle 1 if it is only a sterilization camp. If it is an RCH camp, then circle 2. This identification is important because there are some questions in the checklist which are relevant only for an RCH camp. Venue of RCH/Sterilization Camp: Block Circle the RCH or sterilization as the case may be and write the name of the block in the space provided. Type of facility: PHC / CHC / Others (specify) Circle the appropriate facility if it is a PHC or a CHC. If it is any other location/facility, please specify the name. Distance (Kms) from district headquarters The distance of the facility of the camp from the district headquarters should be mentioned here in Kms. Name and address of the facility Write the name and detailed address of the facility where the camp is organized. CHC/PHC staff/Surgical Team members respondents: Name Designation Write the names and designations of all the personnel who respond during the assessment visit to provide information to complete the checklist in the respective space provided for each. DQAG Members: Name Designation Write the names and designation of the DQAG members present during the visit at the facility. Time started assessment and Time ended assessment Write the time with am and pm on the space provided at the time of starting the assessment and on completing it at the facility on the same day. Date of assessment Write the complete date in the date/month/year format. Signature of the team leader DQAG The leader of the DQAG for this visit will sign the checklist once the assessment is over and all the relevant sections of the checklist are duly filled. NOTE: The checklist is arranged in different sections with questions pertaining to quality indicators for that area. Each question has a response of either Yes or No. Each question with a Yes response has been assigned a score. At the end of each section, the score has to be added and written in the space provided for Score Obtained. Some of the questions in the checklist will have multiple sub-questions or elements. If during assessment, all the sub-questions or elements are correct as per the standards, ONLY then circle the score in the Yes column against that question. Even if one sub-question or element is not per standards, circle the score in the No column. Form 3-A: Providers Availability QA.1 Empanelled surgeon available for sterilization operations For performing a sterilization procedure the medical professional should have the requisite qualifications. The minimum qualification for performing female sterilization by Minilap

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Tubectomy and male sterilization, either by conventional or No-scalpel Vasectomy is trained MBBS doctor. Laparoscopic Sterilization should be performed by a gynaecologist with DGO/MD/MS qualification or a general surgeon with MS degree, trained in Laparoscopic sterilization. Only those doctors whose names appear in the panel (district-wise panel of doctors prepared by states as per the above eligibility criteria based on their qualifications for performing sterilization operations) would be entitled to carry out sterilization operations. The question should be asked for all medical officers of the facility or those deputed from some other facility to conduct sterilization procedure in the RCH camp. QA.2 Availability of trained provider in RTI/STI management The question should be asked for all medical officers/other providers of the facility or those deputed from some other facility, to ascertain whether they are properly trained in managing RTI/STI clients in the RCH Camp. QA.3 Anaesthetist/Provider trained in cardio-pulmonary resuscitation available The question should be asked for all medical officers of the facility or those deputed from some other facility to ascertain the availability of an anaesthetist or a medical officer trained in cardio-pulmonary resuscitation in the RCH camp. QA.4 Surgical team (Surgeon, OT nurse and OT attendant) available at campsite as per scheduled time Mobile sterilization services should preferably be conducted between 09:00 am and 04:00 pm so that the team can have at least 6 hours of time to work. This will ensure sufficient time for postoperative observation and also allow the team and clients to reach their destinations by the end of the day. The mobile team should have surgeon-1, OT nurse-1, OT assistant1 and preferably Anaesthetist-1. The information about timing should be obtained by observing the time of the teams arrival or by asking the staff of the facility. Form 3-B: Infrastructure On the day of visit please physically verify and confirm from QB.1 to QB.16 by visiting different parts of the facility where RCH/sterilization camp has been organized/services in RCH/sterilization camp are being provided. Instructions: Walk around the camp area and check personally the following: Essential Arrangements for the camp - Specified counters/rooms for: QB.1 Site staff duties assigned and communicated Organization of RCH/sterilization services require considerable human resources as the services are provided in a short span of time. The staff required and their roles are explained in SOPs for sterilization camps. Accordingly, mobilize staff from periphery/additional PHC/other sites if required. Observe whether a duty list has been prepared beforehand and staff has been intimated about their role and responsibilities. QB.2 Registration / reception The purpose of looking for specified counters/room for registration/reception is to check out arrangements for clients comfort in connection with a comfortable waiting area ( not too hot, clean place with chairs, benches to sit) in the RCH/sterilization camp. Staff should be available for giving information and also for registration of the clients.

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QB.3 Separate Counselling area Counselling is the process to help the clients to take informed and voluntary decisions about fertility. Counselling is of particular importance when providing RCH/sterilization services as consequences, risks and fears need to be discussed with each client. Providers have an obligation to ensure that client understands the benefits, risks and complications of procedures and those who choose it make a voluntary informed choice. All information shared in counselling sessions is confidential, hence it is necessary to have designated counselling area during the camp, which offers both visual and auditory privacy and ensures avoidance of any interruptions. QB.4 Pre-operative preparation area Pre-operative preparation room has to be used for part preparation-trimming of hair, hand washing, changing of clients street clothes into clean OT clothes, pre-medication and waiting till client is transported to OT for the procedure. QB.5 OT prepared for the procedures Operation theatre should be isolated and fitted with fly-proof netting and should be large enough to allow the operating staff to move freely and to accommodate all the necessary equipment. Lighting should be adequate and the room should be easy to enter and leave in case of an emergency. The room should be thoroughly cleaned and mopped with 0.5% bleaching powder solution. QB.6 Electricity generator with fuel/solar source for alternate electricity is available for power backup during camp hours and connected to OT The purpose of gathering this information is to see if the facility has an alternate electricity source. Availability of continuous supply of electricity in procedure rooms especially OT is of utmost importance. Check availability of generator/inverter or solar source of electricity. Check to see if it is functioning. Check also that alternate source for electricity is connected to the OT (even if electricity supply is present at that time). QB.7 Availability of water (through tap or bucket with tap) in procedure rooms Continuous supply of water in procedure rooms is essential for washing hands and maintaining cleanliness. Running water should be provided in procedure rooms through tap or bucket with tap. QB.8 Functional vehicle with driver and POL available for emergency referral Facility must be able to transfer clients to higher referral centers/district hospitals in case of any complications which cannot be managed during mobile sterilization services. Check for a vehicle in running condition, availability of driver and POL during camp hours. Essential Amenities for Clients Comfort QB.9 Drinking water available for clients The purpose of looking for clean drinking water is to look for basic amenities for the clients comfort. Check availability of clean drinking water that can be provided by taps or clean water containers.

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QB.10 Recovery area with mattresses, blankets and clean bed covers Post-operative recovery area must be spacious and well ventilated. The number of female sterilization clients should determine the number of beds. The area should be clean and be situated adjacent to/near the OT. Beds should have blankets and mattresses with clean bed sheets . QB.11 Functional toilets for clients with water The purpose of this question is to know whether clients can use the toilet at the facility. Check toilets, availability of water in toilets and functioning of flush system. Check that toilets drainage systems are not blocked. Information and Communication Services at Facility Instructions: Observe while going around the facility that banners, posters, wall paintings, are available and handbills are available for distribution. Take the permission and consent of the client, then observe counselling sessions to ensure the use of counselling material. QB.12 IEC material/job aids available for counselling for FP One of the pre-requisites for FP counselling is availability of IEC material, job aids for counselling and contraceptive methods, so that client can make an informed choice after getting information on all the available methods. Check availability of various contraceptive methods that a couple can adopt and IEC material related to it. IEC material needs to be displayed in the facility. QB.13 IEC material/job aids available for MCH and FP counselling IEC material related to counselling for MCH and FP e.g. Posters, cards, models, handouts etc. should be available in the maternity and family planning wing. IEC materials also need to be displayed in the facility. QB.14 IEC material/job aids available for RTI/STI counselling RTI/STI counselling helps the client to comply with correct and complete treatment, know about risk factors and dangers involved, overcome barriers to change sexual behaviour and practice safe sex. Counselling is also a significant component of the client-centered approach to STI/RTI/HIV services. IEC material related to RTI/STI is important to conduct a good counselling session. IEC material also needs to be displayed in the facility. QB.15 Information about services in camp displayed Observe banners, wall paintings, handbills and display board etc. for the information being displayed. QB.16 Information about next camp date displayed

Observe banners, wall paintings, handbills and display board etc. for the information about next camp date displayed. Form 3-C: Essential Formats This section will provide information whether the facility is providing services to the clients as per established protocols and guidelines or not. On the day of visit, physically verify the availability of the job aids in the facility.

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Instructions: Ask the providers to show you the forms and certificates. QC.1 Camp service record register available and being filled for: (a) Sterilization (b) Other FP services (c) RTI/STI services (d) FOR RCH CAMPS ONLY: Maternal Health (e) FOR RCH CAMPS ONLY: Child Health Check availability of earmarked camp service record registers. Check related entries for last camp and current camp. Check for sterilization conducted in last camp, beneficiaries of other FP services, RTI/STI. If it is RCH camp, check also for maternal and child health service record for last camp. QC.2 Last 3 months camp records show compensation money paid to sterilization clients Check availability of payment record and entries for last three months related to sterilization compensation money payment to the sterilization beneficiaries. Form 3-D: Infection Prevention and Surgical Practices All steps of appropriate infection prevention practices should be observed. QD.1 Surgical team does surgical scrub and alcohol scrub as per guidelines All OT staff must wash their hands before and after the procedure/handling instruments/equipment, wearing/taking off gloves and whenever indicated. The operating doctor and assistant must go for surgical scrubbing before the procedure and after 5 cases or 1 hour, whichever is earlier, if they touch anything in between the cases and go out of OT or there is tear or prick in the gloves during the procedure. In between, alcohol scrubbing should be done before wearing gloves. Observe providers while going through the facility and in OT. As mentioned in the NOTE earlier: if all the team members practise these guidelines, circle the score in the Yes column. Even if one member of the team fails to practise these guidelines, then circle the score in the No column. QD.2 Laparoscope is decontaminated with alcohol swab after each procedure and cleaned Observe the procedures in the OT. If done then circle the score in the Yes column else circle the score in the No column. QD.3 Laparoscope is high level disinfected between procedures for 20 minutes in glutaraldehyde solution or 10 minutes with paracetic acid and washed/cleaned with HLD water (water boiled for 20 minutes and cooled.) Observe that both the practices of chemical HLD and washing with HLD water are being followed. If any one of them is not followed or disinfection is done for less than 20 minutes with gluteraldehyde or 10 minutes with paracetic acid or the water used is not HLD as per standards then circle the score in the No column. QD.4 Sterilized surgical cut sheet used for each client Observe that a different sterilized cut sheet is used for each sterilization client in OT. If done then circle the appropriate score.

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QD.5 Gloves being changed by service provider in between procedures Observe the providers in the OT. A fresh pair of sterilized gloves need to be used for each sterilization client by each service provider. If done then circle the appropriate score. QD.6 Waste disposed as per guidelines The purpose of this question is to know whether the facility has arrangements to segregate waste, so that medical waste is either burnt or buried as per standards. QD.7 OT table and floor wiped with 0.5% chlorine solution in between procedures Observe the providers performing these procedures in the OT. If done for both and each time, then circle the score in the Yes column else circle the score in the No column. Form 3-E: Availability of Equipment and Supplies The purpose of questions in this section is to ascertain the availability of equipment and if it is in working condition. Specifically, availability of important and life saving equipment is to be checked. On the day of visit, please go to respective rooms/lab and physically check and confirm availability and proper functioning of all equipment. QE.1 BP apparatus and stethoscope in working order One separate set of functional BP apparatus and stethoscope should be available in preoperative examination room, operation room and post operative room. QE.2 Weighing scales in working order (a) Adult (b) For RCH camp only: Infant (See QE.2 of CHC/PHC Checklist) QE.3 Autoclave and boiler in working order and being used (check log book) (See QE.3 of CHC/PHC Checklist) QE.4 Suction Machine in working order One functional suction machine each in operating room and post operative room/area

QE.5 Adult Ambu bag in working order Adult self-inflating ambu bag and mask available and functional. QE.6 Oxygen cylinder with tubing, wrench and disposable masks in working order (See QE.12 of CHC/PHC Checklist) QE.7 Sufficient number of sterilized syringes and needles with needle cutter/puncture proof boxes for disposal of sharps Enough sterilized syringes and needles should be available as per client load so as to follow one syringe-one needle-one client protocol. If disposable syringes-needles are used then needle cutter/puncture proof box should also be available at each service site. If both sterilised syringes and needle cutter/puncture proof box are available and being used then only circle the score in the Yes column else circle the score in the No column. QE.8 Insufflator available in working order for pneumo-peritoneum (ONLY FOR LAP) If laparoscopic tubectomy services are being provided, check availability of insufflator for pneumo-peritoneum in OT. If it is available then circle the score in the Yes column else circle the score in the No column.

