QUALITY ASSURANCE

Quality in health care:

Lahr KN 1990 explains QA as the extent to which individual and communities achieve
desired health outcomes and are in accordance with knowledge of health care profession

It started with Florence Nightingale identifying the role of nursing in health care
quality and began to measure patient care professionals

Definition:

As per Webster’s dictionary, QA is an activity or programme for monitoring and evaluating

the various aspects of a project, service, or facility, systematically to ensure the desired
standards of quality are begin met.

Purpose of QA

 To assess the product or service in a systematic and comprehensive manner and find
any fault and errors so as to rectify them
 To identify the areas which have not met the criteria or standards and to correct them
immediately
 To improve the efficiency and effectiveness of the service or product
 To motivate for research effort by finding the relationship of services provided with
expected outcomes
 To identify and address various problem

Objectives of QA in nursing:

According to Jonas 2000, the objectives are

 To ensure delivery of quality client care

 To demonstrate the efforts of health care providers to provide the best possible
outcomes
 To provide good quality of service to public
 To improve the efficiency and effectiveness of nursing services

Quality assurance in nursing:

Pre requisites for a QA programme, the nurse administrator should follow the following
steps:

 Set up a system for collecting and reporting data

 Write a clear definition of all activities
 Agree method for establishing current performance
 Identify the resource and list them
 Identify and list the possible source of benchmarks data
 Develop a calendar for reporting
 Define roles and responsibilities
 Identify the training needs requirement
 Plan for training personnel
 Establish a quality assurance committee in hospitals

QUALITY AUDIT:

Quality audit is the process of systematic examination of a quality system carried out
by an internal or external quality auditor or an audit team. It is an important part of an
organization’s quality management system.

Purposes:

 To identify and monitor the progress achieved against organizational goals

 To find out chances for improvement
 To compare the performance of employee with internal and external standards
 To ensure the programme to meet the requirements and needs of the customers. To be
able to set sensible objectives and comply with them
 To establish standards for establishing comparisons
 To ensure each employee is aware of their level of performance
 To identify and highlight quality-related issues and decide the areas for priority action
 To provide feedback for the successful performance
 To make auditing as an integral part of regulatory requirements

Tools to measure quality assurance

  Standards set by Indian nursing council (INC), professional bodies (TNAI), university
(Board of nursing studies).
 Nursing audit of patients record.
 Patient opinion on exit interview on discharge.
 Review of infection control records.
 Patient’s family’s opinion.
 Critical incident technique by nurses.
 Reports on nursing rounds.
 Adhering the unit philosophy and objectives.
 Effectiveness of team conferences and reports.
 Effectiveness of patient teaching program.
 Review of staffing pattern for each unit.
 Use of nursing care plans.
 Observation of nursing activities.

Measuring the outcome of quality care

 Hospital acquired infection, surgical site infection. Inpatient mortality, neonatal

mortality, peri-operative mortality.
 Unplanned re-admission, unplanned admission after outpatient procedures.
 Patient’s falls.
 Incidence of health care associated pressure ulcers.
 Incidence of health care associated infections; Catheter associated urinary tract
infection (CAUTI).
 Patient’s experience of pain management.
 Patient’s experience of the provision of educational information.
 Health-care associated infection (HAI) rate: The number of individuals who develop
any infection while in an inpatient setting.

NURSING AUDIT.

“It is a detailed review and evaluation of selected clinical records by qualified

professional personnel for evaluating quality of nursing care”.
  It is the part of the cycle of QA.
 It incorporates the systematic and critical analysis of care given by nurse.
 It appraises the use of available resources and the impact of it on patient care
outcome.

Purposes:

 To evaluate the nursing care given.

 To achieve the deserved and feasible quality of nursing care.
 To improve the quality of documentation.
 To focus on the care provided and not on the care provider.
 To contribute towards research.

Common approaches to nursing audit:

 Organizational audit.
 Peer review.
 Prospective review.
 Concurrent review.
 Retrospective review.

Nursing audit cycle:

According to FBA clinical governance and nursing audit workshop

(www.Quis.org.uk) the nursing audit cycle describes to start with deciding selected area to
measure, review against standards, identify the gap decide action, implemented action and
review standards.

