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LaQshya - Labour Room Quality Improvement Initiative Guideline
LaQshya - Labour Room Quality Improvement Initiative Guideline
AL
NATION
ISSI N
O
Table of Contents
1. Introduction ............................................................................................................................................1
2. Goal ..........................................................................................................................................................3
3. Strategies ..................................................................................................................................................4
4. Scope ........................................................................................................................................................5
6. Targets ......................................................................................................................................................9
7. Interventions .........................................................................................................................................11
Annexures .....................................................................................................................................................22
Annexure ‘B’..........................................................................................................................................23
Annexure ‘C’..........................................................................................................................................24
Under the National Health Mission, the States within the QA organizational framework.
have been supported in creating Institutional Outlines of Institutional arrangement under
framework for the Quality Assurance - State LaQshya is given in Figure 1.
Quality Assurance Committee (SQAC), District
Quality Assurance Committee (DQAC), (a) National Level
and Quality Team at the facility level. These
committees will also support implementation y National Mentoring Group would include
of LaQshya interventions. For specific technical members of the Programme Divisions,
activities and program management, special IEC Division, NHSRC, NIHFW, AIIMS,
purpose groups have been suggested, and these and Medical Colleges, Nursing collages,
groups will be working towards achievement Schools of Public Health, Professional
of specific targets and program milestones Associations, Hospital Planners, IT
in close coordination with relevant structures professionals, Development Partners,
National
National Level CQSC
Mentoring Group
State
State Level SQAC
Mentoring Group
Responsibilities Responsibilities
i. Periodic visit to the states, and to a i. Visit to the facilities and ‘on-site’ support
sample of the health facilities. for under performing facilities.
ii. Orientation and training. ii. Training & mentoring of the coaching
teams.
iii. Standardization of skill based training
programs. iii. Customisation and approval of SOPs &
Work-instructions.
iv. Development of IEC & resource
material. iv. Performance monitoring.
5. 30% increase in Breast Feeding within 7. 80% of all beneficiaries are either satisfied
one hour of delivery. or highly satisfied.
Structural improvement will include the d) Strengthening the supply chain system
following : of drugs & consumables for ensuring
Labour Room
Standardisation
Structural
Baseline Improvement
Human Resource Labour Room
Assessment Strengthing Certification
(using Guidelines
for LR
Standardisation, Improved
MNH Toolkit & Maternal health
Quality Circles
NQAS) stillbirth &
Process Newborn Health
Improvement Rapid Indicators
Improvement
Cycles-Campaign
13. Use aggressive IEC, user friendly training c) Cycle 3: Assessment, Triage and timely
material and IT-enabled tools. Facilitating management of complications including
branding of all high case load facilities strengthening of referral protocols.
Preparatory Phase
Assessment Phase
2 Months
$Dissemination Improvement Phase
2 Months
$TeFormation
$t Evaluation Phase
$Orientation 12 Months
$#
$ #s $
ov
$
# 2 Months
$Re $Ev
$
ovement hievements
$Te! $ #rtn
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ii. Assessment of the Labour Rooms & xii. Initiation of Patients’ satisfaction survey
Maternity OT against National Quality among all patients reporting in the labour
Standards. room & operation theatre.
iii. Planning for expansion of Labour rooms xiii. Development of IT platform for the
as per ‘Guidelines for Standardisation of initiative or integration with existing IT
Labour Rooms at Delivery Points’ and platform.
upgradation the Maternity OT.
iv. Preparation of time bound action plan, c. Improvement Phase -
based on the identified gaps. 12 Months
v. Planning for creation of Obstetrics HDU i. Launch of rapid improvement cycles.
as per recommendations of ‘Guidelines Each cycle includes one month of
for Obstetrics HDU & ICU’. improvement and subsequent month of
vi. Collation of requirements and resource consolidation and sustenance.
allocation through the PIP process under ii. Ensuring adherence to clinical protocols
the NHM. & peer-mentoring.
vii. Mapping of referral facilities (type of iii. Establish Standard Operating Procedures
facility, distance & travel time, contact for labour rooms& maternity OT.