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QE.9 A minimum of three laparoscopes available (if laparoscopic sterilization offered) A minimum of three laparoscopes should be available per team so that proper timings of high level disinfection can be maintained. If they are available then circle the score in the Yes column else circle the score in the No column. QE.10 At least five NSV sets available A minimum of five NSV sets should be available per team so that proper timing of high level disinfection can be maintained. If they are available then circle the score in the Yes column else circle the score in the No column. QE.11 At least five AT/ML sets available A minimum of five sets of AT/ML should be available per team so that proper timing of highlevel disinfection can be maintained. QE.12 At least one set for laparotomy available One set for laparotomy should be available in case emergency laparotomy is needed. QE.13 At least three IUD insertion/removal sets available A minimum of three IUD insertion/removal sets should be available so that proper timing of high-level disinfection can be maintained. QE.14 Anaesthesia equipment set available On the day of RCH/sterilization camp, an anaesthesia equipment set (Boyles Apparatus) should be available Laboratory Equipment and Supplies On the day of visit to RCH/sterilization camp, please check and confirm availability of the following equipment and supplies for pre-procedure lab tests: QE.15 Sahlis Haemoglobinometer in working condition to be used for measuring Hb with fresh N/10 HCL solution If all the equipment and HCL are present and Hb is being measured then circle the score in Yes column else circle the score in the No column. QE.16 Gram staining (crystal violet, iodine solution, acetone-ethanol and safranin stain) available (See QE.17 of CHC/PHC Checklist) QE.17 Urine albumin (Acetic acid and lamp for heat test or uristix) available If uristix/all the equipment and acetic acid are present and urine is being examined for albumin over heat, then circle the score in Yes column else circle the score in the No column. QE.18 Sugar uristix or Benedict's solution and lamp for heat test available (See QE.20 of CHC/PHC Checklist) Essential Drugs and Consumables Instructions: Do not stock check. Please check the availability for at least 20 clients

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QE.19 Post-operative medicines for sterilization clients Also check and ensure from clients that they are being given medicines. If the medicines are available and being given to clients then only circle the score in the Yes column else circle the score in the No column. QE. 20 Emergency drugs as per the standard list Check availability of emergency drugs as per the standard list given in the SOPs for RCH/sterilization camps. QE.21 Medicines for RTI/STI If the medicines are available then circle the score in the Yes column else circle the score in the No column. Form 3-F: Family Planning Quality Assessment The qualities of RH services provided through RCH/sterilization camps often get compromised due to a large number of clients who need to be served. Poor quality of services translates into post service complications among clients, which results in low acceptance or rejection of services and client dissatisfaction. In RCH/sterilization camps, the team should observe whether providers are following the protocols and guidelines when providing sterilization and FP services. QF.1 Standard guidelines used for pre-operative clinical screening for all sterilization clients (a) Medical eligibility ensured (b) Laboratory examination for Hb, sugar, albumin done (c) Informed consent taken (d) Case record written (e) Medical record check list filled Prior to the surgery, medical history, physical examination and laboratory investigations as per standards need to be done to ensure the eligibility of the client for surgery. Preparation for surgery includes counselling, pre-operative assessment, pre-operative instructions and preparations, reviews of the surgical procedure and post-operative care. It is essential to ensure that the consent for surgery is voluntary and well informed and that the client is physically fit for the surgery. Check that the standard case record and medical record checklist are filled and verified by surgeon QF.2 Pneumo-peritoneum done as per guidelines (FOR LAP ONLY)

Insufflation of abdomen with carbon dioxide are the preferable method. Pneumo-peritoneum must not exceed 15 mm of mercury or 1 litre of air. Slow insufflations with graded insufflators and gradual de-conflation should be done. Check during procedures that providers follow the protocols. QF.3 Client monitored during operative process

Medical records are to be maintained relating to the vital signs (pulse, respiration and blood pressure), level of consciousness, vomiting and any other relevant information. If any drug is administered, its name, dosage, route and time must be recorded. Monitoring is to be done as i) Pre-operative: pulse, respiration and blood pressure should be taken prior to premedication and thereafter every 10 minutes. ii) During operation: (a) maintain verbal communication with client, (b) check, pulse, respiration and blood pressure every five minutes especially during the time of gas insufflations and at the time of Tubal Ligation. iii) Post-operative: pulse, respiration, and blood pressure are to be monitored and recorded

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every 15 minutes for one hour following surgery or longer if the patient is unstable or not awake. Observe during procedures. QF.4 Tubectomy clients transported to recovery area on a trolley/stretcher

Clients are in a state of sedation after the tubectomy and need to be transported to the recovery area on a trolley/stretcher to ensure comfort and confidentially. Observe how clients are being transported after procedure. QF.5 IUD inserted by no-touch and with-drawl technique

Observe/ask how IUD is inserted to the clients. (See QE.1 of Subcenter Checklist) QF.6 Clients counselled about FP methods

Clients are counselled about all available methods and after counselling make informed decision. Observe sessions of counselling. FP Methods Supply Instructions: do not do a FP material stock check just check availability as below. QF.7 OCP at least 20 cycles available QF.8 IUDs At least 20 packets available QF.9 ECP at least 20 packets available QF.10 Condom at least 1200 pieces available Form 3-G: Maternal Health Quality Assessment (APPLICABLE ONLY IN RCH CAMPS) Some indicators related to maternity services need to be measured to assess whether providers are maintaining standards. Screening of ANC clients: (QG.1 QG.3) (See QG.1 to QG.3 of CHC/PHC Checklist) After permission and consent from the client to be present during the session, observe at least one ANC client for screening. Circle the score in Yes column of respective questions if all the activities are being performed as per standard, else circle the score in No column. ANC Counselling: (QG.4 QG.6) (See QG.4 to QG.6 of CHC/PHC Checklist) After permission and consent from the client to be present during the session, observe at least one ANC client for counselling. Circle the score in Yes column of the respective question if all the activities are being performed as per standard, else circle the score in No column. Form 3-H: Child Health/Immunization Quality Assessment (APPLICABLE ONLY IN RCH CAMPS) The objective of this section is to assess the quality of childcare services in RCH Camp. On the day of RCH camp the observers will observe immunization sessions and assess the quality of services being offered. Immunization Service Delivery: Observe the immunization session QH.1 Immunization sessions conducted at the RCH camp

72

Observe that immunization sessions are being conducted during the RCH camp. Circle the score in No if not done. QH.2 Sterile needle not touched by hand or swab during injection process (See QH.3 of CHC/PHC Checklist) QH.3 Needle cutters/puncture proof boxes used for disposal of used syringes (See QH.4 of CHC/PHC Checklist) QH.4 Post-immunization counselling regarding side effects, how to manage them and followup visits (See QH.6 of CHC/PHC Checklist) QH.5 Immunization card updated/completed for each child after vaccination (See QH.7 of CHC/PHC Checklist) Vaccine Supplies and Cold Chain Management: (QH.6 QH.8) QH.6: Measles vaccine QH.7: A.D. syringes at least 20 QH.8: No frozen T series vaccine in the carrier Physically check vaccine carrier. Check availability of vaccine for at least 20 clients. Conduct spot shake test for frozen vaccines. Check that no vaccine is without label and beyond expiry date in the carrier. Check availability of at least 20 AD syringes.

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ANNEXURES
Annexure 1:
Form 1: CHC / PHC quality assessment checklist Form 1A: CHC / PHC quality assessment results summary of major assessment findings at facility Form 1B: CHC / PHC quality assessment results -findings, interpretation and areas of improvement - action plan Form 2: Subcenter quality assessment checklist Form 2A: Subcenter quality assessment results - Summary of major assessment findings at facility Form 2B: Subcenter quality assessment results - Findings, interpretation and areas of improvement -action plan Form 3: RCH /sterilization camp quality assessment checklist Form 3A: RCH camp quality assessment results - Summary of major assessment findings at facility Form 3B: RCH camp quality assessment results- Findings, interpretation and areas of improvement -action plan form Form 1C: monthly QA summary report of CHC / PHC prepared by member secretary actions to be taken at CHC / PHC level Based on all visits made Form 1D: monthly QA summary report of CHC / PHC prepared by member secretary actions to be taken at district level - Based on all visits Form 1E: monthly QA summary report of CHC / PHC prepared by member secretary actions to be taken at state level - Based on all visits made Form 2C: monthly QA summary report of subcenters prepared by member secretary Based on all visits made Actions to be taken at sub centre/ CHC / PHC level Form 2D: monthly QA summary report of subcenters prepared by member secretary Based on all visits made Actions to be taken at district level Form 2E: monthly QA summary report of subcenters prepared by member secretary Based on all visits made - Actions to be taken at state level Form 3C: monthly QA summary report of RCH camps prepared by member secretary Based on all visits made Form 4: client satisfaction with services

Annexure - 2:
Agenda: QA training for DQAG members Agenda: QA orientation workshop of state / district stake holders Agenda: QA orientation workshop of CHC / PHC in-charges

Annexure 3:
Presentations: Session 2: introduction to QA principles & operational manual Session 3: Institutional arrangements & roles and responsibilities of key stakeholders

Annexure - 4:
Suggested readings/References

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ANNEXURE - 1
FORM 1: CHC/PHC QUALITY ASSESSMENT CHECKLIST
QUALITY ASSURANCE GROUP VISIT

IDENTIFICATION State: -------------------------District: ________________ Taluka/tehsil: _________________ Block: ____________Type of Facility: ___ PHC __ CHC Other (specify) ______ Distance from District HQ (Kilometers) ________________________________________ Name & Address of Facility

____________________________________________________________________________ CHC/PHC Staff respondents

Name Designation 1 _____________________________ 2 ______________________________ 3 ______________________________ __________ __________ __________

4 ______________________________
DQAG Members Name Designation 1. ____________________________ ____________ 2. ____________________________ 3. ____________________________ 4. ____________________________ ____________ ____________ ____________

__________

Date when last supervisory visit was made by DHO/CS/ADHO/THO to review QA actions plan or to provide facilitative supervision on QA: ___________________________

Time started assessment: _________ Time ended assessment: ___________

Date of Assessment: __________

Signature of the Team Leader DQAG

75

Q. No. QA.1

QA.2 QA.3 QA.4 QA.5 QA.6 QA.7 QA.8

FORM 1 A. PROVIDERS AVAILABILITY Sub-elements Instructions: On day of visit ASK MO I/C and/or other staff Score and fill the following questions (3) At least one Medical Officer trained in handling Basic Both EmOC Emergency Obstetric Care (PHC)/Comprehensive Emergency and RTI/STI Obstetric (CHC) and RTI/STIs Yes A Medical Officer empanelled in at least one method of sterilization operation available Yes A trained and registered Medical Officer available to conduct MTP Available An HS (LHV) and/or HW (F) trained for RTI/STI screening with and trained per speculum examination Available Lab technician trained in conducting RTI/STI tests and trained Available ONLY CHCs: Lab technician trained in blood storage protocols and trained and cross-matching Yes At least one staff nurse/LHV/ANM available round the clock at the facility in eight hourly duties Yes ONLY CHCs(a) Trained MO for C-section (b) Anaesthetist/Trained MO available/ on call Yes Score Obtained =

