PRC Report Series 2019-20: 2 Enablers and Barriers of NQAS Certification of Hospitals in Kerala Population Research Centre Kerala Ministry of Health and Family Welfare Government of India University of Kerala Thiruvananthapuram 2020 KIRAN ffce2007 1/1/2020 Ohm Contributor Dr. Sajini B Nair District level Contributors Dr. Shylaja L, Dr. Sajini B Nair, Dr. Sreeranjini A, Dr. Oommen P Mathew, Anilkumar K, Dr. Sureshkumar S, Dr. Anithakumari K.R, Sachin K V, Dr. Rajesh J Nair, Dr. Saritha P Viswan and Dr, Sajitha B . 2 | NQAS Certification CONTENTS Foreword 4 Executive summary 6 1. Introduction 8 2. Objectives 10 3. Data and Methodology 10 4. Results 13 4.1 The Kerala Context 13 5. Thiruvananthapuram District 16 5.1 Family Health Centre Poozhanad 16 5.2 Family Health Centre Chemmaruthy 27 5.3 District Hospital Nedumangad 37 5.4 Community Health Centre Poonthura 48 5.5 Family Health Centre Kilimanoor 54 5.6 Family Health Centre Aruvikkara 59 5.7 Family Health Centre Kottukal 63 5.8 Family Health Centre Thonakkal 69 6. Wayanad District 74 6.1 District Hospital Mananthavadi 74 6.2 Family Health Centre Noolpuzha 78 6.3 Family Health Centre Poothadi 89 6.4 Family Health Centre Vengapally 93 6.5 Family Health Centre Appapara 94 7. Palakkad District 96 7.1 Primary Health Centre Peruvemba 96 7.2 Primary Health Centre Thirumittacode 102 3 | NQAS Certification 7.3 Family Health Centre Sreekrishnapuram 102 7.4 W & C Hospital Palakkad 107 7.5 Community Health Centre Koduvayur 111 8. Kollam District 113 8.1 Taluk Head Quarter Hospital Punalur 1114 8.2 Family Health Centre Elampalloor 127 8.3 Family Health Centre Chathannoor 132 8.4 Family Health Centre Perumon 136 8.5 Family Health Centre Kottamkulangara (Chavara) 140 8.6 Family Health Centre Chadayamangalam 145 8.7 Family Health Centre Kulashekarapuram 148 9. Impact of NQAS Accreditation 153 10. Conclusion 156 References 167 4 | NQAS Certification Foreword National Quality Assurance Standards (NQAS) initiative introduced in India brought about tremendous changes in quality of service in the hospitals. Government of Kerala had introduced the Navakerala Mission under which the Ardram Mission provided quality healthcare services in Government hospitals by adding specialty and super specialty facilities in District and Taluk Hospitals and developed Primary Health Centres (PHC) into Family Health Centres (FHC), capable of meeting the healthcare needs of all members of the family. When the hospitals in Kerala underwent the NQAS assessment process, they topped the list of hospitals in India, further raising the reputation of the State at the National level. PRC Kerala embarked on the study on NQAS certification as per the guidelines of the Ministry of Health and Family Welfare, Government of India. The enablers and barriers to NQAS accreditation are studied so as to highlight the process of maintaining quality standards in the State. The districts selected are those selected for NHM PIP Monitoring in Kerala as per the guidelines of the Ministry and hence 25 health facilities including District hospitals, CHCs and PHCs/FHCs form the sample. PRC Kerala sincerely thank the Ministry of Health and Family Welfare, Government of India for conducting studies on NHM Flagship programmes which gave the PRCs the opportunity to carryout the study in the State. We sincerely place on record our gratitude to Dr. Rajan N. Khobragade IAS, Principal Secretary, Health and Family Welfare, Government of Kerala, Dr. Rathan Kelkar IAS, State Mission Director, NHM Government of Kerala, Dr. Sarita.R.L, Director of Health Services, Government of Kerala, Dr. Raju.V.R, Addl.DHS Family Welfare for granting permission and Ms. Beula G.S, Urban MIS Manager, NHM for providing information to carry out the study in Kerala. We sincerely thank the District Programme Managers and District Medical Officers for facilitating the study in the selected districts. Our sincere gratitude goes to the Medical Superintendents, Medical Officers, Staff Nurses, and paramedical and field staff for the time they shared amidst their responsibilities in sharing information for the completion of the study. The PROs of the selected health facilities deserve sincere appreciation for their unending support. I appreciate Dr. Sajini B Nair, Social Scientist for coordinating the study and all the Officers of PRC Kerala for their team work in successfully completing the study on time. I am sure that the findings of the study will be of great use to the State Health Services, Academicians and Policy makers in planning and policy making. Kariavattom Dr. P Mohanachandran Nair March 2020 Director-in charge 5 | NQAS Certification Executive Summary National Quality Assurance Standards (NQAS) assessment has revolutionized the quality aspects of hospitals in the country. NQAS Certification process in Kerala has given a great opportunity to the State to work for best quality standards thereby portraying the quality of care maintained in its hospitals. The top positions occupied by the Primary care institutions of