The document discusses a pilot program to introduce a quality management system for hospitals empaneled under the Rashtriya Swasthya Bima Yojana (RSBY) health insurance scheme in Kerala, India. Over 4 years, 28.1 lakh families (54 lakh people) have been covered under RSBY through 353 empaneled public and private hospitals. The pilot program aims to grade hospitals on a scale of E to A based on criteria covering infrastructure, services, management, and patient care. Hospitals in Thiruvananthapuram district will be initially assessed and graded in order to encourage continuous quality improvement over time.

1. Quality of Health Care services for
RSBY Network Hospitals in the State
of Kerala

2. Quality of health care in RSBY : Pilot in the State of Kerala
2
• Almost 4 years completed by RSBY in state.
• 28.1 lakh families (approx. 54 lakh
population) covered.
• 353 hospitals (Public-153 and Private-200)
empanelled as RSBY network hospitals.
• No consistent nationally applicable quality
improvement process.
• Introduction of Quality Management System
for RSBY Empanelled Hospitals.
Introduction
6-7 Sept 2012

3. Quality of health care in RSBY : Pilot in the State of Kerala
3
– To enable the provision and coordination of health
services which are:
– Equitable
– Patient centered
– Safe
– Effective
– Integrated
– Efficient
– To maintain continuous improvement in quality of
services provided.
– To encourage hospitals to achieve levels of quality over
a period of time.
Objectives
6-7 Sept 2012

4. Quality in medicine
WHO-DALY, LE
Long term
outcomes
-1 yr mortality/ visitation
Short term outcomes
- Hospital mortally.
Process indicators
-Response time etc.
Structural quality
- Availability as per norms
6-7 Sept 2012
Quality of health care in RSBY : Pilot in the
State of Kerala
4

5. Operational Plan
Quality of health care in RSBY : Pilot in the State of Kerala 5
Empanelment
cum grading
criteria
5 Point grading scale (E to A
Grade)
Comprehensive Quality
Criteria Check list provided
by Ministry of Labor and
Employment
Admittance level is “E” Grade
Grading
mechanism
Districts chosen for Pilot
(Thiruvananthapuram)
Quality Criteria Form
Hospitals visited and assessed
Analysis and Grade given
after assessment
6-7 Sept 2012

6. Quality of health care in RSBY : Pilot in the State of Kerala
6
Grade-E
– Basic Empanelment criteria and entry level.
– Includes 10-medical beds, 24 hours drinking water
supply, one toilet for every 12 in-patient beds, basic
system and internet connectivity.
– Medical officer with qualified nursing staff, OT
sterilization, PNDT Act followed, clean bed sheet,
mattresses, bedpans etc, IPD records, Labor room
requirements.
– Hospitals not fulfilling Grade-E will be given 3
months time to upgrade to acceptable level.
Grading criteria
6-7 Sept 2012

7. 7 Grade-D
– Grade D is accepted level in RSBY
– Includes patient mobility within hospital like ramp,
an information provider, documented evaluation and
management of patient, informed consent, providing
discharge summary and other documents to patient.
– OT specifications fulfilling, mopping of all areas of
hospital, emergency power back up.
– System of registration of patient, provision of
privacy, female attendant.
– Privacy of patient and emergency power back up etc.
– Will be motivated to attain to C Level.
Grading criteria-2
6-7 Sept 2012
Quality of health care in RSBY : Pilot in the
State of Kerala

8. Quality of health care in RSBY : Pilot in the State of Kerala
8
Grade-C
– Augmenting supportive services.
– Dietary services, laboratory, radiological services.
– Proper nursing units managed by registered
qualified and experienced nurse.
– Patient care by medical and nursing professionals,
documented rounds, pre-post operative care of
patients, arrangements to meet emergency.
Grading criteria-3
6-7 Sept 2012

9. Quality of health care in RSBY : Pilot in the State of Kerala
9
Grade-B
– Included Intensive Care Unit .
– Blood Bank, documented infection control
practices, proper radiology services, mortuary
services,
– Zoning of OT complex.
– AMC of major medical equipments etc.
Grading criteria-4
6-7 Sept 2012

10. Quality of health care in RSBY : Pilot in the State of Kerala
10
Grade-A
– 24x7 emergency services.
– 24x7 pharmacy facility.
– Qualified anesthesiologist to attend ICU.
– Hospital management system in place.
Grading criteria-5
6-7 Sept 2012