Response Score (1) Only EmOC Only RTI/STI

Score (0) No additional training No No

Available but not trained Available but not trained Available but not trained

Not available Not available Not available No No No

FORM 1 B. INFRASTRUCTURE Q. No. Sub-elements Instructions: Walk around the CHC/PHC area and OBSERVE the following CLEANLINESS OF FACILITY General Cleanliness of the facility a. Surroundings are clean with no water logging or spread of hospital waste b. Clean floors and no seepage from wall and ceiling c. Clean dust bins in all rooms, waiting area and corridor No windows/panes broken No dust in OT and on window panes of OT Proper arrangements for segregation of wastes generated at the facility ESSENTIAL AMENITIES FOR CLIENTS COMFORT Waiting area has benches in covered/shaded area Drinking water available for clients All occupied beds have mattresses, rubber cover and clean bed sheet At least one separate toilet with running water for women A separate labour/delivery room with curtains on doors and windows for privacy FACILITIES A functional OT/procedure room with facility (a) to conduct sterilization operations (b) ONLY CHC: to provide anaesthesia (c) ONLY CHC: to conduct a caesarean section. Functional electricity generator with POL or solar system connected to procedure rooms and OT INFORMATION AND COMMUNICATION SERVICES AT FACILITY Citizens charter in local language displayed at the prominent place Signboard in local language showing different service stations Functional phone available for incoming and outgoing calls A functional CHC/PHC vehicle (with driver) or outsourced vehicle available on call 24 hrs for referrals Score Obtained = Response Score YES NO

QB.1

QB.2 QB.3 QB.4 QB.5 QB.6 QB.7 QB.8 QB.9

1 1 1 1 1 2 2 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0

QB.10

QB.11

3 3 3 3

0 0 0 0

QB.12 QB.13 QB.14 QB.15

3 1 1 3

0 0 0 0

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FORM 1 C. ESSENTIAL PROTOCOLS AND GUIDELINES Sub-elements Q. No. Instructions: Physically verify about the availability of the following guidelines/ protocols/job aids. QC.1 RTI/STI management protocols available QC.2 IUD insertion/removal guidelines available QC.3 MTP guidelines available QC.4 Normal delivery/SBA including essential newborn care guidelines available QC.5 Village Health and Nutrition Day (VHND) guidelines available QC.6 Guidelines mentioning standards for sterilization available QC.7 Waste disposal guidelines available QC.8 Blood storage guidelines available (CHC only) QC.9 Emergency Obstetric and Newborn Care guidelines (for MOs of PHC/CHC) Score Obtained = FORM 1 D. INFECTION PREVENTION PRACTICES Sub-elements Q. No. Instructions: OBSERVE the providers practicing following infection prevention methods QD.1 Providers washed hands with soap and water as indicated and wiped with personal towel/air dried QD.2 Providers wore gloves when required QD.3 Waste disposed off as per guidelines Score Obtained =

Response Score YES 1 1 1 1 1 2 1 1 NO 0 0 0 0 0 0 0 0

Response Score YES 3 3 3 NO 0 0 0

FORM 1 E. AVAILABILITY OF EQUIPMENT AND SUPPLIES Sub-elements Q. No. Instructions: Go to respective rooms/lab and PHYSICALLY VERIFY the availability/functionality QE.1 BP apparatus and stethoscope in working order QE.2 Weighing scales in working order (a) Adult (b) Infant Autoclave/boiler in working order and being used (check log book) QE.3 QE.4 Complete delivery kit with scissors/blades, cord ties/clamps and two cord clamping forceps QE.5 Sterile/HLD Manual Vacuum Aspiration (MVA) syringe with sterile cannula (4 -10 mm) for managing incomplete abortion QE.6 Sterile ovum forceps and curette available QE.7 Paediatric resuscitation kit paediatric self-inflating Ambu bag, newborn mucus extractor or bulb syringe QE.8 Sufficient number of sterilized syringes and needles (50 in PHC and 100 in CHC) with needle cutter/puncture proof boxes for disposing sharps QE.9 Infection prevention supplies available in procedure rooms (a) Surgical and utility gloves (b) Surgical attires (c) Bleaching powder, plastic buckets, mugs, soap and mops QE.10 Sterile/HLD suturing tray containing scissors/blade, needle holder, sterile needles and sterile self dissolving suture thread/chromic cat-gut QE.11 I/V stand, sterile I/V needles/venflos/scalp vein needle and adhesive tape available QE.12 Oxygen cylinder with tubing and wrench and disposable masks in working order. QE.13 At least three suction apparatus in working order QE.14 Emergency tray with emergency injections available Lab equipments and supplies QE.15 Microscope up to 40 *10 X magnification in working order QE.16 Sahlis Haemoglobinometer in working condition to be used for measuring Hb with fresh N/10 HCL solution QE.17 Gram staining (crystal violet, iodine solution, acetone-ethanol and safranin stain) available

Response Score YES 1 1 1 2 2 2 1 2 1 NO 0 0 0 0 0 0 0 0 0 0 1 1 1 2 2 2 2 3 2 2 2 0 0 0 0 0 0 0 0 0 0

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Q. No. QE.18 QE.19 QE.20 QE.21

QE.22 QE.23 QE.24 QE.25

QE.26 QE.27 QE.28 QE.29 QE.30 QE.31 QE.32 QE.33 QE.34 QE.35 QE.36 QE.37 QE.38 QE.39 QE.40 QE.41 QE.42 QE.43 QE.44

Sub-elements Instructions: Go to respective rooms/lab and PHYSICALLY VERIFY the availability/ functionality for at least 20 clients RPR kits (for syphilis) available Urine albumin /Acetic acid and lamp for heat test or uristix available Sugar uristix/Benedict's solution and lamp for heat test available CHC only - Kits for ABO/Rh blood grouping and cross matching available Essential Drugs for RTI/STIs: Do not stock check. Please check for the availability of following or alternate medicines of the same group for at least 10 clients. Tab Norfloxacin 400 mg Tab Azithromycin 1gm Tab Metronidazole 400 mg Tab Flucanozole or Clortimazole Vaginal tabs Essential supplies for active management of infections/ complications in pregnancy/ puerperium and child health care: Check availability for at least 20 clients (B P SINGH & RASHMI to correct this section) Inj Ampicillin 250/500 mgs Inj Gentamycin 20/80 mgs Cap Nifidipine Inj Oxytocin Inj Magnesium Sulphate Normal saline IV/Ringers Lactate/DNS 20 bottles ONLY FOR FRUs: One unit of blood for Rh positive groups (A, B, AB & O) available Inj Lignocaine for local anaesthesia Inj Adrenaline Inj Atropine Inj. TT (Tetanus Toxoid) Tab. Misoprostol Inj Dexamethosone (any cortisone inj) Inj Chlorpheneramine maleate Tab. Cotrimoxazole ORS packets For Disinfection: Glutaraldehyde concentrate Packets of bleach powder/concentrated hypo-chlorite solutions Povidone Iodine/Alcohol/spirit/Cetrimide Score Obtained =

Response Score YES 1 1 1 1 NO 0 0 0 0

1 1 1 1

0 0 0 0

1 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

78

FORM 1- F: FAMILY PLANNING QUALITY ASSESSMENT Sub-elements Q. No. Instructions: Do not stock check. CHECK the availability for at least 20 clients. FP Supplies QF.1 Condoms at least 200 pieces QF.2 OCP at least 20 cycles QF.3 IUDs At least 20 packets available QF.4 ECP at least 20 packet FP Records: Physically verify; ASK THE PROVIDERS to show you the records QF.5 FW records show OCP usage and new acceptance in last 3 months QF.6 Last 3 months records show a. M/F sterilizations conducted at facility b. Sterilization cases followed-up QF.7 FW records show ECP uptake during last 3 months QF.8 FW records show (a) IUDs inserted during last 3 months (b) IUDs removed (needs reasons for removal) FP Counselling: Observation: During visit if any FP client is there, take clients consent before observing the counselling session. QF.9 Informed the client about different FP methods QF.10 Client counselled on how the method works and how it should be used QF.11 Client counselled on side effects and complications and how to manage them and where to go for care Score Obtained = FORM 1- G: MATERNAL HEALTH QUALITY ASSESSMENT Q. No. Sub-elements 3 Screening of ANC clients: VISIT ON ANC DAY AND OBSERVE NEW ANC CLIENTS. Take clients consent before observing. Detection of pregnancy and screening (Physical, per abdomen, foetal assessment by history and calculation of due date Screened for signs of anaemia (pallor on tongue, conjunctiva, nails) and measurement of Blood Pressure and weight Lab tests for Hb, Urine for albumin and sugar done ANC Counselling: OBSERVE ANC clients for counselling. Take clients consent before observing the counselling. Counselling of ANC women on nutrition and rest Counselling on the recognition of danger signs during pregnancy Counselling on breastfeeding and LAM

Response Score YES NO 2 2 2 2 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0

2 2 2

0 0 0

Response Score 1

QG.1 QG.2 QG.3

All All All

Some Some Some

None None None

QG.4 QG.5 QG.6

All All All

Some Some Some

None None None

Q. No.

Sub-elements Labour & Delivery Records: Check last 3 months records to ascertain that these services are being regularly provided.

Response Score YES NO

QG.7 QG.8 QG.9 QG.10 QG.11 QG.12

Copies of partograph available and used in last five deliveries Last 3 months records show women with obstetric complications are managed in the facility Records show deliveries took place between 8 PM and 8 AM in last three months IUD register shows that women were screened for RTI/STI prior to insertion in last three months CHC ONLY: Last 3 months records show that women given blood transfusion during pregnancy, delivery and post delivery period Records/vehicle log book shows that women needing EmOC transported by facility vehicle to referral unit in last 3 months

2 2 2 2 2 2

0 0 0 0 0 0

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QG.13

Indoor records show delivery clients stayed in the facility and kept under observation

QG.14

JSY records maintained and updated up to the previous month Newborn Care: QG. 15, 16 & 18 PHYSICALLY VERIFY; QG.19 & 20CHECK the record. New born baby corner in labour room with baby warming facilities Babys cord has no medicine or bandage and kept clean and dry Breastfeeding initiated within half hour and nothing other then breast milk given to baby (ASK MOTHER or attending Nurse) Newborn properly covered and kept warm Polio 0 dose and BCG administered Records show that newborns managed in the facility for birth asphyxia in last three months Score Obtained =

More 24-48 than 48 hours hours =3 =2 (Yes) 1 Yes 2 2 2 2 1 1

Less Dischar than 24 ged hours immedi =1 ately =0 (No) 0 No 0 0 0 0 0 0

QG.15 QG.16 QG.17 QG.18 QG.19 QG.20

FORM 1- H: CHILD HEALTH/IMMUNIZATION QUALITY ASSESSMENT Sub-elements Q. No. Immunization Service Delivery: VISIT ON IMMUNIZATION DAY For Micro Plan check previous months record. For QH.2 to QH.7 OBSERVE immunization cases MICRO PLAN - Whether immunization sessions conducted as planned Measles vaccines is being administered in between 9-12 months of age Sterile needle not touched by hand or swab during injection process Needle cutter/puncture proof box used for disposing used syringes Vaccine carrier kept closed during immunization session Post-immunization counselling regarding side effects, how to manage side effects and follow-up visits Immunization card updated/completed for each child after administering the vaccine Sub-elements Vaccination Logistics and Supplies: Please physically verify the ILR and Storage No Stock out of Measles vaccine No Stock out of A.D. syringes No stock out of Vitamin-A solution No vaccines stored are beyond expiry date Cold Chain Management: Check yourself the ILR. Conduct spot shake test for frozen vaccines Temperature record card maintained and updated No frozen T series vaccine in ILR at the facility (Frozen T series vaccine are invalid for use) Score Obtained =

