Approaches to Improving Quality of MNCH Services in 24/7 PHCs
Item
- Title
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Approaches to Improving
Quality of MNCH Services
in 24/7 PHCs
- extracted text
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Approaches to Improving
Volume: 1
Quality of MNCH Services
in 24/7 PHCs
Mentors'Manual
1
KHPT
Karnataka Health Promotion Trust
[ 5500
Mentors'Manual
Volume
1
Approaches to Improving
Quality of MNCH Services
in Primary Health Centres
Sukshema
Maternal, Neonatal anc
SOCHARA
Community Health
Library and Information Centre (CLIC)
Community Health Cell
85/2, 1st Main, Maruthi Nagar,
Madiwala, Bengaluru - 560 068.
Tel: 080-25531518
email: clic@sochara.org / chc@sochara.org
www.sochara.org
Sli
Approaches to Improving Quality of MNCH Services in Primary Health Centres
An overview of the On-Site mentoring intervention to institutionalize quality improvement
strategy within 24/7 Primary Health Care centers in Karnataka state. The philosophy, design.
The philosophy, design, implementation process and results are detailed herein.
Copyrights
:
Year of Printing :
Publisher
:
Karnataka Health Promotion Trust and St John's National Academy of Health Sciences
2014
Karnataka Health Promotion Trust
IT Park, 5th Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 044
Karnataka, India
Phone:91-80-40400200
Fax:91-80-40400300
www.khpt.org
This process document is published with the supportfrom the Bill & Melinda Gates Foundation under
Project Sukshema. The views expressed herein do not necessarily reflect those ofthe Foundation.
Mentors'Manual Volume 1
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Government of Karnataka
Department of Health and Family Welfare
National Health Mission
hWj® o
PREFACE
Institutional deliveries in Karnataka have risen over recent years due to the efforts by the state health
directorate which were strongly complemented by various innovations and schemes implemented under
the National Rural Health Mission (NRHM) such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha
Karyakram (JSSK), ASHA support, 108 ambulance services, etc. There has been a reduction in maternal and
newborn mortality rates (MMR, NMR), but not enough to achieve the proposed state targets. With over
30% of pregnant women now delivering in facilities, it is critical that these deliveries are conducted as per
the highest standards for quality of care. To accommodate this rising demand, government had prioritized
jpgradation of Primary Health Centres into 24/7 facilities to provide delivery services in rural areas and
"educe the burden on district and larger hospitals enabling them to function more appropriately as first
referral units (FRU) to provide emergency care. To achieve good quality of services provided in public
health facilities it is important that the service providers working at these facilities are proficient in skills
and practices that are appropriate particularly with reference to pregnant women, mothers and new□orns. To facilitate this, the need for dedicated teams to improve and monitor quality is crucial.
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As a part of technical assistance to NRHM, Karnataka Health Promotion’Trust and its consortium of
partners developed an innovative nurse mentor led quality improvement program after detailed situation
assessment and consultations with government. It was pilot tested in Bellary and Gulbarga during 2012.2013 where trained Nurse Mentors worked with 24/7 primaryjiealth centres (PHCs) staff to improve the
quality of delivery and postpartum care. The mentoring programme integrated elements of clinical
mentoring with facility-based quality improvement processes. Another critical component of the
intervention was the use of revised case sheets by the staff that helped them in multiple ways, i.e. as job aid
to adhere to standard practices, as a simple case documentation tool and as a tool to monitor and audit
quality of care. The intervention results showed marked improvements in facility readiness and provider
preparedness to deal with institutional deliveries and associated complications. Subsequently the
program was scaled up in the remaining high priority districts of northern Karnataka and further taken up
both within and outside the country.
As a part of this intervention, several technical products and training material were developed; they consist
of 1) process documentation of the intervention that details the process of planning, implementing and
monitoring the mentoring program, 2) Facilitator/ Trainer and Participant manuals. These materials have
as annexures within them, various tools including the case sheets that were implemented under this
initiative. We sincerely hope that these resources will be found useful by program managers in terms of
gaining an in-depth understanding of the intervention and replicating it in their respective contexts.