11. Grading criteria-6
Quality of health care in RSBY : Pilot in the State of
Kerala 11
ACCESS AND
PHYSICAL FACILITIES
ManagementAvailability of
Staff
Evaluation and
Care of Patients
Operating
Department
Laboratory
services
Radiology
Diagnostic Services
Infection Control
Practices
Hospital Waste
Management
Support
Services
Access to Blood
Bank
Patient Rights
and Education
Medical
Records
Health and
Safety
Labor Room
ICU
•10 inpatient medical beds for
inpatient health care.
•Availability of 24 hours drinking
water supply
•One toilet for every 12 in-patient
beds
•Adequate privacy in OPD
•Running tap water is facility hospital
•Warm water for winter months.
•Access to road allowing to
Ambulance
•Hospital accessible by wheelchair;
Ramp
•Reception desk Emergency electric
supply.
•Maintaining of medical record
•Documented lines of
responsibility
•Management system in place
•Written and dated job
descriptions
•Written agreement with working
Doctors
•Regular monitoring and review
meeting
•1 medical officer & 1 nurse at all
times
•1information provider at all times
•Registered nurse qualified and/or
experienced per ward
•There is a system for calling
specialists in an emergency
•Emergency department have
MBBS 24x7 basis
•Pre admission physical
examination and medical history
taken written informed consent is
taken
•A copy of the Discharge
summary / Death Summary is
provided to the patient/attendant
•IPD patients are evaluated at
least twice a day
•After examining the course of
action on the OPD card is
endorsed
•If patients are transferred to
another hospital copies
of their clinical notes accompany
them
•OT sterilisation facilities functional.
•Adequate lights and Air conditioning in each
OT
•Height adjustable OT Table, shadowless lamp
•The operating theatre fully equipped for its
purpose
•Informed patient concern andPre-operative
care
•Emergency power supply for OT
•Zoning of OT
•AMC for all major equipments.
•Sterilabels used for autoclaving
•Test results should be
recorded in the Lab
registers, requisition slip
and on the OPD card
•A system for registration of all
investigations for identification
•Written, dated and signed
procedures for the
collection, reception, handling,
abeled, storage,
transportation and disposal of
samples
•All laboratory equipment is
subject to a planned
inspection, and calibration
•Staff are offered appropriate
immunisations
•The services and facilities satisfy statutory
requirements under the PNDT Act
•Test results should be recorded not only in
the x-ray
registers, requisition slip and the OPD card
•Female attendant to accompany female
patients during radiological procedures
•Arrangements are in place for dealing with
out of hours or emergency requests.
•There is an in-charge radiology/ or the
radiologist Signs IN LOCAL LANGUAGE warning
women of childbearing age has dangers of
radiation in pregnancy.
•The protection of staff conforms to the BARC
guidelines
•The waste disposal is in accordance
with the Biomedical waste
management & handling rules
1998
•The health facility has a valid license
from the PCB
•Availability of colour coded Bin in
each ward
•Collection of waste done as per
guidelines in wards,
OPD,OT, labour room.
•Waste treated with bleach or any
solution before disposal
•Fresh clean bedsheets and changed
when required for the patient.
•Bed mattresses of the patients are in
good shape
•Clean bedpans and urinal pans and
dustbin are
available .
•Dietary services are made available to
patients.
•Hygine delivery in place to the IPDs
Laundary system in place
•The health facility has
mechanisms in place for
adequate quantity of blood
without loss of time.
•Storage center meets the
licensing requirement of the Drugs
and Cosmetic Act and Supreme
Court rules
•Blood collected is labeled
appropriately with the donors
name, registration number, blood
group, date and time of collection
and date of expiry, tests carried
out.
•There is adequate provision for patient privacy
in the form of screens and curtains etc
•Rights and responsibility of the patients/
Information
for patient education are displayed at
prominent
places in the health facility.
•The facilities available and services provided
and the charges are also prominently displayed
•There is adequate provision for patient privacy
in the form of screens and curtains etc
•There is evidence that there is a documented
grievance redressal mechanism which is
practised
•Maintaining of necessary records as
required and providing necessary records of
the insured patient to the Insurer or his
representative / Government / Nodal Agency
as and when required.
•There is evidence that the hospital has a
documented policy on creation and
maintenance of
medical records which is practiced
•All emergency telephone numbers concerned with
Health and Safety are displayed
•Pictograms indicating fire exits and escape routes
are properly displayed
•Relevant safety information is available including
Safety regulations,Fire precautions, AIDS/HIV/Other
guidelines
•Hospitals records should be maintained on all
Accidents,Errors, Incidents,Near misses and Violent
episodes.
• There should be evidence of management action
arising from incident reporting i.e. each case is
individually investigated, evaluated and acted upon.
•The Labour room/OT should have Delivery table
Anesthetic machine with emergency
oxygen supplies resuscitation equipment and drugs
for infants and adults
•There is a suitably experienced and qualified
doctor responsible for the day to day management
of the unit.
•A trained mid-wife/nurse is present at every birth.
•Records kept after discharge include maternity
notes and birth registration
•The hospital has 24 hour on-site cover from
qualified medical doctors (including
anesthesiologist An emergency power system
provides heat and light in the event of a mains
power failure.
•A qualified pediatrician to attend Newborn.
•Designated air conditioned space
•Standard ICU bed equipment for the
constant monitoring for vitals emergency
crash cart, defibrillator ventilators,
suction pumps, bedside oxygen facility
•Anesthesiologist-Intensivist
•Nursing Staff: B.Sc Nursing/Diploma:
have 2 years of ICU care of Ratio 1: or 2:1
•Mopping of all areas at least
twice a day with disinfectant
Shredders / needle destroyers are
available in all clinical areas
•Mechanisms to ensure toilet
sanitation (duty roasters for
sweepers)
•Documented Infection control
protocols in place
•Regular documented autoclaving
of instruments &
linen
•Carbolisation of the OT, Labor
Room after every
procedure
17 Sub criteria
6-7 Sept 2012