Response Score 1

QH.1 QH.2 QH.3 QH.4 QH.5 QH.6 QH.7

Yes All All All All All Some Some Some Yes Some Some

No None None None No None None

Q. No.

Response Score YES NO

QH.8 QH.9 QH.10 QH.11

1 1 1 3

0 0 0 0

QH.12 QH.13

1 3

0 0

FORM 1- I: MISCELLANEOUS SERVICES QUALITY ASSESSMENT Q. No. Sub-elements QI.1 QI.2 Last three months records show RTI/STI tests done at the facility. Last 3 months records show that children under age five are managed for Respiratory Tract Infections

Response Score YES NO 1 0 1 0

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QI.3 QI.4

Last 3 months records show that children under age five are managed for diarrhoea IEC material displayed in waiting area on Maternal Care/FP/RTI/STI Score Obtained =

1 1

0 0

FORM 1- J: OUTPUT INDICATORS FOR QUALITY ASSESSMENT No. Review records and calculate Usage over Usage and change when the following to assess any the last compared to same time period (3 change in utilization of services three months) in the last year from CHC/PHCs months Number of Number of Change Percent clients (A) clients (B) in no. of change clients (A-B) (A-B) /A*100 QJ1 Total number of ANC women registered in last 3 months QJ2 Total number of deliveries at this facility. QJ3 Total number of IUD acceptors in last three months QJ4 Total number of IUD acceptors screened for RTI/STI with a lab test in the last three months QJ5 Total number of RTI/STI cases in last 3 months QJ6 Total number of RTI/STI tests done QJ7 Total number of low birth weight babies who stayed at facility for 24 hours observation QJ8 Total number of children received measles vaccine Score obtained

Scores for % Change +1-10 1 +11-25 2 +25 3 No or negative change 0

81

QA ASSESSMENT OUTPUT FORMATS-Summary of Major Assessment Findings at Facility Form 1A CHC / PHC Quality Assessment Results Name of Facility------------------------------------------District----------------------------State------------------------------Date----------------------------I Assessment Component Indicators Total points Response Remarks Score CHC PHC A. Providers Availability General Facility Readiness B. Infrastructure: Cleanliness, Essential amenities, IEC Services C. Essential protocols/and job aids D. IP Practices QA.1 QA.8 QB.1 QB.15 QC.1 QC-9 QD.1 QD.3

II Assessment Response Remarks Score

E. Availability of Equipment QE.1 QE.44 and supplies Sub Total FP Supplies QF.1 QF.4 FP Records QF.5 QF.8 F: Family Planning FP Counselling QF.9 QF.11 Sub Total Screening of ANC Clients QG.1 QG.3 ANC Counselling QG.4 QG.6 G: Maternal Health Labour and Delivery Records QG.7 QG.14 New Born Care QG.15 QG.20 Sub Total Immunization Service Delivery QH.1 QH.7 H: Child Health Vaccine Logistics and Supplies QH.8 QH.11 Cold Chain Management QH.12 QH.13 I: Miscellaneous Service Quality Service Quality Elements QI.1 QI.4 Assessment J: Out put Indicators for Quality Out put Indicators QJ.1 QJ. Assessment Sub Total Total Over all Score Facility Grade: (Grade A = 76% and above score; B = 51% 75% score; Signatures of MO I/C________________________________

C = 26% 50% score;

D = Up to 25% score)

Signatures of QA Team Leader ___________________________

82

Form 1B: CHC / PHC Quality Assessment Results Findings, Interpretation and Areas of Improvement - Action Plan Name of Facility------------------------------------------District----------------------------State------------------------------Date-----------------------------Action Need ed at: Sub Element Due Date by S. Element Problems Solution when action CHC / PHC District State No. will be taken Level Level Level A. Providers Availability B. Infrastructure General Facility Readiness C. Essential protocols and job aids D. Infection Prevention Practices E. Availability of Equipment and supplies FP Supplies F: Family Planning Person responsible for action Primary responsibility Secondary responsibility

FP Records

FP Counselling Cont

83

Form 1B: CHC / PHC Quality Assessment Results (Cont) Findings, Interpretation and Areas of Improvement - Action Plan Name of Facility------------------------------------------District----------------------------State------------------------------Date-----------------------------Action Needed at: Sub Element Due Date by S. Element Problems Solution when action CHC / PHC District State No. will be taken Level Level Level G: Maternal Health 9 10 11 12 13 14 15 H: Child Health Screening of ANC Clients ANC Counselling Labour and Delivery Records New Born Care Immunization Service Delivery Vaccine Logistics and Supplies Cold Chain Management Service Quality Elements

Person responsible for action Primary responsibility Secondary responsibility

16

I: Miscellaneous Service Quality Elements J: Out put indicators for service quality

17

Out put Indicators

Signatures of MO I/C________________________________

Signatures of QA Team Leader ___________________________

84

Form 1A: CHC / PHC Quality Assessment Results (DUPLICATE COPY FOR MO-IC) Name of Facility------------------------------------------District----------------------------State------------------------------Date----------------------------I Assessment Component Indicators Total points Response Remarks Score CHC PHC A. Providers Availability General Facility Readiness B. Infrastructure: Cleanliness, Essential amenities, IEC Services C. Essential protocols/and job aids D. IP Practices QA.1 QA.8 QB.1 QB.15 QC.1 QC-9 QD.1 QD.3 II Assessment Response Remarks Score

E. Availability of Equipment QE.1 QE.44 and supplies Sub Total FP Supplies QF.1 QF.4 F: Family Planning FP Records QF.5 QF.8 FP Counselling QF.9 QF.11 Sub Total Screening of ANC Clients QG.1 QG.3 ANC Counselling QG.4 QG.6 G: Maternal Health Labour and Delivery Records QG.7 QG.14 New Born Care QG.15 QG.20 Sub Total Immunization Service Delivery QH.1 QH.7 H: Child Health Vaccine Logistics and Supplies QH.8 QH.11 Cold Chain Management QH.12 QH.13 I: Miscellaneous Service Quality Service Quality Elements QI.1 QI.4 Assessment J: Out put Indicators for Quality Out put Indicators QJ.1 QJ. Assessment Sub Total Total Over all Score Facility Grade: (Grade A = 76% and above score; B = 51% 75% score; Signatures of MO I/C________________________________

C = 26% 50% score;

D = Up to 25% score)

Signatures of QA Team Leader ___________________________

85

Form 1 B CHC / PHC Quality Assessment Results (DUPLICATE COPY FOR MO-IC) Findings, Interpretation and Areas of Improvement - Action Plan Name of Facility------------------------------------------District----------------------------State------------------------------Date-----------------------------Action Needed at: Sub Element Due Date by S. Element Problems Solution when action CHC / PHC District State No. will be taken Level Level Level A. Providers Availability Person responsible for action Primary responsibility Secondary responsibility

2 General Facility Readiness

B. Infrastructure C. Essential protocols and job aids D. Infection Prevention Practices E. Availability of Equipment and supplies FP Supplies F: Family Planning

FP Records

FP Counselling Cont

86

Form 1 B CHC / PHC Quality Assessment Results (Cont) (DUPLICATE COPY FOR MO-IC) Findings, Interpretation and Areas of Improvement - Action Plan Name of Facility------------------------------------------District----------------------------State------------------------------Date-----------------------------Action Needed at: Person responsible Sub Element Due Date by for action Primary Element Problems Solution when action responsibility CHC / PHC District State will be taken Secondary Level Level Level responsibility Screening of ANC Clients ANC Counselling Labour and Delivery Records New Born Care Immunization Service Delivery Vaccine Logistics and Supplies Cold Chain Management Service Quality Elements H: Child Health I: Miscellaneous Service Quality Elements J: Out put indicators for service quality

S. No.

10 11 12 13 14 15

16

17

G: Maternal Health

Out put Indicators

Signatures of MO I/C________________________________

Signatures

of

QA

Team

Leader

___________________________

87

FORM 2: SUBCENTER QUALITY ASSESSMENT CHECKLIST

QUALITY ASSURANCE GROUP VISIT

IDENTIFICATION State: ------------------------------- District: ____________ Taluka/Tehsil: __________________ Block: ____________ CHC/PHC to which Subcenter is attached _____________________ Distance (Kms.) from: PHC________ Name & Address of Subcenter: Nearest FRU_____________

____________________________________________________________________________
Subcenter Staff Name Designation 1 ______________________________ __________ 2 ______________________________ 3 ______________________________ 4 ______________________________ __________ __________ __________

DQAG Members Name Designation 1. ____________________________ ____________ 2. ____________________________ 3. ____________________________ 4. ____________________________ ____________ ____________ ____________

Date when last supervisory visit was made by DHO/CS/ADHO/THO/MOIC/LHV to review QA actions plan or to provide facilitative supervision on QA: ___________________________ Time assessment started: _________ Time assessment ended: ___________

Date of Assessment: __________

Signature of Team Leader DQAG

88

FORM 2- A. GENERAL FACILITY READINESS Sub-elements Q. Instructions: Walk around the subcenter area and OBSERVE No. the following Location and Condition QA.1 Location of the subcenter

Response Score 3 At the heart of village Owned In SC 1 At village peripheries Rented In Village 0 Outside village peripheries Outside village No = 0 No = 0 No = 0 No = 0

QA.2 QA.3 QA.4

Ownership of building ANM residing Condition of building a. Whitewash b. Seepage No windows/doors broken Solid waste containers available Sub-elements Instructions: Walk around the subcenter area and OBSERVE the following Essential Amenities for Clients Comfort Subcenter has lighting arrangement (a) Running electricity connection (b) power back-up in the form of functional Petromax/ lantern/torch Benches for sitting available and placed in shaded place Toilet with functional water arrangement Drinking water for clients available Curtain on windows to ensure privacy Information and Communication A Signboard/wall-painting exhibiting (a) Available services in the subcenter (b) Days and timing of services Information on Janani Suraksha Yojna (JSY) displayed Score Obtained =

QA.5 QA.6 Q. No.

Yes = 1 Yes = 1 Yes = 1 Yes = 2

YES

Response Score NO

QA.7

1 1 2 1 1 1

0 0 0 0 0 0

QA.8 QA.9 QA.10 QA.11 QA.12

QA.13

1 1 1

0 0 0

FORM 2- B. ESSENTIAL PROTOCOLS AND JOB AIDS Sub-elements Q. Instructions: ASK the ANM to show you the guidelines/protocols/job No. aids. QB.1 IUD insertion/removal guidelines available QB.2 IUD cards or register available and filled for follow up QB.3 Normal delivery /SBA guidelines available QB.4 Village Health and Nutrition Day (VHND) guidelines available Score Obtained = FORM 2- C. INFECTION PREVENTION PRACTICES Sub-elements Q. Instructions: OBSERVE the providers practicing following infection No. prevention methods QC.1 Needle cutter/puncture proof box available and used for disposing used syringes QC.2 Waste disposed off as per guidelines Score Obtained =

Response Score YES 1 1 1 1 NO 0 0 0 0

Response Score YES NO 3 3 0 0

89

FORM 2- D. AVAILABILITY OF EQUIPMENT AND SUPPLIES Q. No. QD.1 QD.2 Sub-elements Instructions: PHYSICALLY VERIFY the availability/ functionality BP Apparatus and stethoscope in working order Equipments available and functioning (a) Baby weighing scale (b) Baby Ambu bag (c) Delees mucus sucker available Delivery kit with scissors/blade, cord ties/clamps Sufficient number of sterilized/HLD syringes available Infection prevention supplies available (a) Soap (b) Gloves and mask (c) Plastic buckets and mugs (d) Working boiler or stove with K-oil available Labour table, Step stool, mattress, mackintosh and Kellys pad available Copies of partograph for progress of labour available and being filled Supplies Condoms at least 50 pieces OCP at least 5 cycles IUDs At least 5 packets available ECP at least 5 packets IFA Tablets - at least for 10 clients TT injections - at least 10 injections Tab. Misoprostol At least for 10 clients ORS packets - at least 20 packets For Disinfections: Small packets of bleach powder/concentrated hypo chlorite solutions available Povidone Iodine/Alcohol/spirit available Score Obtained = Response Score YES NO 1 1 1 1 2 1 1 1 1 1 3 3 2 2 2 2 1 1 2 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