3
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Sint. Sowjanya, i.A5
Mission Director
National He kl nii
Sri. Atui Kumar Tiwari, IAS
Principal Secretary;
Dep!, of Health & Family welfare
Commissioner
& iZmily welfare
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Contents
Acknowledgements
V
About the Manual
VI
Abbreviations
VIII
Glossary of Terminology
XI
SECTION A: Quality Improvement Principles and Approaches
1
Chapter 1.
The MNCH situation and response in Karnataka
2
Chapter 2.
Quality improvement
7
Chapter 3.
The A.M.M.A approach to quality improvement
9
Chapter 4.
Who are the MNCH Mentors?
13
Chapter 5.
Managing a mentoring visit
23
Chapter 6.
Other responsibilities of MNCH Mentors
45
SECTION B : PHC Systems Strengthening
47
Chapter 1.
Infection control
48
Chapter 2.
Referral system
64
Chapter 3.
Supply chain management
68
Appendices: Tools and Formats used by the MNCH Mentor
72
1
: Checklist for MNCH Mentor to guide management of MNCH Mentor visits
73
2
: PHC summary profile
76
3
: The self assessment guides
78
III
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
A.
Clients' Rights to Safe and Competent Care
79
B.
Staff's Right to Supplies, Equipment and Infrastructure
81
C.
Clients' Rights to Access to Services and Continuity of Care
84
D.
Clients' Rights to Infection-free Services
86
E.
Staff's Right to Information,Training and Development
87
F.
Clients' Rights to Privacy, Confidentiality, Dignity, Comfort and
Expression of Opinion
88
G.
Clients' Rights to Information and Informed Choice
89
H.
Staff's Right to Facilitative Supervision and Management and a Safe and
Secure Work Environment
90
4
Client Interview
93
5
Case Sheet Review
95
6
The Action Plan
97
7
MNCH Mentoring Trip Report
99
8
Clinical Mentoring Guide for MNCH mentors
102
9
*: Onsite Clinical Mentoring Plan for PHC staff
109
10
MNCH Mentoring Case Sheet Audit tool
114
11
Essential MNCH Drug List
121
12
Referral Directory Template for 24/7 PHCs
126
13
Maternal and Newborn Case Sheet For Use at 24/7 PHCs
128
14
Case Sheet Summary
149
IV
Mentors'Manual Volume 1
Acknowledgements
Acknowledgements
The authors appreciate the support provided by numerous individuals over an extended period of time to allow
documentation of this important innovation. Special thanks to Dr B.M. Ramesh, former Project Director of Sukshema
Project, for recognizing the importance of documenting the mentoring programme so others can learn from
this activity and for the guidance provided throughout. Thanks to Anna Schurmann for helping to structure the
project's knowledge management strategy and to Baneen Karachiwala who provided independent observation and
interviews of the first mentor training. The dedication of project staff—including several Bangalore-based technical
leaders, support staff, and district programme specialists who coordinated numerous field visits to several districts—
ensured high-quality observations at primary health centres and insightful interviews with those implementing
the intervention. These staff include Dr Swaroop, Dr Mahantesh, Dr Seema, Dr B. Pavan, Dr Nazia Shekhaji, and
Laxshmi C. We thank the team from St John's Research Institute that included Dr Prem Mony, Maryann Washington,
Dr Annamma Thomas, Dr Swarnarekha Bhat, Dr Suman Rao and other consultants for their support in the trainings
and handholding visits and for sharing their experiences that have informed the process document. We appreciate
the support of clinical consultants from University of Manitoba, Lisa Avery and Maryanne Crockett for their support
during the design of the program. We also acknowledge the efforts of Dr Sudarshan and Dr Nagaraj from Karuna Trust
for their support to the implementation of the program. Appreciation is extended to Arin Kar, Deputy Director of
Monitoring and Evaluation, for providing data support and to H.L. Mohan, Director of Community Interventions and
Somshekar Hawaldhar, Deputy Director of the community intervention component for contributing to the discussion
on program coordination. Special appreciation is also due to the nurse mentors for their enthusiastic participation
Jn interviews and focus groups, and for facilitating the ability to observe their work in action. We thank the many
primary health centre staff and district government officials who met with us to share their candid views about the
mentoring programme. Finally, we thank Stephen Moses, Professor and Head of Community Health Sciences of Dr
James Blanchard, Director, Centre for Global Public Health, University of Manitoba for their valuable reviews and
- inputs.
o
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—
The funding support for development of this manual was provided by Bill and Melinda Gates Foundation.