details, availability of services including
facility for the blood transfusion, iv. Quality Circle understands the issues
availability of other specialities such regarding selected theme of alternate
as Physician, Surgeon, Pathology & month and will try to improve the
Biochemistry lab & Ultrasound facility, processes using quality improvement
nearest tertiary care institution). methodology (Plan – DO – Check –Act)
cycle, and sustain them (Figure 4).
viii. Ensuring availability of updated version
of clinical protocols for end users and v. Preparatory visit, followed by monthly
training of labour room & OT staff. visits – Visits in the second month of
each improvement cycle would be in last deployment & skill upgradation in the
week for performance review through labour room & OT will go in parallel.
objective indicators. Support for the
xi. Concurrent evaluation of quality
forthcoming campaign would also be
indicators by SQAC and MH Division/
extended during this visit.
NHSRC and feedback to quality circles.
vi. Documentation and photography of the
xii. Analysis of Patients’ feedback and taking
improvement.
actions for addressing the beneficiaries’
vii. Observation and assessment of concerns.
processes, refresher & hands-on training,
demonstrations and hand-holding. d. Evaluation Phase - 2 Months
viii. IEC campaign for each improvement i. Evaluation of the quality objectives and
cycle – This includes reading material/ indicators.
brochure on the theme, short videos,
presentations, etc. disseminated through ii. External Assessment & Quality certification
social media/dedicated IT platform. of labour rooms & Maternity OT.
ix. Collection and reporting of indicators iii. Awards to best performing quality circles
linked with quality objectives of and Coaching Teams.
each cycle from quality circle to State iv. National level dissemination of
Mentoring Group & SQAC. achievements.
x. Structural augmentation including re- v. Development of Strategy for sustenance
arranging the layout & human resource and scaling-up.
y 80% of the beneficiaries are either These badges should be worn by the care
satisfied or highly satisfied (or providers as well as prominently displayed at
Equivalent score > 4 on Likert scale). relevant places in the hospitals.
Based on Gap analysis, the state may budget Suggested activities for the budgetary support is
the resource requirements and request for given in Box 1.
allocation of the funds in relevant financial There will also be resource requirements for
heads through the NHM PIPs. The PIP would organising trainings, assessment, mobility
include proposals for strengthening the Labour support and other incidental expenses. The
rooms & maternity OTs in the government State may request for allocation of the resources
medical colleges as well. through PIP under NHM.
The initiative will be coordinated by the and consultants at the national level for
Maternal Health Division and supported coordination and intense monitoring of
by the Child Health Division and NHSRC. activities in the States. This unit will keep track
Maternal Health Division will facilitate of the scheduled activities, collate and analyse
preparation of resource package for the the indictors, coordinate with the national
labour room reorganization & standardization mentors and facilitate the training programs.
and improvement in Quality of Care This unit will report to Deputy Commissioner
(QOC), coordinate with the states &UT’s I/C Maternal Health and Advisor
for smooth roll out of the initiative, collate QI NHSRC.
quality scores and indicators, ensure synergy
with the development partners, review PIP In the States, Maternal Health Program officer/
proposals for labour room & maternity OT State Quality Assurance Nodal Officer may be
upgradation, creation of obstetric HDU designated as nodal officer for implementation
and staff augmentation. NHSRC would of the initiative. Coordination with the
coordinate quality certification activities Medical Colleges through Medical Education
under this initiative, undertake documentation Department would be critical. Based on the
of best & replicable practices for cross- number of facilities under this initiative in first
learning and provide necessary support for phase, the states may hire a full-time project
successful implementation of the programme. manager.
Development partners may synergize their
activities for supporting the roll-out of the At the district level, Maternal Health Nodal
scheme in their priority States, support officer & Nodal Officer for Quality Assurance
National& State Mentoring Groups, and will be responsible for this implementing the
support development of technical resource activities.
material as required.
Details of activities, required to be undertaken
A small project management unit may be by different stakeholders are given in
established with full time program managers Annexure ‘D’.
Under the LaQshya initiative, multiple The data for these indictors can be directly pulled
interventions are envisaged to be undertaken from the respective systems. All indicators need
within the stipulated time frame and impact of to be reported by facility on monthly basis after
interventions is required to be simultaneously verification from respective coaching teams.
measured through verifiable indicators in real
Monitoring of the program activities
time. Therefore, efficient reporting of status of
such as assessment, labour room & OT
activities and achievement of targets are critical
reorganization, progress on establishing
for the success of initiative.