 Defining standards: It is based on the Donabedian model of quality assurance. The

three dimensions measured are-
 structure

process

outcome

 Structure: environmental elements required to deliver care.

Ex-all infrastructure facilities, policy, procedures, equipment, record keeping system.
 Process: professional and technical elements required to deliver care.
 Outcome: measurable elements demonstrating results of care.
Ex- leg ulcer healing time, immunization levels, pressure ulcer prevalence, falls,
infection rate, mortality etc.

 Identify the problem regarding quality nursing care by conducting a baseline

survey.

 To read widely from available literature.

 Identify gaps in providing care by analysing.

- What are the reasons for not meeting the standard?
- How can the services be implemented?

 Implement action.
- This is the hardest area to address and the involves the input from whole team.
- An action plan needs to be developed.

 Review standards.
- To know whether the developed standards met the needs and to assess the status of
standards whether they are high- or low-level stand
GUIDELINES FOR QUALITY ASSURANCE
Quality in Health Care
Quality in Health System has two components:
Service Delivery and Client Satisfaction.
Technical Quality: on which, usually service providers (doctors, nurses & Para-medical
staff) are more concerned and has a bearing on outcome or end-result of services delivered.
Service Quality: pertains to those aspects of facility-based care and services, which patients
are often more concerned, and have bearing on patient satisfaction.
Sub components of quality
Technical –clinical protocol, infection control, emergency response,
Service quality - Prompt Service Delivery, Courteous Behaviour of Staff, Hygiene &
Cleanliness, and Privacy & Dignity.
Working definition- WHO defines Quality of Healthcare services in following six
subsets:Patient-Cantered: delivering health care, which takes into account preferences and
aspirations of the service users, and is in congruent with their cultures? It implies that
patients are accorded dignified and courteous behaviour. Their reasonable belief, practices
and rights are respected. Equitable: delivering health care which does not vary in quality
because of personal characteristics such as gender, caste, socioeconomic status, religion,
ethnicity or geographical location.
Accessible: delivering health care that is timely, geographically reasonable, and provided in
a setting, where skills and resources are appropriate to the medical need.
Effective: delivering health care that is based on the needs, and is in compliance to available
evidences. Therefore, observance of treatment guidelines and protocols is important for
ensuring the quality of care. The delivered health care results into the improved health
outcomes for the individuals in particular, and community in general.
Safe: delivering health care which minimizes risks and harm to the users.
Efficient: delivering health care in a manner which maximizes productivity out of the
deployed resources. The wastes are avoided.
Quality as Perceived by Different Stakeholders although everyone values quality, but
perceives it differently. Patients, Communities (Society), Clinicians, and Administrators
have different definitions of quality.
 patient
requirement

service
society Quality of provider/
requirement care clinicians
perception

administrato
rs
requirement

Quality in Health Care

Quality in Health System has two components:
Service Delivery and Client Satisfaction.
Technical Quality: on which, usually service providers (doctors, nurses & Para-medical
staff) are more concerned and has a bearing on outcome or end-result of services delivered.
Service Quality: pertains to those aspects of facility-based care and services, which patients
are often more concerned, and have bearing on patient satisfaction.
Sub components of quality
Technical –clinical protocol, infection control, emergency response,
Service quality - Prompt Service Delivery, Courteous Behaviour of Staff, Hygiene &
Cleanliness, and Privacy & Dignity.
Working definition- WHO defines Quality of Healthcare services in following six
subsets:
Patient-Cantered: a. delivering health care, which takes into account preferences and
aspirations of the service users, and is in congruent with their cultures. It implies that patients
are accorded dignified and courteous behaviour. Their reasonable belief, practices and rights
are respected.
Equitable: delivering health care which does not vary in quality because of personal
characteristics such as gender, caste, socioeconomic status, religion, ethnicity or
geographical location.
Accessible. Delivering health care that is timely, geographically reasonable, and provided in
a setting, where skills and resources are appropriate to the medical need. Effective.
Delivering health care that is based on the needs, and is in compliance to available
evidences. Therefore, observance of treatment guidelines and protocols is important for
ensuring the quality of care. The delivered health care results into the improved health
outcomes for the individuals in particular, and community in general.
Safe: delivering health care which minimizes risks and harm to the users. Efficient.
Delivering health care in a manner which maximizes productivity out of the deployed
resources. The wastes are avoided.
Quality as Perceived by Different Stakeholders although everyone values quality, but
perceives it differently. Patients, Communities (Society), Clinicians, and Administrators
have different definitions of quality.
 patient
requirement

