INITIATIVES UNDER QUALITY ASSURANCE PROGRAMME IN GOVERNMENT HOSPITALS

2.  Quality is the degree of Adherence to pre-
determined standards.
 Quality is Minimizing variations.
 Quality is Standardization.
 Quality is Meeting and Surpassing the
Customer Expectations.
 Quality is Doing Right Things, in Right Way,
First Time & Every time.

3.  EFFECTIVENESS : Achieving outcomes as desired by
doing right things.
 EFFICIENCY : Relates to maximizing the quality of
health care delivered or health benefit achieved for a
given unit of health care resources used.
 EQUITY : Relates to providing health care of equal
quality to those who may differ in personal
characteristics
 PATIENT : CENTREDNESS Relates to meeting patients'
needs and preferences.
 SAFETEY : Avoiding harm to patients from care that is
intended to help them.
 TIMELINESS : Relates to obtaining needed care while
minimizing delays.

4. STRUCTURE OUTCOME
PROCESS
QUALITY

7. AIM
1. To ensure access to quality health services through
National Quality Assurance Program.
2. Ensure advocacy and implementation of global
best practices, evidences and policy
recommendations to reduce the harm to patients.
3. Enhancing satisfaction/experience among users of
the Government Health Facilities and reposing trust in
the Public Health System.

8.  Formation of Quality Assurance Team at Facility Level
 Internal Assessment
 Patient Satisfaction Survey (PSS) - Empanelled to Mera Aspataal to capture
patients' feedback.
 Key Performance Indicators (KPIs)- Integration of IT based dashboard for
reporting and monitoring of the indicators..
 Quality Policy & Objectives
 Undertaking Rapid Improvement Events (Gap identifications, Setting-up an
objectives, Root-Cause Analysis, Measuring indicators, PDCA (Plan-Do-Check
Act) Cycle
 Medical & Deaths Audits
 Standards Operating Procedures & Work Instructions
 External Quality Assurance of measuring equipments and Laboratories..
 Competency and Performance Assessment
 .Development and Implementation of Risk Management Framework.
 Clinical Governance

9. Empanelment of external assessor
Selection of assessor for national assessment
Certification Cell at NHSRC
 Certification Process
Document Verification and clearance
 Compliance criteria
Validity of the certificates
 Surveillance assessments
 Re-certificationVirtual
 online Assessments & its protocols

10. NAQS 2021-22 Facility Status of District Dhule
Sr. No. Year Name Of Faclity
Baseline
Assessment
Internal
Assessment
State
Assessment
National
Assessment
1
2021-22 DISTRICT HOSPITAL, DHULE YES In Process NA NA
2
2021-22 DONDAICHA SDH YES In Process NA NA
3
2021-22 RH PIMPALNER YES In Process NA NA
4
2021-22 LAMKANI PHC YES In Process NA NA
5
2021-22 JAITHANE PHC YES In Process NA NA
6
2021-22 NARDANA PHC YES In Process NA NA
7
2021-22 ARVI PHC YES YES NA NA
8
2021-22 KHEDA PHC YES In Process NA NA
9
2021-22 SC TARWADE, PHC SHIRUD YES In Process NA NA
10
2021-22 SC MEHERGAON, PHC LAMKANI YES In Process NA NA

11. 1. LaQshya is all about improving Quality of Care
around birth.
2. Quality Certification of LR and/or OT-through
the existing system.
3. Attainment of 75% of Facility level targets.
4. At least 80% beneficiaries are satisfied with the
care.

12. 1. To reduce maternal and newborn mortality &
morbidity due to APH, PPH, retained placenta,
preterm, preeclampsia & eclampsia, obstructed
labour, puerperal sepsis, newborn asphyxia, and
sepsis, etc.
2. To improve Quality of care during the delivery
and immediate post-partum care, stabilization of
complications and ensure timely referrals, and
enable an effective two-way follow-up system.
3. To enhance satisfaction of beneficiaries visiting
the health facilities and provide Respectful
Maternity Care (RMC) to all pregnant women
attending the public health facility.