HDU, trainings, visits of coaching teams etc.
A dedicated data entry module and dashboard Will be done through a dedicated web based
may be created in this purpose. Many of these tracking system. This website will also host all
indicators are already reported through HMIS, relevant guidelines, resource material, updates
Labour room, HIS and SNCU online system. and progress reports.
Annexure ‘A’
Promoting Respectful Maternity Care & Cognitive Development of Baby
Comfortable Birth Avoiding
Position during Birthing Companion Stress
Encourage mothers to Walk,
Timely arrival to avoid
Move around and Change Educating Birth
emergency stress
position during Labour companio
Promotes cognitive
development of babies
Do not separate mother Avoid Induction
LDR Concept
and baby for routine care of Labour
No use of radiant Avoid Augmentation
Avoid Bright Lights
warmer for routine care of Labour
All the labour rooms, whether newly constructed or re-rganized from an existing labour room,
should have Human Resources (HR) in adequate numbers strictly, as per the recommendations
given below. If needed, redeployment or hiring of new staff should be done. HR posted in the
labour room should not be rotated outside the labour room.
CHC/AH/SDH/DH/Medical Colleges
No. of Staff Nurse Staff Nurse MO House- DEO Guard
Deliveries (with LDR) (without keeping
(per month) LDR)
100 – 200 In LDR 8 4 MO, 1 OBG/ EmoC, 4 1 4
facility 1 Anaesthetist/ LSAS,
there 1Pediatrician
200- 500 should be 4 12 1 OBG (Mandatory) + 4 OBG/ 8 1 6
staff nurses EmoC
per LDR +1 Anaesthetist
unit (1 for + 4 LSAS
each shift + 1 Paediatrician
and 1 back + 4 MO
up)
>500 16 3 OBG (Mandatory) + 4 EmoC 12 1 8
+1 Anaesthetist
+ 4 LSAS
+ 1 Paediatrician
+ 4 MO
PHC
MO Staff Nurse/ ANM Housekeeping Guard
1-2 4 ANM/ Staff nurses Round the clock Services Round the clock
services
*All normal deliveries in labour room in the district hospital should be conducted by staff nurses. OBG, EmoC trained MO, and
anaesthetists should also be available on call always.
15th Month Launch of Ensuring Infection Facility visit for Ensuring Hand
Imp- Improvement Control protocols are on-site training Hygiene and personal
rovement Cycle on Infection disseminated to all and handholding protection practices
Cycle 6 Prevention and Waste labour rooms for Infection Ensuring waste is
management Arranging booster prevention and waste disposed as per BMW
Dissemination of training of Labour management rules 2016
Resource Package on Room In charges/
Ensuring sterilized
Coaching teams if
infection control instrument and
necessary through
existing program such supplies are available
as Dakshata and Skill for delivery and
Labs newborn care
Ensuring supplies for Ensuring staff is
infection control and trained and skilled for
waste management infection control and
are in place Waste Management
16th Month Collating and analysing Collating & analysing Handholding the Standardizing
state wise progress the progress, Quality Circle for and sustain the
Assisting states not Improvements and sustaining the efforts improvement gained
making expected Indicators, of Cycle 1, 2, 3, 4, 5 in Cycle 1, 2, 3 & 4, &
progress Focusing on the &6 5&6
facilities not making Verifying the Reporting the
Visit of National
expected progress indicators Indicators
Mentors to sample
including onsite visit
facilities
if necessary
y If Labour rooms are ready they can apply for the NQAS certification early.
y Actions for closure of structural and HR gaps will be initiated simultaneously. State and facility
incharges should ensure that Labour Room preferably in LDR format with requisite equipment
and HR are ready within one year of commencement of this initiative.
y Rapid Improvement Cycles have been planned to emphasize and improve critical processes
through more focused campaign mode. Focusing on one issue doesn’t mean that other issues
will not be addressed in that window period. Critical gaps should be addressed as and when
required. Improved practices and performance gained during one campaign should be sustained
during the subsequent cycles.
y Indicators will be reported on monthly basis in the first week of next month.