service
society Quality of provider/
requirement care clinicians
perception

administrato
rs
requirement

Patient’s Requirement: Although patients are deeply concerned, how good clinical care is,
but very often, they themselves are not able to judge the technical aspect of the care. Patients
are mostly concerned about the issues, other than clinical guidelines & protocols. Usual
expectations of patients are given in the
Users’ experiences of health care in a facility, whether personal or shared, have a major
impact in their decision of seeking the services at a particular facility. People do not wish to
go to a facility where they receive rude treatment.
Society’s Definition: At the broader societal level, the definition of quality of care reflects
concern of cost effectiveness, equal access and equity in service delivery, transparency and
extent of out of pocket expenditure. Society also perceives quality in terms of protection of
health rights specialty of marginalized and vulnerable populations.
Healthcare Providers: Clinicians, who provide healthcare services, tend to equate quality of
care with technical performance. Often for health care providers, the desired outcomes are
related to successful treatment of patients with reduction in morbidity, mortality and
disability limitation. For example, doctors’ expectation of quality services is that
investigation reports are available on time, drugs are available in the dispensary, and patients
are getting cured timely.
Governments/Administrators Definitions: An administrator perceives quality in terms of
optimal and rational utilization of resources, maximum satisfaction by the users of health
facility, delivery of all components under the health programmes, compliance to treatment
guidelines & clinical protocols, and improvement in the health status of population.
Quality of care
Well frame-work for assessing the quality of care on the well accepted ‘Donabedian
model’, which classifies QOC in terms of three aspects – structure, process, & outcome.
Structure: Structural aspect of QOC includes material resources like infrastructure, drugs
and equipment; and Human Resources such as availability of adequate number of personnel,
who have requisite knowledge and skills. Evaluation of the quality that relies on such
structural elements implicitly assumes that well qualified people with well-appointed and
well-organized settings will provide high quality care. However, it is not always the case.
Also, it is acknowledged that in the Public Health System, full compliance to infrastructure
and HR norms may not be possible. However, after meeting the minimum infrastructure and
HR norms for a Public Health Facility, it would be logical to expect a minimum quality in
the available services at the Public Health Facility. The proposed system strives to provide
QOC within these. Constraints.
Process: Care can also be evaluated in terms of processes & sub-processes required for
delivery the care. This refers to what takes place during its delivery – such as how quickly
registration of a patient is done, and s/he is attended, courteous behaviour of the service
providers, especially of doctors & nurses, conduct of examination with respect to privacy,
confidentiality and for patient’s right, etc.
Outcome: The other aspect of quality of care can be assessed in terms of outcome
measurements, which denote to what extent goals of the care have been achieved.
All three aspects of the QOC have different connotation to different stakeholders, viz.
Patients, Service providers and Health System.

Stakeholder Input Process Output

Patient *Barrier Free Access *Minimum waiting *No out of pocket
expectation - „ Prompt & time prompt referral expenditure
courteous services - if required. *Availability of
No exclusion on the *Good behaviourby services as
basis of caste and „ service providers guaranteed
socio-economic Privacy & *High Patient
status. confidentiality Satisfaction
*Clean & Inviting „ *Grievance *Treatment and
environment at the Redressed „ *Access Cure.
health facility -- to Information „ and
*Availability of involvement in
services „ decision making for
*Availability of drugs the care.
and „ consumables.
 Service *Adequate and *Adherence to *Low mortality and
Providers planned infrastructure clinical „ Protocols morbid
Requirements *Serviceable *Infection Control „ complications and
&calibrated „ Practices *Training referrals, etc.
Equipment and Skill „ *Effectiveness of
*Availability of Development the care „ in term
Quality Drugs „ *Safe and effective „ of average length of
* Human Resource in Nursing care stay, bed occupancy,
„ numerical etc. *Adverse drug
adequacy with reactions „ and
knowledge and skills Hospital acquired
*Enabling Work „ infection
Environment *Employees’
Satisfaction „
Health Systems
Health *Allocation of *Efficient logistics „ *Optimal utilization
Systems adequate „ resources management of resource.
Requirements *Facilities provide * Monitoring and „ *Measurable
full range „ of Supervision deliverables „ of
services *Adequate *Effective programmes
Technical Support „ implementation „ of *Improvement in
programmes Health „ Indicators
*Enhanced
Productivity in „
terms of volume