Kerala in the list of NQAS accredited list of hospitals in the country is testimony to this aspect. The present study on this flagship programme of NHM carried out in Kerala identifies the enablers and barriers of NQAS certification of hospitals in the State. Thiruvananthapuram, Kollam, Palakkad and Wayanad, the districts identified by the Ministry of Health and Family Welfare, Government of India for NHM PIP Monitoring during 2019-20 formed the sample. From the selected districts 7 health facilities that have been NQAS accredited are included to understand the factors that enabled the facilities to be certified. The facilities that have applied for NQAS and received Kayakalp awards at the State level formed the second group of 5 facilities which revealed the enablers of excellence in Kayakalp assessment and also the barriers to NQAS accreditation to some extent. The third group included 13 facilities which have to attempt NQAS accreditation reflecting more of the barriers. An understanding of the factors that facilitated the DH/FHC to achieve its goal of NQAS certification was observed to be both intrinsic, extrinsic factors and contextual. The criteria for certification varied between a PHC and a District level hospital and hence the interplay of enabling factors and barriers varied considerably. The ‘Intrinsic Factors’ identified thus have been Services, Team work and Leadership, Staff attitude and Staff Satisfaction, Staff competency and trainings, Functional coordination with field staff, Documentation and Resource availability. The ‘Extrinsic factors’ that enabled NQAS accreditation had been LSGD participation, Involvement of NGOs, Community support, Geographical location (in case of the FHC). A third set of factors that enabled the NQAS accreditation can be derived, the lack of which stood as barriers to development. These are the contextual factors but linked mostly to those explained as intrinsic and extrinsic factors. These are the ‘Contextual factors’ like the Type of hospital, General Administration and Work load . The facilities that had depicted these features with all the services as per guidelines achieved the goal like THQH Punalur at SDH level in Kollam, FHC Poozhanad and FHC Chemmaruthy in Thiruvananthapuram, FHC Noolpuzha and FHC Poothady in Wayanad, FHC Sreekrishnapuram and FGC Peruvemba in Palakkad district. The impact of NQAS accreditation is most conspicuous in the OPD attendance and consequently in the performance of the laboratory. The Kayakalp assessment initiative first offered better infection control and NQAS assessment followed. Conversion of FHCs also happened during 2017. FHC Poozhanad shows a 136 percent increase in OPD attendance and FHC Chemmaruthy depicts 126 percent increase. The lab tests done are proportional to the OP in most of the facilities. An increase of 124 percent in number of lab tests in 6 | NQAS Certification FHC Poozhanad and 85 percent in FHC Chemmaruthy during 2018-19 to 2019-20. In FHC Noolpuzha and FHC Poothady too there has been increase in OPD of 10 to 20 percent. Since these facilities had good OPD attendance during the past 10 years due to its location in a tribal dominated district the utilization has been almost hovering around 5500 per month and has been steady. THQH Punalur, at the Taluk level serves about 60000 patients on an average every month (2019-20). Over 73000 lab tests are performed every month in the lab of this hospital. This has been a steady increase over the years. Among the facilities that fall in group 3 or those which have not achieved desired quality standards in Kayakalp, conversion to FHC has improved service delivery considerably. Among the FHCs under study in Thiruvananthapuram district, FHC Thonakkal tripled its OPD attendance per month in 2 years 2017-18 to 2019-20 whereas FHC Kottukal and FHC Kilimanoor saw its OPD doubling in 2 years and FHC Aruvikkara showed 50 percent increase in OP during the period of 2 years. All the hospitals developed a patient friendly attitude. Attitudinal change in the Staff through trainings is a great achievement. Quality of service improved tremendously with NQAS accreditation. Patient Satisfaction Score is reflective of it. Availability of doctors throughout the day and services rendered are being appreciated by the public. The population of FHCs now owns the hospitals and feels proud for having the centre in their Panchayat. Bonding between the Panchayat and the FHC was strengthened. LSGD involvement in the functioning of the hospitals increased substantially. Documentation of services improved and data quality management has now become a group initiative. Community level activities increased and formation of self help groups, Arogyasena etc brought the people of the community closer to each other. Wherever the field staff led by the Health inspectors kicked off newer initiatives, scoring in certification process contributed immensely. Infact the process of certification of each hospital is a story unique to each be it an FHC/PHC or a District Hospital.