The following institutions and individuals have contributed to development of volume 1 of the SUKSHEMA
Facilitator's Manual.
Karnataka Health Promotion Trust (KHPT)
St John's National Academy of Health Sciences (SJNAHS)
University of Manitoba (UoM)
Dr LTroy Cunningham, KHPT
Mrs Janet Bradley, UoM
Dr John Stephen SJNAHS
Ms Maryann Washington, SJNAHS
Dr Sanjiv Lewin SJNAHS
Dr K Karthikeyan, Independent Consultant
Dr Manoharan, Independent Consultant
Dr Savitha Kamalesh, SJNAHS
Ms N Gayathri, SJNAHS
Dr Reynold Washington, KHPT/UoM
Dr Lisa Avery, UoM
Dr B M Ramesh, KHPT/UoM
Mr Arin Kar, KHPT
Mohan H L, KHPT/UoM
Dr Swaroop N, KHPT
Dr Krishnamurthy, KHPT/UoM
V
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
About the Manual
The Sukshema project aims at providing technical support to National Rural Health Mission of Karnataka
to improve maternal, newborn and child health (MNCH) outcomes in Karnataka with a focus on eight
districts of northern Karnataka. As part of the project, several interventions are implemented at facility,
community and health systems level to improve availability, accessibility, quality, utilization and coverage
of critical MNCH services. One of the interventions is on-site mentoring at 24/7 PHCS to improve quality of
delivery and postpartum care with the help of a new cadre of nurse mentors. Being a new cadre, the project
designed a training program and manuals for training nurse mentors. The nurse mentors are expected to
be proficient in clinical skills related to delivery and postpartum care and also have the right attitudes and
abilities to provide mentorship to PHC staff. They will be responsible for onsite, on the job coaching and
facilitating change in provider practices that will ensure better quality care for mothers and babies. The
purpose of this manual is to guide the MNCH mentors of Sukshema project in how to assist health care
providers at primary health care centres (PHCs) to improve the quality of labour and delivery, postpartum
and newborn care services. This manual is used by participants during initial training and also as a guide
during mentoring activities in the field.
This manual is divided into three volumes.
Volume 1 - Volume 1 has two sections.
Section A - Quality Improvement Principles and Approaches
This section introduces the context of MNCH mentoring intervention in the Sukshema Project, Karnataka,
principles of quality improvement, Sukshema's quality improvement approach and tools and their use at
various levels qualities of an MNCH mentor, and mentor responsibilities.
Section B - PHC Systems Strengthening
This section contains technical information related to systems strengthening in PHCs and covers infection
prevention, referral system strengthening and supply chain management.
Volume I appendix include various tools and reporting formats that the MNCH mentors use to plan,
implement and report on their PHC visit activities.
Volume 2 - Skilled Birth Attendance during Labour, Delivery and Postnatal Periods
at 24/7 PHCs
This volume contains information related to clinical knowledge and skills required to provide quality
care during labour, delivery and postnatal period at 24/7 primary health centres. The section covers both
provision of routine delivery and postnatal care as well as identification, management and referral of most
common maternal complications during these periods.
Q
Mentors'Manual Volume 1
About the Manual
Volume 3 - Essential Newborn Care at 24/7 PHCs
This volume contains information related to clinical knowledge and skills required to provide quality
care during early neonatal period at primary health centres. This section covers both provision of routine
newborn care as well as identification, management and referral of most common newborn complications.
Though this manual is divided into three volumes for the convenience of readers, each volume has
links and cross references with the others. It is highly recommended that the mentors consult all three
volumes when preparing for a mentoring visit and also have them available for ready reference during a
mentoring visit.
This section introduces the context of MNCH mentoring intervention in the Sukshema Project, Karnataka,
principles of quality improvement, Sukshema's quality improvement approach and tools and their use at
various levels qualities of an MNCH mentor, and mentor responsibilities we introduce the A.M.M.A approach
to Quality Improvement. A.M.M.A approach refers to assess (A), manage (M), measure (M) and advocate (A)
for continuous quality improvement and has at its core, the key principles of client and provider rights, self
assessment and team building, and mentoring.This approach can be used at several levels to improve PHC
linkages with the community, to address PHC level problems, to improve individual provider's knowledge
and skills and to improve PHC linkages with the wider health system.