Quality Assurance American Society for Quality refers to Quality Assurance as

“planned and systematic activities, which are implemented in a quality system, so that
quality requirements of a product or service would be fulfilled”. It essentially entails doing a
set of activities that include defining quality standards and assessing, monitoring and
improving the quality of services against those standards, so that the care provided is as
efficient, effective and safe as possible.
Four Principles of Quality Assurance
  Quality Assurance is oriented toward meeting the needs and expectations of the
patients.
 Quality assurance focuses on the systems and processes. „
 Quality assurance uses data to analyse service delivery processes. „
 Quality assurance encourages a team approach to problem solving and quality
improvement.

Quality Assurance (QA) in Public Health is a cyclical process involving following major
components:
 Setting up Standards and Measurable elements.
 Assessment of health facilities against the set standards.
 Analysing the problems.
 Preparing and implementing action plan.
NATIONAL QUALITY ASSURANCE STANDARDS 2018
INTRODUCTION:
Often, measuring the quality in health facilities has never been easy, more so, in
Public Health Facilities. We have hadqualityframe-
workandQualityStandards&linkedmeasurementsystem,globallyandaswellasin
India.Theproposed system has incorporated best practices from the contemporary systems,
and contextualized them for meeting the needs of Public Health System in the country.
The system draws considerably from the guidelines(morethan one hundred fifty
innumber), Standards and Textson the Quality in Healthcare and Public health system, which
ranges from ISO 9001 based system to healthcare specificstandards suchas JCI,IPHS.
Operational Guidelines for National Health Programmes and schemes have also been
consulted.
We do realise that there would always be some kind of ‘trade-off’, when measuring
the quality. One may have short and simple tools, but that may not capture all micro details.
Alternatively, one may devise all-inclusive detailed tools, encompassing the micro-
details but the system may become highly complex and difficult to apply across public health
facilities in the country.
Another issue needed to be addressed is having some kind of universal applicability of
the quality measurement tools, which are relevantand practicalacross
thestates.Therefore,proposedsystemhasflexibility tocaterfordifferential baselines and
priorities of the states.

Following are salient features of the proposed quality system:

1.Comprehensiveness: Theproposedsystemisall inclusive andcapturesall aspectsof
qualityofcarewithinthe eight areas ofconcern. Thedepartmental check-liststransposed
within Quality Standards,and commensurate measurable elements provide an exhaustive
matrix to capture all aspects of quality of care at the Public Health Facilities.
2.Contextual: The proposed system
hasbeendevelopedprimarilyformeetingtherequirementsofthePublic Health Facilities;
since Public Hospitals have their own processes, responsibilities and peculiarities, whichare
very different from ‘for-profit’ sector. For instance,thereare standards
forprovidingfreedrugs, ensuring availability of clean linen, etc. which may not be
relevant for other hospitals.
3.Contemporary:Contemporary Quality standards such as NABH, ISO and JCI, and Quality
improvement tools such as Six Sigma, Lean and CQI have been consulted and their relevant
practices have been incorporated.
4.User Friendly: ThePublicHealthSystem requiresacredible Qualitysystem it
hasbeenendeavourof the team to avoid complex language and jargon. So that the system
remains user-friendly to enable easy understanding and implementation by the service
providers. Checklists have been designed to be user-friendly with guidance for each
checkpoint. Scoring system has been made simple with uniform scoringrulesand
weightage.Additionally,aformulafittedexcel sheet tool hasbeen provided
fortheconvenience, and also to avoid calculation errors.
5.Evidence based: TheStandardshavebeen developedafterconsultingvast
knowledgeresourceavailable on the quality. All respective operational and technical
guidelines related to RMNCH+A and National Health Programmes have been factored in.
6. Objectivity: Ensuring objectivity in measurement of the Quality has always been a
challenge. Therefore, in the proposed quality system, each Standard is accompanied with
measurable elements & Checkpoints to measure compliance to the standards. Checklists
have been developed for various departments, which also captures inter-departmental
variability for the standards. At the end of assessment, there would be numeric scores,
bringing out the quality of care in a snap-shot, which can be used for monitoring, as well as
for inter-hospital/ inter-state(s) comparison.
7. Flexibility: The proposed system has been designed in such a way thatstates and
Health facilities can adapt the system according to their priorities and requirements. State or
facilities may pick some of the departments or group of services in the initial phase for
Quality improvement. As baseline differs from state to state, checkpoints may either be made
essential or desirable, as per availability of resources. Desirable checkpoints will be counted
in arriving at the score, but this may not withhold its certification, if compliance is
still not there. In this way the proposed system provides flexibility, as well as ‘road-
map’.
8.Balanced: All three components of Quality – Structure, process & outcome, have been
given due weightage.
9.Transparency: All efforts have been made to ensure that the measurement system remains
transparent, so that assesses and assessors have similar interpretation of each checkpoint.
10.Enabler: Though standards andchecklists are primarily meant for the assessment, it can
also be used as a ‘road-map’ for improvement.
NATIONALQUALITY ASSURANCE STANDARDS FOR DISTRICT HOSPITAL:

