TCIHC Quality Assurance Approach Lets UPHC Staff Tackle Quality Issues on Their Own

Contributors: Izhar Uddin Qureshi and Dr. Renita Bhamrah

A quality Improvement committee meeting at the Sanjay Nagar UPHC led by Dr. Jyoti Gadam (center), who firmly believes that sustained quality will lead to satisfied clients.

The Challenge Initiative for Healthy Cities (TCIHC) in India uses a Quality Assurance (QA) approach that is designed to ultimately lead to a client’s satisfaction with family planning service delivery. India’s National Urban Health Mission specifies dedicated attention and focus on bringing QA to services such as family planning across all service delivery points including urban primary health centers (UPHCs).

In Ujjain, Madhya Pradesh, TCIHC recently conducted an analysis of a Quality Assessment checklist that the medical officer in charge (MoIC) of the Sanjay Nagar UPHC completed with her staff. Dr. Jyoti Gadam was surprised by the findings and said no one had ever done such an analysis of her facility before. The analysis revealed the following issues:

• Since at least November 2018, the UPHC had low volume of about 700 to 800 clients per month
• Only two auxiliary nurse midwives (ANMs) and four accredited social health activists (ASHAs) were working for the facility although 13 ANMs and ASHAs were sanctioned for the facility
• The intrauterine contraceptive device (IUCD) insertion kit had not been utilized since February 2019

TCIHC recommended establishing a Quality Improvement (QI) committee to help collectively identify issues, come up with solutions to address them and then monitor those solutions. Dr. Gadam formed a QI team in April 2019 and its first meeting in May 2019 brought together ASHAs, ANMs, the pharmacist, staff nurses and others to discuss the low volume situation and a possible solution. All of the ASHAs and ANMs agreed to mobilize the community to make them aware of the timing and services available at the facility. The committee also discussed the IUCD issue and agreed to begin utilizing the IUCD kit more.

Other issues discussed in subsequent QI meetings included the injectable Antara that was only administered during the fixed day static services/family planning day. Because of an increase in outpatient volume, the committee decided to make the injectable available to all clients any day of the week. It also assessed data showing a three-fold increase in client volume to 2,000-2,500 clients per month, a clear indication of ASHAs becoming more active in mobilizing clients.

Dr. Gadam said TCIHC also helped them with other aspects, such as staff morale and family planning counseling.

“We oriented the staff nurse on the importance of counseling and I advised her to counsel each client coming to the clinic on family planning choices and lifestyle maintenance for general well-being,” she said “To set a precedent, I started investing time in counseling clients on all methods of family planning and other health aspects.”

Due to regular QI meetings, the Sanjay Nagar UPHC scores on the TCIHC quality assessment checklist improved from 80% in May 2019 to 92.5% in September 2019. These QI meetings streamlined the process of identifying issues and finding mutually agreeable solutions with staff, Dr. Gadam said.

“These meetings have made the UPHC team realize that minor issues can be tackled by them on their own, like getting an IUCD kit and making the IUCD services available; like a staff nurse spending a little extra time on counseling a client on family planning choice has made basket of choice available to women,” she said

TCIHC has successfully advocated for the formation of QI committees in all of its supported UPHCs across 31 cities. As of November 2019, 502 UPHCs have formed QI committees and most hold regular monthly meetings. As a result of this effort, nearly all UPHCs are counseling on family planning choice.