QD.3 QD.4 QD.5

QD.6 QD.7 QD.8 QD.9 QD.10 QD.11 QD.12 QD.13 QD.14 QD.15 QD.16 QD.17

FORM 2- E: Family Planning Quality Assessment Q. No. Sub-elements Providers Knowledge: ASK the ANM to ascertain her knowledge about contraceptive methods Whether ANM has correct IUD Knowledge Does the ANM know (a) About longevity of an IUD? (b) About No-touch and withdrawal technique of insertion of IUD? (b) About removal technique? (c) About side effects/warning signs? Whether ANM has correct OCP Knowledge (a) What would the ANM suggest the women if she has missed the OCPs for 2 days? (b) From which month a breastfeeding mother can take OCP? Whether ANM has correct ECP knowledge What is the maximum time limit after unprotected sex for starting ECPs? Response Score YES NO

QE.1

1 1 1 1

0 0 0 0

QE.2

1 1 1

0 0 0

QE.3

Q. No.

Sub-elements FP Records: PHYSICALLY VERIFY; Ask the providers to show you the register/records FW records show OCP usage and new acceptance in last three months

Response Score YES NO

QE.4

90

QE.5

FW records show (a) IUDs inserted during last 3 months (b) IUDs removed (needs reasons for removal) (c) Sterilization cases followed up FP Counselling: Observation: During visit if any FP client is there, OBSERVE Informed the client about different FP methods Client counselled on how the methods work and how to use it Client counselled on side effects and how to manage them and complications Score Obtained = 1 1 1 0 0 0

QE.6 QE.7 QE.8

2 2 2

0 0 0

FORM 2-F: Maternal Health Quality Assessment Q. No. Sub-elements Screening of ANC clients: During QA visit, if you find new ANC cases in the Subcenter then OBSERVE at least one ANC client for screening. Take clients consent before observing the session. Detection of pregnancy and screening (Physical, per abdomen, foetal assessment by history and calculation of due date Screened for signs of anaemia (pallor on tongue, conjunctiva, nails) and measurement of Blood Pressure and weight Tests for Hb and Urine for albumin done ANC Counselling: During QA visit, if you find a new ANC case in the Subcenter then OBSERVE for QF.4 and QF.5. Take clients consent before observing the counselling session. If you do not get an ANC client, Ask ANM about QF.6 to QF.8 Counselling of ANC women on nutrition, birth preparedness and warning signs ANC women encouraged for institutional deliveries What ANM will tell to client to recognize complications during antenatal period? Does ANM know when a client should come for ANC/PNC checkups? Does the ANM know of how a woman can recognize onset of delivery and signs of labour? Records: CHECK last 3 months records to ascertain that these services are being regularly provided. Last 3 months records show women with labour are managed in the facility Last three month records show women with obstetric complications identified and timely referred Last three months records show that newborns for birth weight less than 2 Kgs. referred to higher centers Newborn and Child Care: ASK the ANM about Newborn care The ANM knows about the components of essential newborn care Do ANM know about the Kangaroo Care for maintenance of temperature of hypothermic newborn Tab. Cotrimoxazole available and being used for managing Respiratory Tract Infections in children ORS packets being used for managing diarrhoeal diseases in children Score Obtained = Response Score YES NO

QF.1 QF.2 QF.3

3 3 3

0 0 0

QF.4 QF.5 QF.6 QF.7 QF.8

2 2 2 2 2

0 0 0 0 0

QF.9 QF.10 QF.11

2 2 2

0 0 0

QF.12 QF.13 QF.14 QF.15

2 2 2 2

0 0 0 0

91

FORM 2- G: CHILD HEALTH/IMMUNIZATION QUALITY ASSESSMENT Sub-elements Q. No. Immunization Service Delivery: (Visit on Immunization day) For Micro Plan CHECK previous months record. For QG.2 to QG.7OBSERVE the immunization session MICRO PLAN - Whether immunization sessions conducted as planned Measles vaccine is being administered between 9-12 months of age Sterile needle not touched by hand or swab during injection process Needle cutter/puncture proof box used for disposing used syringes Vaccine carrier kept closed during immunization session Post-immunization counselling regarding side-effects and follow-up visits Immunization card or register updated/completed for each child after administering the vaccine Vaccination Supplies and Cold Chain Management: Please PHYSICALLY VERIFY the vaccine carrier. Conduct spot shake test for frozen vaccines Availability of supplies in subcenter a. No Stock out of A.D. syringes b. No vaccines without labels No vaccines beyond expiry date in the vaccine carrier No frozen T series vaccine in the vaccine carrier Community mobilization: ASK the ANM / HW (F) about participation of Anganwadi workers and ASHA. CHECK records to ascertain that drop out cases were traced and vaccine provided. Anganwadi workers participated in Village Health and Nutrition Day (VHND) ASHA participated in Village Health and Nutrition Day (VHND) Drop out cases were traced and vaccines provided Score Obtained = 2- H: MISCELLANEOUS SERVICES QUALITY ASSESSMENT Sub-elements

Response Score YES NO

QG.1 QG.2 QG.3 QG.4 QG.5 QG.6 QG.7

1 3 3 3 1 3 3

0 0 0 0 0 0 0

QG.8

QG.9 QG.10

1 1 3 3

0 0 0 0

QG.11 QG.12 QG.13 FORM Q. No. QH.1

1 1 1

0 0 0

Last three months records show RTI/STI cases referred for tests/management. 1 QH.2 Untied Funds available and utilized Score Obtained = FORM 2- I: OUTPUT INDICATORS FOR QUALITY ASSESSMENT QI Review records and calculate the Usage over Usage and change when No. following to assess any change last three compared to same time period (3 in utilization of services from months months) in the last year Subcenters Number of Number Change Percent clients (A) of in no. of change clients clients (A-B) (B) (A-B) /A*100 QI.1 Total number of ANC women registered in last 3 months QI.2 Total number of deliveries at this facility. QI.3 Total number of IUD acceptors in last three months QI.4 Total number of RTI/STI cases referred in past 3 months QI.5 Total number of low birth weight babies referred to higher facility in past three months QI.6 Total number of children received measles vaccine Score obtained

Response Score YES NO 1 0 0

Scores for % Change +1-10 1 +11-25 2 +25 3 No or negative change 0

92

Form 2A: -Subcenter Quality Assessment Results Summary of Major Assessment Findings at Facility Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------I Assessment Component Indicators Total Response Remarks points Score A. Facility Readiness: Location, Condition QA.1 QA.13 Essential amenities B. Essential protocols QB.1 QB-4 and job aids C. Infection QC.1 QC.2 Prevention Practices D. Availability of Equipment and QD.1 QD.15 supplies Sub Total Providers Knowledge QE.1 QE.3 E: Family Planning Quality FP Records QE.4 QE.5 Assessment FP Counselling QE.6 QE.8 Sub Total Screening of ANC Clients QF.1 QF.3 QF.4 QF.8 ANC Counselling F: Maternal Health Quality Assessment QF.9 QF.11 Records New Born and child Care QF.12 QF.15 Sub Total Immunization Services QG.1 QG.7 G: Child Vaccine Logistics & Supplies QG.8 QG.10 Health/Immunization Quality Assessment Cold Chain Management QG.11 QG.13 H: Miscellaneous service quality elements I: Out put indicators for quality assessment Service quality elements Out put indicators Sub Total Total Over all Score Facility Grade: (Grade A = 76% and above score; B = 51% 75% score; Signatures of ANM/ MO I/C____________________________ C = 26% 50% score; D = Up to 25% score) Signatures of QA Team Leader _________________________ QH.1 QH.2 QI.1 QI.6

II Assessment Response Remarks Score

A. General Facility Readiness

93

Form 2B: Subcenter Quality Assessment Results Findings, Interpretation and Areas of Improvement -Action Plan Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Action Needed at: Due Date by when Sub CHC/ Dist. State S. Ele Sub Element Center PHC Level Level action Problems Solution No. men will be Level Level t taken A. Facility Readiness B. Essential protocols and job aids C. Infection Prevention Practices D. Availability of Equipment and supplies Providers Knowledge

Persons responsible for the action Primary Responsibility Secondary Responsibility

1 General Facility Readiness E: Family Planning

FP Records

FP Counselling Cont

94

Form 2B: Subcenter Quality Assessment Results (Cont) (DUPLICATE COPY FOR ANM/MO-IC) Findings, Interpretation and Areas of Improvement -Action Plan Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Action Needed at: Sub CHC/ Dist. State S. Eleme Sub Element Center PHC Level Level Problems Solution No. nt Level Level

Due Date by when action will be taken

Persons responsible for the action Primary Responsibility Secondary Responsibility

10 11 12

F: Maternal Health G: Child Health /Immunization

Screening of ANC Clients ANC Counselling Records New Born Care Immunization Service Delivery Vaccine Logistics and Supplies Cold Chain Management

13 14 15

16

Miscellaneous service quality assessment Out put indicators for quality assessment

Signatures of ANM/ MO I/C____________________________

Signatures of QA Team Leader _________________________

Form 2A-Subcenter Quality Assessment Results

95

Summary of Major Assessment Findings at Facility Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------I Assessment Component Indicators Total Response Remarks points Score A. Facility Readiness: Location, Condition QA.1 QA.13 Essential amenities B. Essential protocols and job aids C. Infection Prevention Practices D. Availability of Equipment and supplies QB.1 QB-4 QC.1 QC.2 QD.1 QD.15 QE.1 QE.3 QE.4 QE.5 QE.6 QE.8 QF.1 QF.3 QF.4 QF.8 QF.9 QF.11 QF.12 QF.15 QG.1 QG.7 QG.8 QG.10 QG.11 QG.13 QH.1 QH.2 QI.1 QI.6

II Assessment Response Remarks Score

A. General Facility Readiness

Sub Total Providers Knowledge E: Family Planning Quality FP Records Assessment FP Counselling Sub Total Screening of ANC Clients ANC Counselling F: Maternal Health Quality Assessment Records New Born and child Care Sub Total Immunization Services G: Child Vaccine Logistics & Supplies Health/Immunization Quality Assessment Cold Chain Management H: Miscellaneous service quality elements I: Out put indicators for quality assessment Service quality elements Out put indicators Sub Total Total Over all Score

Facility Grade: (Grade A = 76% and above score; B = 51% 75% score; Signatures of ANM/ MO I/C____________________________

C = 26% 50% score; D = Up to 25% score) Signatures of QA Team Leader _________________________

96

Form 2B Subcenter Quality Assessment Results (DUPLICATE COPY FOR ANM/MO-IC) Findings, Interpretation and Areas of Improvement -Action Plan Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Action Needed at: Due Date by when Sub CHC/ Dist. State S. Ele Sub Element Center PHC Level Level action Problems Solution No. men will be Level Level t taken A. Facility Readiness B. Essential protocols and job aids C. Infection Prevention Practices D. Availability of Equipment and supplies Providers Knowledge

Persons responsible for the action Primary Responsibility Secondary Responsibility

1 General Facility Readiness E: Family Planning

FP Records

FP Counselling Cont

97

Form 2B Subcenter Quality Assessment Results (Cont) (DUPLICATE COPY FOR ANM/MO-IC) Findings, Interpretation and Areas of Improvement -Action Plan Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Action Needed at: Sub CHC/ Dist. State S. Eleme Sub Element Center PHC Level Level Problems Solution No. nt Level Level

Due Date by when action will be taken

Persons responsible for the action Primary Responsibility Secondary Responsibility

10 11 12

F: Maternal Health G: Child Health /Immunization

Screening of ANC Clients ANC Counselling Records New Born Care Immunization Service Delivery Vaccine Logistics and Supplies Cold Chain Management

13 14 15

16

Miscellaneous service quality assessment Out put indicators for quality assessment