Area of Concern - A: Service Provision

Standard A1 The facility provides curative services
Standard A2 The facility provides RMNCHA services
Standard A3 The facility provides diagnostic services
Standard A4 The facility provides services as mandated in National Health
Programmes
Standard A5 Thefacilityprovidessupport services
Standard A6 Health services provided at the facility are appropriate to community needs.

Area of Concern - B: Patient Rights

Standard B1 The facility provides information to care seekers,attendants &
communityabout the available services and their modalities.
Standard B2 Services are delivered in a manner that is sensitive to gender, religious and
cultural needs, and there are no barriers on account of physical economic,
cultural or social reasons.
Standard B3 The facility maintains privacy, confidentiality & dignity of patient,and
has a system for guarding patient related information.
Standard B4 The facility has defined and established procedures for informing patients
about the medical condition, and involving them in treatment planning, and
facilitates informed decision making.
Standard B5 The facility ensures that there are no financial barriers to access, and
thatthere is financial protection given from the cost of hospital
services.
Standard B6 The facility has defined framework for ethical management including
dilemmas confronted during delivery of services at public health facilities.

Area of Concern - C: Inputs

Standard C1 Thefacility hasinfrastructure fordelivery
ofassuredservices,andavailableinfrastructuremeetstheprevalent
norms.
Standard C2 Thefacilityensuresthephysicalsafetyoftheinfrastructure
Standard C3 Thefacility hasestablishedProgrammefor fire safety and other disaster
Standard C4 The facilityhas adequatequalifiedandtrained staff,
requiredforprovidingtheassuredservicestothecurrent case load.
Standard C5 Thefacility providesdrugsand consumablesrequired forassuredlist
ofservices
Standard C6 Thefacilityhasequipment&instrumentsrequired forassured
listofservices.
Standard C7 The facilityhasa definedand established
procedureforeffectiveutilization,evaluationandaugmentationof
competence and performance of staff
Area of Concern - D: Support Services
Standar The facilityhas established Programme forinspection,testingandmaintenance
d D1 andcalibrationof Equipment.
Standar Thefacility hasdefined procedures forstorage,
d D2 inventorymanagementanddispensingof drugs inpharmacy and patient
care areas
Standar Thefacility providessafe,secureand comfortable environment tstaff,patientsand
d D3 visitors.
Standar Thefacility hasestablishedProgrammefor maintenance andupkeep
d D4 ofthefacility.
Standar Thefacility ensures24X7waterand power backupper requirement
d D5 ofservicedelivery,andsupportservices norms.
Standar Dietary services are available as per service provision and nutritional requirement
d D6 of the patients.
Standar Thefacility ensurescleanlinen tothe patients.
d D7
Standar Thefacility hasdefined andestablishedproceduresfor promoting public
d D8 participation in managementof hospital transparency and accountability.
Standar Hospitalhas definedand established procedure for financial management
d D9
Standar The facilityiscompliantwith allstatutory
d D10 andregulatoryrequirementimposedbylocal,stateorcentralgovernment
Standar Roles & Responsibilities of administrative and clinical staff are determined as per
d D11 govt. regulations and standards operating procedures.
Standar The
d D12 facilityhasestablishedprocedureformonitoringthequalityofoutsourcedservice
sand adheres to contractual obligations.