12. Grading -7
6-7 Sept 2012
Quality of health care in RSBY : Pilot in the
State of Kerala
12
Criteria Count
Access and facilities 23
Management 8
Availability of Staff 5
Evaluation and care of inpatient 8
Anesthesia 4
Operating departments 10
Laboratory services 10
Radiology services 13
Infection control 7

13. Grading-8
Criteria Count
Hospital waste management 7
Support services 7
Access to blood bank 6
Patient rights and education 8
Medical records 3
Health and safety 9
Labour room if available 6
Intensive care unit 4
6-7 Sept 2012
Quality of health care in RSBY : Pilot in the
State of Kerala
13

14. Grading mechanism
14
Districts for
Pilot Study
Thiruvananthapura
m
27 public
27 private
Hospitals
visited and
assessed
• Empanelment
cum grading
criteria filled1
• Infrastructure
and services
assessed
Analysis and
grade given
after
assessment
• Grade from E
to A
6-7 Sept 2012
Quality of health care in RSBY : Pilot in the
State of Kerala

15. Grading Criteria
Quality of health care in RSBY : Pilot in the State of Kerala
15
Grade Benchmark
Below E
less than 15 (the hospital will not be meeting in
any of given criteria properly.
Grade E 15 + 50% of D
Grade D E (15) + 14 + 25 % of C
Grade C E + D + 80 % of C + 80% of B
Grade B E + D + 80 % of C + 80% of B + 50 % of A
Grade A E + D + C + B + A
E-19,D-32,C-32, B-31, A-24
6-7 Sept 2012

16. Quality of health care in RSBY : Pilot in the State of Kerala
16
a) Hospitals not meeting detailed empanelment criteria
will be given time to improve or would be de-
empanelled
b) Hospitals meeting just the revised empanelment
criteria will be placed in the lowest grade E. These
hospitals would continue to be empanelled providers
but would be advised to work towards achieving next
higher grade within next 3 months failing which it
will be de-empanelled.
c) Hospitals meeting and exceeding the empanelment
criteria would be graded from Grade D-A.
(
Follow up
6-7 Sept 2012

17. 6-7 Sept 2012
Quality of health care in RSBY : Pilot in the
State of Kerala
17
Thanks for kind attention
More details on:
www.rsby.gov.in
Or
Dr K Madan Gopal
madan.kavuru@giz.de