Provide Quality Health Care Service in India & beyond, Only Aim to improve the Quality Health Care Service in India. Dr. J. L. Meena

1. How to achieve NABH “Governance”
Standards in PHCs
Dr J L Meena
State Quality Assurance Officer
Department of Health & Family welfare
Government of Gujarat
Email:- drjlmeena@gmail.com
Web:- www.gujhealth.gov.in/quality-assurance-program.htm
304

2. SECTION – C:
Governance Standards

3. 21. Ownership of Building
Objective Elements
• A building of the facility to be owned by the
government.
• It shall have the approved building plan
along with sanction from the local
authorities.
• The X-ray facility (at CHC) shall be approved
by AERB.

4. A building of the facility to be owned by the
government

5. A building of the facility to be owned by the
government

6. It shall have the approved building plan along with
sanction from the local authorities

7. The X-ray facility (at CHC) shall be approved by AERB.

8. 22. Quality Assurance
Objective Elements
• The facility shall have a quality assurance
manual.
• Standards operating procedures to be available
at various patient care area e.g. OPD,
Pharmacy, Lab., Imaging and Wards.
• The manual shall include infection control and
waste management issues.
• Safety of patients and staff shall have due
consideration in the manual.

9. The facility shall have a quality assurance manual

10. Standards operating procedures to be available at
various patient care area e.g. OPD, Pharmacy,
Lab., Imaging and Wards

11. Standards operating procedures to be available at various patient care
area at Sub centers.
SOPs for Sub Centers
NO. CONTENTS PAGES
Introduction and Brief abut Sub-centers 4
1 Village Health and Nutrition Day 7
2 High risk pregnancy cases Identification and treatment 10
3 Prevention and Treatment in case of Anemia 11
4 Treating 36-38 week pregnancy 12
5 After Delivery care 12
6 High risk Infant care 12
7 Biomedical Waste Management 13
8 Chlorination procedure 14
9 Emergency case transfer procedure 16
10 Treatment in case of Fever
National vector borne diseases Control program
17
11 Treatment in case of Diarrhea 18
12 Treatment in case of Pneumonia – 0 to 5 years 19
13 RNTCP 20
14 NLEP 20
15 NBCP 20
16 Family Planning Program 20
17 School Health Program 21
18 Treatment through Outreach OPD 21
19 Measles outbreak control 21
20 AFP S urveillance 22
21 Village Health Committee Meeting 22
22 Registers at sub centre 22
23 Procedure for Reporting 23

12. The manual shall include infection control and waste
management issues

13. Safety of patients and staff shall have due
consideration in the manual

14. Objective Elements
• Rights and responsibility of the patients shall be
accordance with IPHS.
• A citizen charter to be displayed mentioning the
user charges, quality of the services, name of the
medical officer with the telephone numbers etc.
• The rights of the patients as a consumer have to be
respected and displayed e.g. right to choose, right
to deny, right to gather information etc.
• A mechanism for grievance redressal to be in place
and practiced.
23. Rights and Responsibility of
Patients

15. 318
Rights and responsibility of the patients shall be
accordance with IPHS.

16. 319
Rights and responsibility of the patients shall be
accordance with IPHS.

17. A citizen charter to be displayed mentioning the user
charges, quality of the services, name of the
medical officer with the telephone numbers etc

18. A citizen charter to be displayed mentioning the user
charges, quality of the services, name of the
medical officer with the telephone numbers etc

19. The rights of the patients as a consumer have to be
respected and displayed e.g. right to choose, right
to deny, right to gather information etc.

20. All redressal mechanisms to be documented.

21. A mechanism for grievance redressal to be in place
and practiced

22. • All redressal mechanisms to be documented.
• Users and providers will be jointly responsible to
maintain the building of the PHC and CHC in an orderly
manner.
• Patients to follow the instruction of the health care
providers sincerely.
• The patients have the right to their privacy,
information and disease condition that shall not be
disclosed to others.
• Citizen charter and rights of the patients should be
displayed in local language and should be universal for
the state.
23. Rights and Responsibility of
Patients Cont…

23. All redressal mechanisms to be documented.

24. Users and providers will be jointly responsible to
maintain the building of the PHC and CHC in an
orderly manner

25. Patients to follow the instruction of the health care
providers sincerely

26. Patients to follow the instruction of the health care
providers sincerely

27. The patients have the right to their privacy,
information and disease condition that shall not
be disclosed to others