Area of Concern - E: Infection Control

Standard E1 Thefacility hasinfection controlProgrammeand procedures
inplaceforpreventionand measurementof hospital associated
infection.
Standard E2 Thefacility hasdefined
andimplementedproceduresforensuringhandhygienepracticesandantis
epsis
Standard E3 The facilityensuresstandard practicesandmaterialsforPersonalprotection.
Standard E4 Thefacility hasstandard procedures
forprocessingofequipmentandinstruments.
Standard E5 Physical layout and environmental control of the patient care areas ensures
infection prevention.
Standard E6 Thefacility hasdefined
 andestablishedproceduresforsegregation,collection,treatmentand
disposalof Bio Medical and hazardous Waste.
Area

Area of Concern - F: Clinical Services

Standard F1 The facilityhas definedprocedures
forregistration,consultationandadmission ofpatients
Standard F2 The facilityhas definedand established procedures for
clinicalassessment andreassessment ofthe patients.

Standard F3 Thefacility hasdefined and established procedures

forcontinuityofcareofpatientandreferral.
Standard F4 Thefacility hasdefined andestablishedproceduresfornursingcare.

Standard F5 Thefacility has aprocedure toidentifyhighriskand

vulnerablepatients.
Standard F6 Thefacility followsstandardtreatmentguidelines definedby
state/Central governmentforprescribingthe generic drugs & their
rational use
Standard F7 Thefacility hasdefined procedures for safe drug administration

Standard F8 Thefacility hasdefined andestablishedproceduresfor

maintaining,updatingofpatients’clinicalrecords and their
storage.
Standard F9 Thefacility hasdefined
andestablishedproceduresfordischargeofpatient.
Standard F10 Thefacility hasdefined andestablishedproceduresfor intensivecare.

Standard F11 Thefacility hasdefined andestablishedproceduresfor

EmergencyServicesa Disaster Management.
Standard F12 Thefacility hasdefined andestablishedproceduresofdiagnosticservices

Standard F13 Thefacility hasdefined andestablishedproceduresfor

BloodBank/StorageManagementand Transfusion.

Standard F14 Thefacility hasestablishedproceduresforAnaestheticServices.

Area of Concern - G: Quality Management
Standar The facility has established organizational framework for quality improvement.
d G1
Standar The facility has established system for patient and employee satisfaction.
d G2
Standar The facility has established internal and external quality assurance Programmes
d G3 wherever it is critical to quality
Standar Thefacility
d G4 hasestablished,documentedimplementedandmaintainedStandardOperatingPr
ocedures for all key processes and support services
Standar Thefacility maps itskeyprocessesandseekstomakethemmoreefficientby
d G5 reducingnonvalue addingactivities and wastages
Standar Thefacility hasestablishedsystemof periodicreviewas internalassessment,
d G6 medical&death audit and prescription audit.
Standar Thefacility hasdefined Mission,Values,Quality policy
d G7 andObjectives,andprepares astrategicplanto achieve them.
Standar Thefacility seeks continually improvementbypracticingQualitymethodsand
d G8 tools.
Standar Thefacility hasdefined, approvedandcommunicatedRisk
d G9 Managementframework forexisting and potential risks.
Standar Thefacility has established procedures for assessing,
d G10 reporting,evaluatingand managingriskasperRisk Management Plan

Area of Concern - H: Outcome Indicator

Standard H1 The facility measures Productivity indicators and ensures compliance
with State/National benchmarks.
Standard H2 The facility measures Efficiency indicators and ensure to reach
State/NationalBenchmark.
Standard H3 The facility measuresClinicalCare&Safetyindicatorsandtries toreach
State/Nationalbenchmark.
Standard H4 The facilitymeasures ServiceQualityindicatorsand endeavours
toreach State/Nationalbenchmark
Component of quality measurement system and their intent:
The main pillars of Quality Measurement Systems are Quality Standards. These
standards have been defined for various levelof facilities. The Standards have been grouped
withinthe eight Areas of Concern. Each Standard further has specific Measurable Elements.
These standards and measurable elements are checked in each department of a health
facility through department specific Checkpoints. All Checkpoints for a department
are collated, and together they form assessment tool called ‘Checklist’. Scored/filled-in
Checklists would generate scorecards.