13. SR No Year
Name Of
Faclity
Baseline
Assessmen
t
Internal
Assessme
nt
State
Assessme
nt
National
Assessment
REMARK
LR OT LR OT LR OT LR OT
1
2018-19 Shirpur SDH YES YES YES YES YES YES YES YES
STATE CERTIFIED, DIFFER IN NATIONAL
ASSESSMENT . NOW DOCUMENTATION IS
IN PROCESS FOR NATIONAL ASSESSMENT
2
2018-19
Dondaicha
SDH
YES YES YES YES YES YES NO NO
STATE CERTIFIED, NATIONAL ASSESSMENT
DOCUMENTATIONIS IN PROCESS
3
2018-19 GMC Dhule NO NO NO NO NO NO NO NO
We will start again from Baseline
Assessment
4
2019-20 Sakri RH YES YES YES YES NO NO NO NO
NOT QUALIFIED IN STATE ASSESSMENT,
Gaps will be close with in 15 days.
5
2020-21
Pimpalner
RH
YES YES YES YES NO NO NO NO
INTERNAL ASSESSMENT DONE 11/11/2021,
LR Under Construction

15.  VISION : To create a responsive health care
system which strives to achieve zero maternal
and infant deaths through quality care provided
with dignity and respect.
 GOAL : To end all preventable maternal and
newborn deaths.
 OBJECTIVES: Assured, dignified, respectful and
quality healthcare at no cost and zero tolerance
for denial of services for every woman and
newborn visiting the public health facility to end
all preventable maternal and newborn deaths and
morbidities and provide a positive birthing
experience.

16. •To provide high quality medical, sugical and emergency care services in a
dignified and respectful manner as per SUMAN service package at no cost to
the benefiaries.
•To leverage institutional and community-based platforms to help create
awakeness in the community on the entitlements under SUMAN.
•To strengthen Grievance Redressal Mechanism by incorporating client
feedback.
•To orient service providers and build their capacity for delivering SUMAN
package.
• To ensure reporting and review of all maternal
and infant deaths.

17. All Pregnant
Women
All Mother up
to 6 months
post delivery
All sick
Infants

18. S.No Year
Name of
Facility
Baseline
Assessment
Cross Assessment
Internal Assessment (NQAS
Assessment)
1 2020-21 PHC Arvi
Done Done Done
2 2020-21 PHC Kheda
Done Done In-Process
3 2020-21 PHC Lamkani
Done Done In-Process
4 2020-21 PHC Jaitane
Done Done In-Process
5 2020-21 RH Pimpalner
Done Done In-Process
6 2021-22 PHC Nardana
Done Done In-Process

21.  Meaning of Data Items in Patient CSV File
 1. ninlD — Hospital NIN ID.
 2. Patient ID — This is a string. This is a unique Id provided to
the patient at the time of registration.
 3. PatientName — string.
 4. Age — Integer. Rounded to nearest year
 5. Gender - Interger. Male (1) or Female (2) or Transgender (3)
 6. Mobile — integer. It must be of 10 digits. 0 if not available.
 7. Landline - patient data file should include the STD code
without any delimiters. 0 if not available. Ex: Delhi landline numb
ers should be "1188888888"
 8. PatientTypelD - integer attribute in the patient data file
denotes a. (1) for IP patient and b. (2) for OR
 9. DepartmentlD - integer attribute in patient data file denotes
Department ID. This has to be shared by the facility or state at
the time of integration.

22. ninID patientID patientName
Mobile
Landline departmentID patientTypeID gender age

23.  SDH Shirpur 100Beded

25.  Swachh Bharat Abhiyan
launched by Prime
Minister on 2nd October
2014 focuses on
“promoting cleanliness in
Public Spaces”
• Kayakalp- Clean Hospital
Award for Public Health
Facilities Launched by
Union Health Minister on
15th May 2015

26. Improved
cleanliness
Improved
Aesthetics
Enhanced Patient
Satisfaction
Speedy Recovery
Healthy Behaviour
Reduced Infections
Less Hospital Stay
Morbidity
Quality
of Care

27.  To promote cleanliness, hygiene and
Infection Control Practices.
 To incentivize and recognize public
healthcare facilities that show exemplary
performance adhering cleanliness and
infection control.
 To inculcate a culture of ongoing assessment
and peer review of performance.
 To create and share sustainable practices
related to improved cleanliness.

28.  Assessment on predefined objective criteria
 System of Peer-review
 Cash Award for two DHs and two SDHs/CHCs in
a State (one award in each category for small
states)
 Cash Award for one PHC in each District
 Certificate for commendation & cash award for
facilities achieving more than 70% score
 Felicitation of best Hospitals at National Level

29. Category Type of
Facility
Assessment Score Amount (Rs.
in Lakhs)
I. Large
States
DH Highest (Best) Rs. 50.00
Runner-up Rs. 20.00
SDH/ CHC Highest (Best) Rs 15.00
Runner-up Rs. 10.00
PHC One in each District Rs. 2.00
II. Small
States
DH Highest (Best) Rs. 50.00
CHC Highest (Best) Rs. 15.00
PHC One in each District Rs. 2.00
Commendation & Cash Award (70% or more)
All States DH More than 70% Score Rs. 3.00
SDH/CHC Rs. 1.00

30. Cleanliness is next to Godliness
Swachhta
Thank You
Dr. Upendra Kushwah
DQAC, NHM Dhule