A
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Abbreviations
ABO
Blood groups A, B, O
coc
Combined oral contraceptive
A.M.M.A
Assessing and diagnosing,
CPD
Cephalopelvic disproportion
managing, measuring and
CVS
Cardiovascular system
DBF
Direct breast feeding
DDK
Disposable delivery kit
DHO
District health officer
advocating
Active management of the third
AMTSL
stage of labour
ANC
Antenatal care
ANM
Auxiliary nurse midwife
APH
Antepartum hemorrhage
DNS
Dextrose normal saline
ASHA
Accredited social health activist
DPS
District programme specialist
ART
Antiretroviral therapy
EBM
Expressed breast milk
AWW
Anganwadi worker
ECP
Emergency contraceptive pill
Zidovudine
EDD
Expected date of delivery ■*
BCC
Behaviour change communication
FEFO
First expired, first out
BEmONC
Basic emergency obstetric and
FHR
Fetal heart rate
neonatal care
FHS
Fetal heart sound
BM
Breast milk
FIFO
First in, first out
BMV
Bag and mask ventilation
FRU
First referral unit
BPL
Below poverty line
FS
Female sterilisation
CBO
Community-based organisation
Gol
Government of India
CCT
Controlled cord traction
H/O
History of
CEmONC
Comprehensive emergency
Hb
Haemoglobin
obstetric and neonatal care
HBV
Hepatitis B virus
CHC
Community health centre
HCP
Health care providers
CBMWTF
Common bio-medical waste
Hg
Mercury
treatment facilities
HBsAg
Hepatitis B surface antigen
Chief medical officer
HCG
Human chorionic gonadotrophin
DMPA
° AZT
CMO
m
Mentors'Manual Volume 1
Depot medroxyprogesterone
acetate
II1SISS
Abbreviations
Development
HIV
Human immuno deficiency virus
HLD
High level disinfection
MPHW
Multipurpose health worker
HMIS
Health management information
system
MRP
Manual removal of placenta
MTP
Medical termination of pregnancy
MVA
Manual vacuum aspiration
NFHS
National Family Health Survey
NGO
Non-governmental organisation
NRHM
National Rural Health Mission
NS
Normal saline
NSSK
Navjaat Shishu Suraksha
Karyakram
NSV
No-scalpel vasectomy
PEP
Post-exposure prophylaxis
HR
Heart rate
h2o
Water
IM
Intramuscular
Inj
Injection
IV
Intravenous
ICTC
Integrated counselling and testing
centre
IFA
Iron and folic acid (supplements)
IMNCI
Integrated management of
neonatal and childhood illness
IUCD
Intrauterine contraceptive device
PHC
Primary health centre
IUD
Intrauterine deat
PIH
Pregnancy induced hypertension
IUGR
Intrauterine growth retardation
PIP
Project implementation plan
JSY
Janani Suraksha Yojana
PNC
Postnatal check-up
JHFA
Junior health female assistant
POC
Products of conception
KMC
Kangaroo mother care
PPE
Personal protective equipment
LAM
Lactational amenorrhea method
PPH
Postpartum hemorrhage
LBW
Low birth weight
PPTCT
LHV
Lady health visitor
Prevention of parent-to-child
transmission
LMP
Last menstrual period
PPV
Positive pressure ventilation
MgSO4
Magnesium sulfate -
PRI
Panchayati Raj Institution
MM
MNCH mentor
PROM
MMR
Maternal mortality ratio
Premature or pre-labour rupture of
membranes
MNCH
Maternal neonatal and child health
P/A
Per abdomen
MO
Medical officer
P/S
Per speculum
MoHFW
Ministry of Health and Family
Welfare
P/V
Per vaginum
QI
Quality improvement
Ministry of Women and Child
RCH
Reproductive and child health
MoWCD
IX
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
RDK
Rapid diagnostic kit
STI
Sexually transmitted infection
Rh
Rhesus factor
TBA
Traditional birth attendant
RL
Ringer lactate
TT
Tetanus toxoid
RPR
Rapid plasma reagin
UTI
Urinary tract infection
RR
Respiratory rate
VDRL
Venereal Disease Research
RTI
Reproductive tract infection
SBA
Skilled birth attendant
VHND
Village health and nutrition day
SC
Sub-centre
WBC
White blood cell
SDM
Standard days method
WHO
World Health Organization
SN
Staff nurse
3TC
Lamivudine
Laboratory
Units of measurement
At the rate of - to measure speed
%
KCal
Kilocalories- to measure energy
produced
Percent - to compare anything to
100
Kg
Kilogram - to measure weight
°C
Degree Celsius - for temperature
L
Litre to measure volume
cc
Cubic centimetre - to measure
lb
Pound to measure pressure
mcg
Microgram to measure weight
mg
Milligram to measure weight
min
Minute
ml