Following are the area of concern in a health facility:

1. Service Provision
2. Patient Rights
3. Inputs
4. Support Services
5. Clinical Services
6. Infection Control
7. Quality Management
8. Outcome

ASSESSMENT PROTOCOL:

A. General Principles
Assessment of the Quality at Public Health facilities is based on general principles
of integrity, confidentiality, objectivity and Replicability
1.Integrity.
 Assessors and persons managing assessment programmes should
 Perform their work with honesty, diligence and responsibility
 Demonstrate their competence while performing assessment
 Performance assessment in an impartial manner
 Remainfairand unbiasedin their findings
2. Fair Presentation
 Assessmentfindingsshouldrepresentthe assessment activities
truthfullyand accurately.Anyunresolved diverging opinion should
between assessors and assesses should be reported.

3.Confidentiality.
  Assessors should ensure that information acquired by them during the course
of assessment is not shared with any authorised person including
media. The information shouldnot beusedfor personalgain.

4.Independence.
 Assessors should be independent to the activity that they are assessing and
should act in a manner thatisfreefrombias and conflictof interest.for
internalassessment,the assessorshould not assess his or her
own department and process. After the assessment, assessor should handhold
to guide the service providers for closing the gap and improving the services.

5.Evidence based approach.

 Conclusionsshouldbearrived based onevidences,whichare
objective,verifiableandreproducible.