28. Citizen charter and rights of the patients should be
displayed in local language and should be
universal for the state

29. Citizen charter and rights of the patients should be
displayed in local language and should be
universal for the state

30. Objective Elements
• The staff should respect patients' right.
• They should carry out their respective job
responsibilities as described in IPHS.
• They should demonstrate reasonable skill to provide
care to the patients.
• They are entitled to all the benefits (immunization,
healthcare cover through insurance, semi to fully
furnished staff quarters as per entitlement and
availability, its maintenance and security) due to them
by virtue of their employment.
• Employees to be immunized for Hepatitis, Tetanus etc.
24. Rights and Responsibility of Staff

31. Rights and Responsibility of Staffs

32. The staff should respect patients' right.

33. They should carry out their respective job responsibilities as
described in IPHS “twins delivery at PHC Salun”

34. They should demonstrate reasonable skill to provide
care to the patients

35. They should demonstrate reasonable skill to provide
care to the patients

36. They are entitled to all the benefits (immunization, healthcare cover
through insurance, semi to fully furnished staff quarters as per
entitlement and availability, its maintenance and security) due to
them by virtue of their employment

37. Employees to be immunized for Hepatitis, Tetanus
etc

38. 25. Training Development and
Motivation of Staff
Objective Elements
• The facility shall arrange for continuous updation
of knowledge and skills of the staff.
• Periodic training programs on the subjects of
waste management, infection control,
communication etc. to be carried out and
documented.
• Training for behavioral change communication
shall be carried out and documented.
• Training on all aspects of various national health
programs to be carried out.

39. The facility shall arrange for continuous updation of
knowledge and skills of the staff

40. The facility shall arrange for continuous updation of
knowledge and skills of the staff

41. Periodic training programs on the subjects of waste
management, infection control, communication
etc. to be carried out and documented

42. Training for behavioral change communication shall
be carried out and documented

43. Training on all aspects of various national health
programs to be carried out

44. • Evaluation of all such training to be documented.
• Several cash and non-cash incentives to be given
so as to constantly motivate the staff.
• All trainings provided must be on both
theoretical as well as practical aspects.
• There should be policy on encouragement and
appreciation of performers through incentives
and awards.
25. Training Development and
Motivation of Staff Cont…

45. Evaluation of all such training to be documented

46. Several cash and non-cash incentives to be given so
as to constantly motivate the staff

47. All trainings provided must be on both theoretical as
well as practical aspects

48. There should be policy on encouragement and appreciation of performers through
incentives and awards
NABH ACCREDITATION AWARD FUNCTION BY GOVT. OF GUJARAT & QCI, NEW DELHI
IN “National Conference in Best Health care Practices”.

49. 26. Surveillance of ANMs, LHVs and
other Field Workers
Objective Elements
• The activities of ANM, health workers female &
male to be reviewed regularly by the Medical
officer-in charge (MOIC).
• Feedback mechanisms to exit so as to asses the
visits of the above workers in the community.
• PRI to be involved in the surveillance program.
• Monitoring of distribution of iron tablets,
motivating patient for institutional deliveries
to be carried out as an on going program.

50. The activities of ANM, health workers female & male to be reviewed
regularly by the Medical officer-in charge (MOIC)

51. The activities of ANM, health workers female & male to be
reviewed regularly by the Medical officer-in charge
(MOIC)

52. Feedback mechanisms to exit so as to asses the visits
of the above workers in the community

53. Centre should have in use feedback mechanism like use of feedback
forms, suggestion forms to be dropped in suggestion / complaint
boxes at identified places

54. Centre should have in use feedback mechanism like use of feedback
forms, suggestion forms to be dropped in suggestion / complaint
boxes at identified places

55. PRI to be involved in the surveillance program

56. Monitoring of distribution of iron tablets, motivating
patient for institutional deliveries to be carried
out as an on going program

57. • The field workers shall have sufficient materials
for their use.
• A training and motivational program to exist for
the above workers.
• Validation of the process should be carried out
by higher authorities.
26. Surveillance of ANMs, LHVs and
other Field Workers Cont…

58. The field workers shall have sufficient materials for
their use

59. A training and motivational program to exist for the
above workers

60. A training and motivational program to exist for the
above workers

61. Validation of the process should be carried out by
higher authorities

62. 27. Public Private Partnerships
Objective Elements
• The organization shall proactively participate in
various public private partnership e.g. referring
patients for ultrasound to a private practitioner
on the basis of an agreed terms and conditions.
• Involving a private provider for scavenger
services.
• Involving a private transporter for transporting
patients.