Millilitre to measure volume
mm
Millimetre to measure length
mmHg
Millimetre of mercury to
volume
cm
Centimetre - to measure length
dl
Decilitre - to measure volume
°F
Degree Fahrenheit - for
temperature
gm
Gram - to measure weight
hrs
Hours - to measure time
IU
International units - to measure
measure BP
secs
Seconds
U
Units to measure dose
dose
Mentors' Manual Volume 1
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Glossary of Terminology
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Glossary of Terminology
Abortion: Termination of pregnancy by the removal or expulsion of a foetus or embryo from the uterus
before 20 weeks of pregnancy
Abscess: A localized collection of pus in any part of the body, with pain and redness.
Amniotic fluid: Fluid present in the uterus during pregnancy which protects the fetal inside
Amnionitis: Infection of the protective lining around the baby (amnion or inner lining);
occurs in PROM
Anaemia: Condition caused by low hemoglobin in blood
ANC: Check up done during pregnancy to determine the condition of the woman and fetus
APGAR: The APGAR score indicates the newborn's well-being. It will be calculated at 1 minute and at
5 minutes after birth. An APGAR score of more than 7 is considered satisfactory. Less than 7 APGAR babies
need referral to a higher centre for further management
APH: Bleeding in pregnancy (before delivery)
Asphyxia: Condition in a newborn due to severely deficient supply of oxygen to the body when the baby
is unable to breathe normally
Atonic: Lack of muscle tone; loose or soft
Assisted deliveries: Vaginal delivery when the baby's delivery has to be assisted/helped out by using
forceps or vacuum extraction applied to the baby's head
Blurred vision: Unclear or hazy vision, associated with high blood pressure, weakness
Breech presentation: When the buttocks of the fetus are in the lower area of the uterus
Chorioamnionitis: Infection of the protective lining around the fetus (amnion or inner lining and
chorion or outer lining); occurs in premature rupture of membranes (PROM)
Clammy skin: When the skin is cool, moist, and pale. Sign of emergency such as shock, dehydration
CPD: Size or space of pelvis is narrow and does not allow baby to pass through
CVS: System related to heart and circulatory system
Diastolic blood pressure: Lower reading of blood pressure
Depressed/depression: Sadness, no interest in surroundings; may be seen in postnatal period
DMPA: Injectable contraceptive whose action lasts for 6 months
ECP: To be taken by a woman within 72 hours of unprotected, unplanned sexual contact to prevent a
pregnancy
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Effacement: Thinning of cervix at the time of labour
Endometritis: Infection of uterus; after PROM, repeated per vaginal (PV examination, unsterile conditions,
after abortion/ MTP done in unsterile conditions
Engorgement: Filling up/ swelling
Flank pain: Pain in the side of the abdomen below the ribs
Fluctuant: Moving
Floppy: Poor muscle tone, limp
Fetal: Developing unborn baby inside the uterus
Fetal distress: Condition when the fetus is having some problem inside the uterus; detected by abnormal
heart rate (FHR more than 160/min or less than 120/min), or irregular FHR
Fundal height: Height of the uterus which increases with pregnancy and decreases after delivery;
measuring the upper border of the uterus and comparing with the standard in weeks of pregnancy gives
the approximate duration of pregnancy
Gestation: Pregnancy/the period of development of the fetus in the uterus from conception until birth
Gestational age: Age of an embryo or fetus; calculated in weeks
Gravidity/gravid:The number of times the woman has been pregnant
Icterus: Jaundice or yellowish discolouration of sclera (white part of eye) in adult or skin in newborn
Infant: Baby from one month after birth to one year of age
IUGR: Inadequate/ slow growth of a fetus inside the uterus
Jerky movement: Fast movements which are not controlled and that have no purpose. Seen in fits