B. Planning Assessment Activities

Following assessment activities are undertaken at different level
1. Internal Assessment at the facility level– A continuous process of assessment within
the facility by internal assessors. 1.
2. Assessment by District and State Quality Assurance Units.
3. Accreditation assessment – Assessment by national assessors for the purpose for
certification/ accreditation
Internal Assessment- Internal assessment is a continuous process and integral part of facility-
based Quality assurance program. Assessing all departments in a health facility every month
may not be possible. The hospital should prepare a quarterly assessment schedule. It
needs to be ensured that every department would be assessed and scored at least once in
a quarter. This plan should be prepared in consultation with respective
departments. Quality team at the facility can also prioritize certain departments, where
quality of services has been a cause of concern.
For internal assessment, the Hospital QualityTeamshouldappointa
coordinator,preferablythehospital managerorquality manger, whose main responsibilities are
given below: -
1. Preparing assessment plan and schedule.
2. Constitute an assessment team for internal assessment.
3. Arrange stationary (forms & formats) for internal assessment.
4. Maintenance of assessment records.
5. Communicating and coordinating with departments.
6. Monitor & review the internal assessment programme
7. Disseminate the findings of internal assessment.
8. Preparation of action plan in coordination with quality team and respective
departments.
Assessment by DQAU/SQAU – DQAU and SQAU are also responsible for
undertaking an independent quality assessment of a health facility. Facilities having poor
quality indicators would have priority in the assessment programme. Visit for the
assessment should also be utilised for building facility level capacity of quality assurance
and handholding. Efforts should be made to ensure that all departments of the hospital
have been assessed during one visit.
C. Constituting assessment team
Assessment team should beconstitutedaccording tothe scope
ofassessmenti.e.departmentsto beassessed. Team assessing clinical department
should have at least one person form clinical domain preferably a doctor, assessing
patient care departments. Indoor departments should also have one nursing staff in the
team. It would be preferable to have a multidisciplinary team having at least one doctor
and one nurse during the external assessment. As DQAU/ SQAU may not have their own
capacity for arranging all team members internally, a person form another hospital may
be nominated to be part of the assessment team. However, it needs to be ensured that
person should not assess his/herowndepartmentand there isno conflictof
interest.for externalassessment,the teammembers shouldhave undergone the
assessors’ training.
D. Preparing assessment schedule
Assessment schedule is micro-plan for conducting assessment. It constitutes of details
regarding departments, date, timing, etc. Assessment schedule should be prepared
beforehand and shared with respective departments.
E. Performing Assessment –
I) Pre-assessmentpreparation–Teamleaderof the assessment team
shouldensurethatassessment schedulehas been communicated
torespectivedepartments.Teamleadershould assign the area of
responsibilitytoeachteammember,according to the schedule and competency of the
members.
ii) Opening meeting – A short opening meeting with the assesses department or hospital
should be conducted for introduction, aims & objective of the assessment and role clarity.
iii) Reviewing documents –The availablerecords and documents such as
SOPs, BHT, Registers, etcshould bereviewed.
F. Communication during assessment
Behavioursandcommunicationof theassessors shouldbepolite and
empathetic.Assessmentshouldbe fact findingexerciseandnot afault-
findingexercise.Conflictsshouldbeavoided.
 G. Using checklists Checklists are the main tools for the assessment. Hence, familiarity
with the tools would be important
Assessor should gather information and evidences to assess compliance to the
requirement of measurable element and checkpoints at Health Facility being assessed.
Information can be gathered by following four methods.
i) Observation– Compliance to many of the measurable elements can be assessed by
directly observing the articles, processes and surrounding environment. Few
examples are given below
a) Enumeration of articles like equipment, drugs, etc.
b) Displays of signages, work instructions, important information.
c) Facilities - patient amenities, ramps, complaint-box, etc.
d) Environment – cleanliness, loose-wires, seepage, overcrowding,
temperature control, drains, etc.
e) Procedures like measuring BP, counselling, segregation of biomedical
waste,
Record Review – It may not be possible to observe all clinical procedures. Records
also generate objective evidences, which needtobetriangulated with
findingoftheobservation.Forexample,onthedayofassessment,drug
trayinthelabourroommay have adequate quantity of Oxytocin, but if review of the
drugexpenditure register reveals poor consumption pattern of Oxytocin, then more enquiries
would be required to ascertain on the adherence to protocols in the labour room. Examples of
the record review are given below
a) Review of clinical records - delivery note, anaesthesia notes, maintenance of
treatment chart, operation notes, etc.
b) Review of department registers like admission registers, handover registers,
expenditure registers, etc.
c) Reviewoflicenses,formatsfor legal compliances like Blood bank
licenseandform‘f’ forPNDT.
d) Review of SOPs for adequacy and process
e) Reviewofmonitoring records–TPR chart, input/output
chart,culturesurveillancereport,calibration records, etc.
f) Review of department data and indicator
iii. Staff interview –Interaction with the staff helps in assessing the knowledge and
skill level, required for performing job functions. Examples
a) Competency testing – Quizzing the staff on knowledge related to their job
b) Demonstration – Asking staff to demonstrate certain activities like hand-washing
technique, new born resuscitation, etc.
c) Awareness - Asking staff about awareness off patients’ right, quality policy, handling
of high alerts drugs, etc.
d) Attitude about patient’s dignity and gender issues.
e) Feedback about adequacy of supplies, problems in performing work, safety issues, etc.
 iv. Patient / Client Interview– Interaction with patients/clients may be useful in getting
information about quality of services and their experience in the hospital. It gives us users’
perspective. It should include
a) Feedback on quality of services staff behaviour, food quality, waiting times, etc.
b) Out of pocket expenditure incurred during the hospitalisation.
c) Effective of communication like counselling services and self-drugadministration
Assessor may use one these method to asses certain measurable element. Suggestive
methods have been given in the Assessment methodcolumn against
eachcheckpointMeansofverificationhas been given against each
checkpoint.Normalflow ofgatheringinformationassessmentwouldbe asgiveninfigure
4 -

Figure 4: Flow of Information

Familiarise with Measurable element and Checkpoint

Understand the Assessment method and Means of verification

Gather the information & Evidence

Compare with checkpoint and meansof verification

Arrive at a conclusion for compliance

H. Assessment conclusion
After gathering information and evidence for measurable elements, assessors should
arrive at a conclusion for extent of compliance - full, partial or non-compliance for each
of the checkpoints. If the information and evidence collected gives an impression of not
fully meeting the requirements, it could be given ‘Partial compliance’, provided there
some evidences pointing towards the compliance. Non-compliance should be given of
none or very few of the requirements are being met.
After arriving on conclusion, assessor should mark ‘C’ for compliance, ‘P’ for partial
compliance and ‘N’ for noncompliance in Compliance column.