Signatures of ANM/ MO I/C____________________________

Signatures of QA Team Leader _________________________

98

QUALITY ASSURANCE GROUP VISIT FORM 3: RCH/STERILIZATION CAMP QUALITY ASSESSMENT CHECKLIST

IDENTIFICATION State: ------------------------------- District: ____________Taluka/Tehsil: ___________________

Type of camp: 1. Sterilization Camp

2. RCH Camp

Venue of RCH/Sterilization Camp: Block: ____________ Type of Facility: PHC ____________ CHC__________ Other (specify) ____________

Distance (Kms.) from District Headquarters________________________________________ Name & Address of Facility_____________________________________________________

CHC/PHC Staff / Surgical Team members respondents

Name 1 ______________________________ 2 ______________________________ 3 ______________________________ 4 ______________________________

Designation __________ __________ __________ __________

DQAG Members Name 1. ____________________________ 2. ____________________________ 3. ____________________________ 4. ____________________________ Designation ____________ ____________ ____________ ____________

Date when last supervisory visit was made by DHO/CS/ADHO/THO to review QA actions plan or to provide facilitative supervision on QA: ___________________________ Time started assessment:____________ Time ended assessment: ___________ Date of Assessment: __________________

Signature of Team Leader DQAG

99

A. PROVIDERS AVAILABILITY Q. No. QA.1 QA.2 QA.3 QA.4 Sub-elements Instructions: On day of visit ask MO I/C and identified staff and fill the Personnel Assessment section Empanelled surgeon available for sterilization operations Availability of trained provider in RTI/STI management Anaesthetist/any other provider trained in cardio-pulmonary resuscitation available Surgical team (empanelled surgeon, OT nurse and OT attendant for female sterilization) reached camp site as per scheduled time Score Obtained = Response Score YES 3 3 3 2 NO 0 0 0 0

B. INFRASTRUCTURE Q. No. Sub-elements Instructions: Walk around the camp area and check the following ESSENTIAL ARRANGEMENTS FOR THE CAMP Specified counters/rooms for: Site staff duties assigned and communicated Registration/reception Separate counselling area Pre-operative preparation area OT prepared for the procedures Alternate electricity supply source for electricity available during camp hours and connected to OT Availability of water (through tap or bucket with tap) in procedure rooms Functional vehicle with driver and POL available for emergency referral ESSENTIAL AMENITIES fOR CLIENTS COMFORT Drinking water available for clients Recovery area with mattresses, blankets and clean bed cover Functional toilets for clients with water INFORMATION AND COMMUNICATION SERVICES AT FACILITY IEC material/job aids available for FP counselling ONLY FOR RCH CAMPS: IEC material/job aids available for MCH counselling IEC material/job aids available for RTI/STI counselling Information about services in camp displayed Information about next camp date displayed Score Obtained = Response Score YES NO

QB.1 QB.2 QB.3 QB.4 QB.5 QB.6 QB.7 QB.8

2 1 1 1 2 3 2 3

0 0 0 0 0 0 0 0

QB.9 QB.10 QB.11 QB.12 QB.13 QB.14 QB.15 QB.16

1 1 1 1 1 1 1 1

0 0 0 0 0 0 0 0

C. ESSENTIAL FORMATS Q. No. QC.1 Sub-elements Instructions: Ask the providers to show you the forms. Camp service record register available and being filled for: a. Sterilization b. Other FP services c. RTI/STI services d. FOR RCH CAMP ONLY: Maternal Health e. FOR RCH CAMP ONLY: Child health Last 3 months camp records show compensation money paid to sterilization clients Score Obtained = Response Score YES 1 1 1 1 1 1 NO 0 0 0 0 0 0

QC.2

100

D. INFECTION PREVENTION AND SURGICAL PRACTICES Sub-elements Q. No. Instructions: Observe the providers practicing following infection prevention methods QD.1 Surgical team does surgical scrub and alcohol scrub as per guidelines QD.2 Laparoscope is decontaminated with alcohol swab after each procedure and cleaned QD.3 Laparoscope is high level disinfected between procedures for 20 minutes in glutaraldehyde solution or 10 minutes with paracetic acid and washed/cleaned with HLD (boiled for 20 mins.) water QD.4 Sterilized surgical cut sheet used for each client QD.5 Gloves being changed by service provider in between procedures QD.6 Waste disposed as per guidelines QD.7 OT table and floor wiped with 0.5% chlorine solution in between procedure Score Obtained = E. AVAILABILITY OF EQUIPMENT AND SUPPLIES Sub-elements Q. No. Instructions: Go to respective rooms/lab and physically verify the availability/ functionality QE.1 BP apparatus and stethoscopes in working order QE.2 Weighing scales in working order (a) Adult (b) FOR RCH CAMP ONLY: Infant Autoclave and boiler in working order and being used (check log book) QE.3 QE.4 Suction Machines in working order QE.5 Adult Ambu Bag in working order QE.6 Oxygen cylinder with tubing, wrench and disposable masks in working order. QE.7 Sufficient number of sterilized syringes and needles with needle cutter/puncture proof boxes for disposing sharps QE.8 Insufflator available in working order for pneumo-peritoneum (ONLY FOR LAP) QE.9 A minimum of three laparoscopes available ( if laparoscopic sterilization services offered) QE.10 At least 5 NSV sets available ( if NSV services offered) QE.11 At least 5 sets of AT/ML sets available( if AT/ML services offered) QE.12 At least one set for laparotomy available (if female sterilization services offered QE.13 At least three IUD insertion/removal sets available QE.14 Anaesthesia equipment set available (if female sterilization services offered Lab equipments and supplies QE.15 Sahlis Haemoglobinometer in working condition to be used for measuring Hb with fresh N/10 HCL solution QE.16 Gram staining (crystal violet, iodine solution, acetone-ethanol and safranin stain) available QE.17 Urine albumin (Acetic acid and lamp for heat test or uristix) available QE.18 Sugar uristix or Benedict's solution and lamp for heat test available Essential Drugs and Consumables: Do not stock check. Please check the availability for at least 40 clients. QE.19 Post-operative medicines for 40 sterilization clients QE.20 Emergency drugs as per the standard list QE.21 Medicines for RTI/STI Score Obtained =

Response Score YES 3 3 3 NO 0 0 0

1 1 1 1

0 0 0 0

Response Score YES 1 1 1 2 2 2 2 1 2 2 1 1 1 1 NO 0 0 0 0 0 0 0 0 0 0 0 0 0 0

2 2 1 1

0 0 0 0

1 1

0 0

101

FORM 3- F: FAMILY PLANNING QUALITY ASSESSMENT Sub-elements Q. No. Instructions: Confirm by observing/seeing the relevant documents QF.1 Standard guidelines used for pre-operative clinical screening for all sterilization clients (a) Medical eligibility ensured (b) Laboratory examination for Hb, sugar, albumin done (c) Informed consent taken (d) Case record written (e) medical record checklist filled QF.2 Pneumo-peritoneum (using air) done as per guidelines QF.3 Client monitored during operation process QF.4 Tubectomy clients transported to recovery area on a trolley/stretcher QF.5 IUD inserted by no touch and with-drawl technique QF.6 Clients counselled about FP methods FP Methods Supply QF.7 OCP at least 20 cycles available QF.8 IUDs At least 20 packets available QF.9 ECP at least 20 packets available QF.10 Condom at least 1200 packets available Score Obtained =

Response Score YES 2 2 2 2 2 2 1 1 1 2 2 2 2 2 NO 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FORM 3- G: MATERNAL HEALTH QUALITY ASSESSMENT (APPLICABLE ONLY IN RCH CAMPS) Response Score Sub-elements Q. No. YES NO Screening of ANC clients: Observe at least one ANC client for screening. Take clients permission and consent before observing 3 0 QG.1 Detection of pregnancy and screening (Physical, per abdomen, foetal assessment by history and calculation of due date) 3 0 QG.2 Screened for signs of anaemia (pallor on tongue, conjunctiva, nails) and measurement of Blood Pressure and weight 3 0 QG.3 Lab tests for Hb, Urine for albumin and sugar done ANC Counselling: Observe at least one ANC client for counselling. Take clients consent before observing the counselling 2 0 QG.4 Counselling of ANC women on nutrition and rest 2 0 QG.5 Counselling on the recognition of danger signs during pregnancy and actions to be taken 2 0 QG.6 Counselling on breastfeeding and Lactational Amenorrhea Method (LAM) Score Obtained = FORM 3- H: CHILD HEALTH/IMMUNIZATION QUALITY ASSESSMENT (APPLICABLE ONLY FOR RCH CAMP) Response Score Sub-elements Q. No. YES NO Immunization Service Delivery: Observe the immunization session 1 0 QH.1 Immunization sessions conducted at the RCH camp 3 0 QH.2 Sterile needle not touched by hand or swab during injection process 3 0 QH.3 Needle cutters/puncture proof boxes used for disposing used syringes 3 0 QH.4 Post-immunization counselling regarding side-effects, how to manage them and follow-up visits 3 0 QH.5 Immunization card updated/completed for each child after vaccination Vaccine Supplies and Cold Chain Management: Please physically verify vaccine carrier. Check availability for at least 20 clients. Conduct spot shake test for frozen vaccines 1 0 QH.6 Measles vaccine 1 0 QH.7 A.D. syringes at least 20 1 0 QH.8 No frozen T series vaccine in the carrier Score Obtained =

102

Form 3A - RCH Camp Quality Assessment Results Summary of Major Assessment Findings at Facility Name of Facility--------------------------------District----------------------------------------State------------------------------Date----------------------------I Assessment II Assessment Total Component Indicators Response Response points Remarks Remarks Score Score A. Providers QA.1 QA.4 Availability B. Infrastructure : Arrangements, Essential QB.1 QB.16 amenities, IEC Services C. Essential QC.1 QC-2 Formats D. Infection Prevention QD.1 QD.7 Practices E. Availability of Equipment and QE.1 QE.21 supplies Sub Total FP Procedures QF.1 QF.6 F: Family Planning Quality Assessment FP Supplies QF.7 QF.10 Sub Total Screening of ANC Clients QG.1 QG.3 G: Maternal Health ANC Counselling QG.4 QG.6 Sub Total Immunization Service Delivery QH.1 QH.5 H: Child Health/Immunization Vaccine Supplies and cold QH.6 QH.8 Quality Assessment chain management General Facility Readiness Sub Total Total Over all Score CAMP Grade: (Grade A = 76% and above score; B = 51% 75% score; C = 26% 50% score; D = Up to 25% score)

Signatures of Camp In-charge________________________

Signatures of QA Team Leader _______________________

103

Form 3B - RCH Camp Quality Assessment Results Findings, Interpretation and Areas of Improvement -Action Plan Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Due Action Needed at: Sub Element Date by S. Elemen when CHC / Problems Solution District State No. t action PHC Level Level will be Level taken 1 A. Providers Availability

Persons responsible for the action Primary Responsibility Secondary Responsibility

2 General Facility Readiness F: Family Planning Quality Assessment

B. Infrastructure

C. Essential Formats D. Infection Prevention Practices E. Availability of Equipment and supplies FP Procedures

FP Supplies Cont

104

Form 3B - RCH Camp Quality Assessment Results (Cont) Findings, Interpretation and Areas of Improvement -Action Plan

Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Action Needed at: Sub Element S. Element CHC / Problems Solution District State No. PHC Level Level Level

Due Date by when action will be taken

Persons responsible for the action Primary Responsibility Secondary Responsibility