63. The organization shall proactively participate in various
public private partnership e.g. referring patients for
ultrasound to a private practitioner on the basis of an
agreed terms and conditions “108”
• Launch Date : 29th August, 2007 (14
Ambulances).
• Existing Fleet of : 506 Ambulances.
• Calls Answered : 99% in Two Rings.
• Total Emergencies Attended: 24,99,025
– Medical : 24,64,721
– Police : 29,066
– Fire : 5,238
• Pregnancy Related Cases: 8,25,616
• Trauma: 3,86,063
• Cardiac: 1,24,371
• Lives Saved: 1,23,879
• Deliveries in Ambulance & at Scene: 22,011

64. The organization shall proactively participate in various
public private partnership e.g. referring patients for
ultrasound to a private practitioner on the basis of an
agreed terms and conditions “Chiranjeevi Scheme”

65. Total
Deliveries
under
Chiranjeevi
scheme
Estimated
Maternal
Death
Maternal
death
reported
under CY
Mothers
saved
under CY
Estimated
Early Neo-
Natal
death
Early Neo-
Natal death
reported
under
Chiranjeevi
scheme
Early
Neonates
saved
689127 1020 102 918 33078 2305 30773
Outcome of Chiranjeevi Scheme: ( Up to September-11)
Normal Deliveries: 612495
C-Section: 42895 (6.2%)
Complicated Deliveries: 33737 (4.9%)
Private specialist enrolled: 646
(Source: State MIS)
368

66. Involving a private provider for scavenger services
“Institutional Delivery”

67. The organization shall proactively participate in various public private
partnership
- PHC Salun building is donated by Mrs. Sudhaben Patel, London &
PHC Jetalpur building donated by Swaminarayan sanstha

68. The organization shall proactively participate in various public private
partnership

69. Involving a private transporter for transporting
patients

70. 28. Pricing and Services
Objective Elements
• Unifield pricing mechanism as per the policy of
the state concerning the user fee to be applied.
• Patients to be informed about the charges.
• Always a receipt to be given to the patients.
• Proper accounting of the collections to be
maintained.

71. Patients to be informed about the charges

72. Always a receipt to be given to the patients

73. Involving a private transporter for transporting
patients

74. Proper accounting of the collections to be
maintained

75. Objective Elements
• A mechanism for micro health insurance
through a co-operative approach to exist so as
to cater to the requirements of the patients.
• PRI and co-operative society to be involved to
arrange for certain basic expenses for the
patients.
29. Community Based Health
Insurance

76. A mechanism for micro health insurance through a
co-operative approach to exist so as to cater to the
requirements of the patients

77. PRI and co-operative society to be involved to
arrange for certain basic expenses for the patients
Through Rogi Kalayan Sameeti (RKS)

78. 30. License and Statutes
Objective Elements
• All licenses to be available in the facility e.g.
Narcotics, Waste management, BARC, AERB,
fire safety etc as applicable.
• Statutory requirements concerning patient and
staff safety and welfare shall be met with.

79. All licenses to be available in the facility e.g.
Narcotics, Waste management, BARC, AERB, fire
safety etc as applicable
Biomedical waste management & handling
rules
License for procurement, storage and use
of spirit
Registration of vehicle
NOC from fire safety officer
Certificate for FAR
Building safety certificate
Permission for building construction

80. Statutory requirements concerning patient and staff
safety and welfare shall be met with
Biomedical waste management & handling
rules
License for procurement, storage and use
of spirit
Registration of vehicle
NOC from fire safety officer
Certificate for FAR
Building safety certificate
Permission for building construction

81. 31. Local Social Customs
Objective Elements
• Respect for local social customs to be given by
the organization.
• Myths concerning health availing practices to be
evaded e.g. taking of local pudia for viral
hepatitis (jaundice), isolating post partum
mothers etc.

82. Respect for local social customs to be given by the
organization “Gaytri Yagan”

83. Respect for local social customs to be given by the
organization “Gaytri Yagan”

84. Myths concerning health availing practices to be
evaded e.g. taking of local pudia for viral hepatitis
(jaundice), isolating post partum mothers etc

85. 32. End of Life Care
Objective Elements
• Center to provide appropriate respect and
dignity to the dying and the dead.
• All death cases to be recorded and reported.
• Death certificate (MCCD-Medical Certificate for
Cause of Death) to be issued to the next of kin.
• Centre should carry out Death Audits
periodically.

86. Center to provide appropriate respect and dignity to
the dying and the dead

87. S. No. Detailed NC = 0 PC = 5 FC = 10
1
All weather approachable road with Road light
and sounding cleanliness.
2
Counseling room with table and chairs for Doctors
and relatives.
Human Anatomy Charts Male & Female (Internal
&External body Part).
3 Office Room contain as per below.
Table and Chairs for Doctors.
Storage space for supplies (Gloves, Apron, Gum
boots, Goggles, Agarvati, Machish and Masks as per
requirements).
Storage space for equipment (PM Set, Suturing
material, Cotton, Bandages, Electric saw for cutting of
the skull bone, Empty Specimen bottles and salt as per
requirement etc).
Cold Storage space (Domestic freeze) for specimens.
Storage space for dead body cloths.
Within 48 hrs specimen and cloths should be giving to
the police.
End of life care (Mortuary Facility) Checklist
NC (Non Compliance = 0), PC (Partial Compliance = 5), FC (Fully Compliance = 10)

88. S. No. Detailed NC = 0 PC = 5 FC = 10
4 Post Mortem (Autopsy) Area.
Proper Exhaust facility.
Post mortem platform (Autopsy table) with 24 hrs running
water and proper drainage facilities.
Proper space around Post mortem platform (Autopsy table).
Work counter with a sink equipped for hand washing.
A deep sink for washing of specimens.
Proper Natural or near Natural light.
Proper Biomedical waste facility.
Display the Standard Operation Procedure (SOP) for
Autopsy.
5 Refrigerated facilities for dead body holding.
Refrigerators for dead body holding.
Display the Standard Operation Procedure (SOP) for
Refrigerators.
Regular temperature monitoring of Refrigerators with
regular AMC & CMC.
Cabinet for record keeping.
Proper Exhaust facility.
NC (Non Compliance = 0), PC (Partial Compliance = 5), FC (Fully Compliance = 10)
End of life care (Mortuary Facility) Checklist

89. S. No. Detailed NC = 0 PC = 5 FC = 10
6 Cleanliness of the postmortem room.
Every day once in a morning with high
concentrate (2 %) Sodium Hypocloride
Solution.
Immediate after Autopsy clean with high
concentrate (2 %) Sodium Hypocloride
Solution.
Detailed Cleaning with standard methods
(Walls, windows, doors, cabinets, Fens,
instrument, equipment and surrounding area
etc) at least once in a week.
All instruments, Equipment should be clean
with high concentrate (2%) Sodium
Hypocloride Solution.
7 Proper signage's.
NC (Non Compliance = 0), PC (Partial Compliance = 5), FC (Fully Compliance = 10)
End of life care (Mortuary Facility) Checklist

90. Center to provide appropriate respect and dignity to
the dying and the dead

91. All death cases to be recorded and reported
INFORMATION OF INFANT MORTALITY RATE
P.H.C.-JETALPUR
sr. no. Year
Total
live
birth
Child Death of 0 to 1 year
Total IMR -24 hour 1 to 7 Day
8 to 28
Day
29 day to 1
year
1 2004-2005 1069 6 3 3 5 17 15.9
2 2005-2006 842 14 5 6 11 36 42.85
3 2006-2007 878 5 10 7 5 27 30.75
4 2007-2008 901 6 4 4 6 20 22.2
5 2008-2009 920 8 8 5 2 23 25
6 2009-2010 915 5 7 3 4 19 20.8

92. Death certificate (MCCD-Medical Certificate for
Cause of Death) to be issued to the next of kin

93. Centre should carry out Death Audits periodically

94. Centre should carry out Death Audits periodically
“Causes of < 5 mortality & Neonatal Mortality”

95. Centre should carry out Death Audits periodically

96. Health for All