G: Maternal Health

Screening of ANC Clients

ANC Counselling

H: Child Health/ Immunization Quality Assessment

10

Immunization Service Delivery

13

Vaccine Supplies and cold chain management

Signatures of Camp In-charge________________________

Signatures of QA Team Leader ______________________

105

Form 3A - RCH Camp Quality Assessment Results (DUPLICATE COPY FOR MO-IC) Summary of Major Assessment Findings at Facility Name of Facility--------------------------------District----------------------------------------State------------------------------Date----------------------------I Assessment Total Component Indicators Response points Remarks Score A. Providers QA.1 QA.4 Availability B. Infrastructure : Arrangements, Essential QB.1 QB.16 amenities, IEC Services C. Essential QC.1 QC-2 Formats D. Infection Prevention QD.1 QD.7 Practices E. Availability of Equipment and QE.1 QE.21 supplies Sub Total FP Procedures QF.1 QF.6 F: Family Planning Quality Assessment FP Supplies QF.7 QF.10 Sub Total Screening of ANC Clients QG.1 QG.3 G: Maternal Health ANC Counselling QG.4 QG.6 Sub Total Immunization Service Delivery QH.1 QH.5 H: Child Health/Immunization Vaccine Supplies and cold QH.6 QH.8 Quality Assessment chain management General Facility Readiness Sub Total Total Over all Score CAMP Grade: (Grade A = 76% and above score; B = 51% 75% score; C = 26% 50% score; D = Up to 25% score) II Assessment Response Remarks Score

Signatures of Camp In-charge________________________

Signatures of QA Team Leader _______________________

106

Form 3B - RCH Camp Quality Assessment Results (DUPLICATE COPY FOR MO-IC) Findings, Interpretation and Areas of Improvement -Action Plan Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Due Action Needed at: Sub Element Date by S. Elemen when CHC / Problems Solution District State No. t action PHC Level Level will be Level taken 1 A. Providers Availability

Persons responsible for the action Primary Responsibility Secondary Responsibility

2 General Facility Readiness F: Family Planning Quality Assessment

B. Infrastructure

C. Essential Formats D. Infection Prevention Practices E. Availability of Equipment and supplies F P Procedures

FP Supplies Cont

107

Form 3B - RCH Camp Quality Assessment Results (Cont) (DUPLICATE COPY FOR ANM/MO-IC) Findings, Interpretation and Areas of Improvement -Action Plan

Name of Facility---------------------------------------------------District-----------------------------------------------State------------------------------Action Needed at: Sub Element S. Element CHC / Problems Solution District State No. PHC Level Level Level

Due Date by when action will be taken

Persons responsible for the action Primary Responsibility Secondary Responsibility

G: Maternal Health

Screening of ANC Clients

ANC Counselling

H: Child Health/ Immunization Quality Assessment

10

Immunization Service Delivery

13

Vaccine Supplies and cold chain management

Signatures of Camp In-charge________________________

Signatures of QA Team Leader ______________________

108

FORM 1C: Monthly QA Summary Report of CHCs/PHCs Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of CHC/PHCs visited ____________ Actions to be Taken at CHC/PHC LEVEL Section A: Providers Availability Recommended for ALL CHC/PHCs Section B: Infrastructure Section C: Protocols and job aids Section D: Infection Prevention Practices Section E: Equipment & supplies Section F: Availability of Family Planning Services Section G: Section H: Maternal Health Newborn Care & screening and immunization counselling

Recommended for facility (specify) 1. ______________

2.______________

3. ______________

4. ______________

5. ______________

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

109

FORM 1D: Monthly QA Summary Report of CHCs/PHCs Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of CHC/PHCs visited ____________ Actions to be Taken at DISTRICT LEVEL Section A: Providers Availability Recommended for ALL CHC/PHCs Section B: Infrastructure Section C: Protocols and job aids Section D: Infection Prevention Practices Section E: Equipment & supplies Section F: Availability of Family Planning Services Section G: Section H: Maternal Health Newborn Care & screening and immunization counselling

Recommended for facility (specify) 1. ______________

2.______________

3. ______________

4. ______________

5. ______________

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

110

FORM 1E: Monthly QA Summary Report of CHCs/PHCs Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of CHC/PHCs visited ____________ Actions to be Taken at STATE LEVEL Section A: Providers Availability Recommended for ALL CHC/PHCs Section B: Infrastructure Section C: Protocols and job aids Section D: Infection Prevention Practices Section E: Equipment & supplies Section F: Availability of Family Planning Services Section G: Section H: Maternal Health Newborn Care & screening and immunization counselling

Recommended for facility (specify) 1. ______________

2.______________

3. ______________

4. ______________

5. ______________

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

111

FORM 2C: Monthly QA Summary Report of SUBCENTERS Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of Subcenters visited ____________ Actions to be Taken at SUBCENTER/PHC LEVELS Section A: Facility Readiness Recommended for ALL Subcenters Section B: Protocols and job aids Section C: Infection Prevention Practices Section D: Equipment & supplies Section E: Availability of Family Planning Services Section F: Maternal Health screening and counselling Section G: Newborn Care & immunization

Recommended for Subcenter (specify) 1. ______________

2.______________

3. ______________

4. ______________

5. ______________

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

112

FORM 2D: Monthly QA Summary Report of SUBCENTERS Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of Subcenters visited ____________ Actions to be Taken at DISTRICT LEVEL Section A: Facility Readiness Recommended for ALL Subcenters Section B: Protocols and job aids Section C: Infection Prevention Practices Section D: Equipment & supplies Section E: Availability of Family Planning Services Section F: Maternal Health screening and counselling Section G: Newborn Care & immunization

Recommended for Subcenter (specify) 1. ______________

2.______________

3. ______________

4. ______________

5. ______________

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

113

FORM 2E: Monthly QA Summary Report of SUBCENTERS Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of Subcenters visited ____________ Actions to be Taken at STATE LEVEL Section A: Facility Readiness Recommended for ALL Subcenters Section B: Protocols and job aids Section C: Infection Prevention Practices Section D: Equipment & supplies Section E: Availability of Family Planning Services Section F: Maternal Health screening and counselling Section G: Newborn Care & immunization

Recommended for Subcenter (specify) 1. ______________

2.______________

3. ______________

4. ______________

5. ______________

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

114

FORM 3C: Monthly QA Summary Report of RCH CAMPS Prepared by Member Secretary Based on ALL Visits Made in the Month of ____________ Year______ Number of RCH Camps visited ____________ ACTION TO BE TAKEN Section A: Providers Availability Section C: Essential Forms and Cards Section D: Infection Prevention Practices Section E: Equipment & supplies Section F: Availability of Family Planning Services Section G: Section H: Maternal Health Newborn Care & screening and immunization counselling

Section B: Infrastructure

Recommended for All RCH Camps in the District

(F / D / S level) (F / D / S level) Recommended for individual facility organizing RCH Camp 1. ______________ (F / D / S level) (F / D / S level)

(F / D / S level)

(F / D / S level) (F / D / S level)

(F / D / S level)

(F / D / S level)

(F / D / S level)

(F / D / S level)

(F / D / S level) (F / D / S level)

(F / D / S level)

(F / D / S level)

(F / D / S level)

2. ______________

(F / D / S level) (F / D / S level)

(F / D / S level)

(F / D / S level) (F / D / S level)

(F / D / S level)

(F / D / S level)

(F / D / S level)

Signatures of QAG Member Secretary _______________________

Signatures of CDHO __________________________

ANY OTHER COMMENTS: ___________________________________________________________________________________________________ _________________________________________________________________________________________

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FORM 4: CLIENT SATISFACTION WITH SERVICES

Name of Facility:________________ Sex: Male / Female CHC/PHC/SC/Camp____________ Date:___________

Dear Client, As the In-charge of this health facility, I want to thank you for giving us the opportunity to serve you. Please help us serve you better by taking a couple of minutes to tell us about the service that you have received today. Your inputs will help the health system to improve the quality of services provided by the facilities. We appreciate your suggestions and want to make sure we meet your expectations when you visit the facility the next time. Please respond to the following questions and drop this sheet in the Suggestions Box kept in the waiting area. You may take the help of any person in the facility or your companion to help you fill the form. Please circle your appropriate response to each question. You do not need to put your name on the form. Sincerely, MS/MO I/C
1. Please write what service you received today ___________________. What do you think about the quality of service you received today? Very good Good OK/Satisfactory Not so good/Poor Very bad 2. What would you say about the waiting time you faced to receive the services? Too much More than other places Normal Less than other places Did not have to wait 3. What would you say about convenience of location of facility for you? Very far Far ReachableNot so far Very close Very Somewhat 4. What do you think about the process of getting poor satisfactory the following services? (a) Registration (b) Consultation with Doctor/ANM (c) Laboratory (d) Pharmacy 5. How satisfied are you with the behaviour of the (a) Doctor? (b) Nurse? (c) ANM? (d) Lab technician? (e) Pharmacist? Very rude Not satisfied

Satisfactory

Good

Very good

Did not avail

Neutral/OK

Somewhat satisfied

Very satisfied

Did not meet

6. What would you say about overall cleanliness of the facility? Very clean Clean OK/Satisfactory Not so clean Dirty 7. How about friendliness and courtesy of the staff? Very good Good OK Not so good Very bad 8. Would you recommend others to receive services from this facility? Definitely May be yes Neutral May be not Definitely Not 9. In your opinion which of the following need improvement at this health facility to provide quality services? (Circle all that you feel needs improvement) Doctor ANM Lab tech. Availability of medicines Cleanliness Laboratory services OT services Other (write)_____________________ 10. Did the provider maintain privacy during consultations and examination/procedure? Yes, completely Yes, to some extent Neutral Not so much No privacy 11. Overall, how satisfied are you with the services you received today? Very satisfied Somewhat satisfied Neutral Somewhat dissatisfied Very dissatisfied

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ANNEXURE 2
AGENDA: QA TRAINING FOR DQAG MEMBERS Venue: Date and Timings: ..

Day 1
Morning Session 1: Session 2: Session 3: Session 4: Afternoon Session 4 Continues Welcome and opening remarks by State Director Overview of the QA programme and QA manual Formation of the District Quality Assurance Group (DQAG) and roles and responsibilities of key persons Briefing on CHC/PHC checklists and scoring procedure LUNCH Briefing on CHC/PHC checklists and scoring procedure

Day 2
Morning Session 5: Session 6: Afternoon Session 7 Briefing on Subcenter checklist and Scoring Procedures Briefing on RCH Camps checklist and Scoring Procedures LUNCH Mock sessions and Practice on the scoring of findings based on mock sessions (Use transparencies of checklists)Briefing on CHC/PHC checklists and scoring procedure

Day 3:
Field practice (Form into three groups and ensure at least one group covers each a CHC, a BPHC/APHC and a Subcenter. If RCH camp is on, then more groups can be formed and accordingly planned

Day 4
Morning Session 8: Review of the forms filled in the field, discussions on any difficulties faced and analysis LUNCH General discussions on how improvements in the quality will be brought about and assessed and wrap-up Valedictory session

Afternoon Session 9 Session 10:

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AGENDA: ORIENTATION WORKSHOP OF STATE / DISTRICT STAKE HOLDERS

Venue... Duration: Half day Date and Timings: . OBJECTIVE: To orient the state /district level stake holders about the QA programme. Session 1: Session 2: Session 3: Welcome and opening remarks by District Magistrate Overview of the QA programme and QA manual (Use session 2 presentation) Formation of the District Quality Assurance Group (DQAG) and roles and responsibilities of key persons (Use session 3 presentation) Discussion and closing remarks

Session 4:

LUNCH / REFRESHMENT

AGENDA: ORIENTATION WORKSHOP OF CHC / PHC IN-CHARGES

Venue:.. Duration: One day Date and Timings: OBJECTIVE: The purpose of this one day orientation workshop is to orient the Medical Superintendents and Medical Officer In-Charges of CHC/PHC about the QA programme. Session 1: Session 2: Welcome and opening remarks by AD / CMO Overview of the QA programme and QA manual (Use session 2 presentation) Session 3: Formation of the District Quality Assurance Group (DQAG) and roles and responsibilities of key persons (Use session 3 presentation) Session 4: Briefing on CHC/PHC/Subcenter/RCH Camp checklists and scoring procedure (Use Session 4 Presentation only and conclude it is similar for other levels) LUNCH / REFRESHMENT Session 4 Continues Session 5: Briefing on CHC/PHC/Subcenter/RCH Camp checklists and scoring procedure (Use Session 4 Presentation only and conclude it is similar for other levels) Discussion and closing remarks

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ANNEXURE 3 PRESENTATIONS

Session 2
Introduction to QA Principles & Operational Manual

Guiding Principles of Developing QA Manual

Simple and easy to comprehend and use Minimum load on programme managersbuilds on existing supervisory functions Flexible to include new elements of services Built on principles of facilitative supervision Developed on the basis of prior piloting experiences in other states and specifically Gujarat where it has been scaled up to cover the entire state Above all, the larger framework of RCH II M&E System has been kept in mind

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Quality of Care & Quality Assurance

Quality of Care Attributes of a service program that reflect adherence to professional standards, in a congenial service environment and satisfaction on the part of user (UNFPA technical report 1999) Quality Assurance Mechanism/process that contribute to defining, designing, assessing, monitoring and improving quality of health care Two Components
Quality Assessment Quality Improvement

Operationalizing QA in a district
QA Approach - Elements of Quality Institutional Arrangements QA Assessment Methodology QA Tools/Checklists

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QA Approach-Elements of Quality
Identifies nine elements for measuring quality of care adapted from UNFPAs technical report entitled Planning Population and Development Projects with a focus on decentralization and quality of care Five are generic elements
Service environment Client provider interaction Informed decision making Integration of services Womans participation Access to services Equipment and supplies Professional standards and technical competence Continuity of care

Four are service specific elements

Elements of Quality-Generic
Service environment infrastructure, basic amenities, clients comfort, privacy etc. Client provider interaction - nature of provider client relationship and information exchanged between them Informed decision-making - availability of relevant information and service procedures that facilitate informed choice by client Integration of services - linkage of services and health institutions Womens participation in management Women participation in planning, implementation and monitoring of RH services

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Elements of Quality-Specific
Access to services Location, distance, timing of facility, affordability in terms of travel cost, lost wages etc. Equipment and supplies - Equipment of standard specifications are available? In working order? Sufficient supplies available? Professional standards and technical competence providers competent? Service guidelines/protocols available? Service standards established? Continuity of care clients follow up regular and effective? Side effects/complications managed? MIS designed and maintained?

RCH Quality Framework for Assessment

RCH facility based Services to be assessed Family Planning INPUTS PROCESS OUTPUTS

Maternity Care

Building Infrastructure Equipment Personneltraining Supplies

RTI/STI & HIV -VCT Child Health

Clinic-wide procedures e.g.Schedules, Hygiene, Asepsis Technical competence Client Provider interaction

FP method mix Complications Follow-up ANC/PNC Norms at Deliveries Complications managed Lab tests Case treatment Follow-up Cold chain maintenance Safe injection practices AD syringe use and disposal

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Thank you

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Session 3
Institutional Arrangements & Roles and Responsibilities of Key Stakeholders

Institutional Arrangements
State Health Mission State QA Nodal Officer District Health Mission

DQAG

CMHO (Chairperson)
DyCMO/ACMHO/ RCHO

Nodal Officer

DQAG Teams

Four members

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Setting up QA Mechanism
Following steps are recommended for setting up DQAG:

The State Health Mission will setup a QA unit within the DPMU DQAG will be a part or extension of DQAC setup for FP services under
Supreme Courts direction

State may nominate few additional members from NGOs, Medical Collages,
state/district officials

The DQAG should consist of six to eight members, of which one member
should be a female

CDHO will be the Chair of DQAG A team of 2-3 members will make a QA visit Each QA team will visit 4 to 5 facilities per month DHS/District health Mission will supervise the QA activities

Key Players in QA Activities

State Health Mission DHS/District Health Mission CDHO the Chair of DQAG Member Secretary of DQAG Team Leader of QA visit Data entry and analysis person Field Agency

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Role of State Health Mission

Setup the QA unit Identify a State Nodal Officer for QA Communicate the decisions taken by state to
DHS/District Health Mission and CDHO

Provide technical/logistical support to

DHS/District Health Mission to conduct QA activities

Monitor the QA activities and report to Ministry

Role of DHS/District Health Mission

Assist in setting up the DQAG, nominating the
members

Supervise all QA activities in the district Provide logistical support to DQAG including
POL, computer, data entry person, space, among others

Report to state nodal person about project

progress

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Role of CDHO
Responsible for all QA activities in the district Organize monthly meeting to discuss gaps and
recommendations for improvements

Decide on actions need to be taken for quality

improvement

Sign memos communicating the decisions Decide on actions to resolve any operational problems Take continuous feedback from DQAG member
secretary

Role of Member Secretary

Prepare a visit schedule for six months state
the name of facilities, date of visit and QA team members conducting the assessment.

Ensure that the MO I/C of the facility has been

informed at least one week before the visit.

Distribute the QA visit plan to all team members Confirm the availability of all members at least
one day before the visit

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Role of Member Secretary (Cont)

Designate a Team Leader for each QA visit Convene meetings of DQAG twice a month Discuss with team leaders and prepare a
summary of actions that need to be taken at
Facility level District and state level

Place the summary report before CDHO to

discuss the actions in monthly meetings

Role of Data Entry Person

Enter visit data within 2 days of QA visit Maintain log of visits to selected facilities Analyze QA and prepare tables/graphs
as requested by member secretary or CDHO

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Role of Field Agency

Assist state/district in setting up DQAG Train the DQAG members Provide technical inputs in terms of
Data processing and analysis Preparation of reports

Ensure adherence of timeline of various QA activities Participate in joint monitoring visits and district review
meetings

Provide independent update and feedback to DQAG

QA Assessment Design
Sampling Frame of a Bi-annual Cycle (District with 1-1.5 million Pop) Estimated number of facilities Sample Coverage

CHC/BPHC (10-12) Sector PHC (35) Sub-center250 RCH Camps-250

CHC/BPHC (10-12) Sector PHC (12) Sub-center24 (approx10% RCH ) Camps-25 (10%)

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QA Assessment Design
Approximately, will result in 4-5 days of field visit by each QA team in a month. This is almost equal to the presently proposed supervisory visits to sub-district facilities

QA visit to CHC/PHC/SC
The following steps are required for planning QA visits:

Each participating facility should be visited bi-annually A bi-annual visit plan will be prepared - stating the name of
facilities, date of visit and QA team members conducting the assessment.

The DHS/District Health Mission would provide the logistical

support including POL for QA visits

The MO I/C of the facility will be informed at least one week before
the visit.

The visit timings should be planned so that facilities routine work

least disturbed

Untied funds available with facilities should be used in bridging the

gaps identified during QA visit

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Role of Team Leader

Visit as per plan Visit at appropriate time ensure least disturbance to routine
work at facility Predefine and divide the assessment work at facility who will complete which section Check for completeness of checklists Prepare with other QA members the output summary (Form 5) Discuss the assessment during debriefing session Discuss with MO I/C (& other staff) the gaps in service quality Discuss with them the actions that need to be taken at different
levels

Get signatures of MO I/C or person in-charge of facility on the

output forms Submit the completed checklists to data entry person

QA Tools/Checklists
Practical: Possible to complete within 3-4 hrs by a team of 2-3 people Specific: Critical to assess functionality of services: Proxy elements Feedback: Could provide it immediately to CHC/PHC MOs/ANM so as to initiate follow-up actions Transparent: Prior awareness of visit & criteria for assessment by QA team Amenable: Improvements and change quantifiable

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Sum up
Methodology has been kept simple As a beginning, few critical elements/subelements of RCH considered In the piloting phase, efforts will be to institutionalize the QA implementation Once the process is established and districts starts doing it on their own, then expansion to include other elements can be taken up

Criteria for district selection

80% HR in-position Well connected within 2 hrs travel time from state head quarters A data entry operator available in the district At least 5 PHCs offering 24 hr services and two FRUs

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Thank you

133

ANNEXURE - 4
SUGGESTED READINGS/REFERENCES
1. Reference for National Level: Quality Assurance Reproductive & Child Health Project (Phase 2, 2004) Results, New Delhi. Ministry of Health & Family Welfare and International Institute for Population Science Mumbai. 2. Reference for National Level: Quality Assurance National Family Health Survey (NFHS-2) 2005-2006. International Institute for Population Science Mumbai and ORC Macro Calverton, Maryland, USA. 3. Reference for Health Care Quality Health Care Quality: An international Perspective. Edited by A.F. Al-Assaf, WHO, Regional Officer for South-East Asia. WHO Regional Publication, SEARO, No. 35, 2001 4. Reference for Quality Improvement CHECKLISTS Lande, R.E. Performance Improvement. Population Reports. Series J, No. 52, Baltimore. The Johns Hopkins Bloomberg School of Public Health, Population Information Programme, Spring 2002. 5. Reference for Quality Improvement Manual District Quality Assurance Programme for Reproductive Health Services: An Operational Manual. Manual developed by FRONTIERS Programme and UNFPA for Department of Health and Family Welfare, Government of Gujarat. May 2006. 6. Reference for Quality Improvement Standards Infection Prevention Curriculum-A training course for health care providers and other staff of hospitals and clinics. EngenderHealth, NY, 1999 7. Reference for Quality Improvement Standards Standards for Female and Male Sterilization Services RSS Division MOHFW, October 2006 8. Reference for Quality Improvement Standards Quality Assurance Manual for Sterilization Services RSS Division MOHFW, October 2006 9. Reference for Quality Improvement Process COPE Hand Book: A Process for Improving Quality in Health Services. EngenderHealth, NY, 2003 10. Reference for Quality Improvement CHECKLISTS Rudy, S., Tabbutt-Henry, J., Schaefer, L. and McQuide, P. Improving Client-Provider Interaction. Population Reports, Series Q, No.1. Baltimore, Johns Hopkins Bloomberg School of Public Health, the INFP Project, Fall 2003. 11. Reference for Quality Improvement CHECKLISTS The Health Sector Reform Research Work Programme. Quality Assurance in Health Care. Number 1. 1999.

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12. Reference for Quality Improvement CHECKLISTS Quality Improvement for Emergency Obstetric Care: Leadership Manual. EngenderHealth and Mailman School of Public Health, Columbia University. 2003. 13. Reference for Quality Improvement CHECKLISTS Miller, Robert, et.al. The Situation Analysis Approach to Assessing Family Planning and Reproductive Health Services: A Handbook. Population Council. 1997. 14. Reference for Quality Improvement CHECKLISTS ACQUIRE facility Survey 2004 baseline Observation of Client Consultation. The ACQUIRE Project, MEASURE Evaluation, and The AMKENI Project. 15 Reference for Quality Improvement CHECKLISTS Mullick, Saiqa, David McCoy, Mags Beksinska, Anne Moys. Evaluating the Quality of Care for Sexually Transmitted Infections using DISCA (District STI Clinic Assessment): A Report from 3 Health Districts. Reproductive Health Research Unit (RHRU) and Initiative for Sub-District Support (ISDS). 16. Reference for Standard Guidelines Reference Manual for Medical Officers in Basic Emergency Obstetric Care. Health & Family Welfare Department, Govt. of Gujarat, India. 2003. 17. Reference for Standard Guidelines Reference National Guidelines on Prevention, Management and Control of Reproductive Tract Infections including Sexually Transmitted Infections, Ministry of Health & Family Welfare and National AIDS Control Organisation, November 2006 18. Reference for Standard Guidelines Guidelines for Medical Officers for Medical termination of Pregnancy up to Eight Weeks Using Manual Vacuum Aspiration Technique. Ministry of Health & Family Welfare, Dept. of Family Welfare, Govt. of India. 2001. 19. Reference for Standard Guidelines Reference IUCD Reference Manual for Medical Officers, Family Planning Division, Ministry of Health & Family Welfare, Government of India, July 2007 20. Standard Operating Procedures for Sterilization Services in Camps Draft RSS Division Ministry of Health & Family Welfare, Government of India, March 2008 21. Reference for Standard Guidelines Reference National Guidelines for Skilled Attendance at Birth and Ante-Natal Care, Maternal Health Division, Ministry of Health & Family Welfare, Government of India, 2005

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