KMC: Care given to small baby by placing over the chest of mother/parent to provide extra warmth to the
baby
LAM: Used as a traditional temporary method of contraception, when a woman does not have her monthly
periods due to breast feeding
Latent: Developing or present but not visible
LBW: When the baby weight is below 2500gms (standard weight)
Lump: A localised swelling; may be hard or soft
Lochia: Discharge from the vagina from delivery up to a week
Liquor: Same as amniotic fluid
LMP: First day of last menstrual period a woman had before pregnancy, used to calculate FDD
Madil u kit: This is a postnatal kit given to mothers after delivery under a government scheme for postnatal
care of mother and baby
Mastitis: Infection of breast; seen as pain and redness
Meconium: Yellow or green coloured stools passed by the fetal inside uterus or by newborn at birth
XII
Mentors'Manual Volume 1
Glossary of Terminology
MRP: Done by removing the placenta by hand in condition of retained placenta
Murmur: An abnormal sound of the heart
MVA: Method of performing MTP where suction is created by a manual pump to remove contents in uterus
Misoprostol: Drug used to cause contraction of uterus and thereby prevent or treat postpartum
hemorrhage; available as tablets of 200mcg; not given to women with asthma
Magnesium sulfate: An anti-convulsant drug used for preventing/treating eclampsia/severe
pre eclampsia without causing sedation in mother or baby
Monitoring: Observe and check the progress or quality over a period of time
Nasal flaring: An increase in nostril size due to any difficulty in breathing
Newborn: A recently born baby
Obstetric: Related to pregnancy
Obstructed: Blocked; unable to come out
Oedema: Swelling due to accumulation of water
Outcome: End result
Pallor: Lack of colour especially in the face; seen in anaemia and long standing diseases
Parity/Para: Total number of deliveries and abortions a woman has had till present pregnancy
Pelvis: Cavity formed by joining together of the two hip bones and sacrum; contains, protects, and
supports the intestines, bladder, and internal reproductive organs
Perineum: Area around vagina and the anus in females
PIH: Increased blood pressure (more than 140/90 mmHg) without proteinuria in a woman after 20
weeks gestation
Preterm: Pregnancy less than 37 completed weeks gestation
Pre-referral management: Activities carried out to stabilise the complicated cases before referring
to a higher centre
Presentation: That part of the fetal lying over the pelvic inlet which would be first to come out at delivery
P/S: Using the speculum to view the vagina and cervix
P/V: Vaginal examination
Prolonged: Long duration/delayed
PROM: Rupture of membranes (bag of waters) before labour has begun; can be before 37weeks premature or before delivery - term or mature
Puerperal: The period immediately after delivery to 42 days
Purulent: Containing pus
Pustule: A small boil over skin filled with pus; a pimple
Retained:To hold in a particular place; not coming out
XIII
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
RPR: A newer blood test to screen routinely for syphilis in pregnant women
RR: Rate of breathing in one minute
Respiratory distress: Condition in which patients are not able to breathe properly and get enough
oxygen
SBA: Person (doctor, nurse, ANM) trained in pregnancy, delivery, postnatal and newborn care
SDM: Used as a traditional temporary method of contraception where a woman tracks the days of her
menstrual cycle and avoids unprotected sexual contact on fertile days of the cycle
Sepsis: Condition where infection from any site spreads throughout the body
Seizures: Convulsions, fits
Spontaneous: Without any effort or natural
Sterilization: A procedure to make free from live bacteria, virus or other microorganisms, used for
cleaning needles and surgical instruments
Stillbirth: Birth of a dead fetus any time after the completion of 20 weeks of gestation.
Syphilis: A sexually transmitted disease which in pregnancy may cause congenital defects in the fetus
Systolic blood pressure: The upper level of blood pressure
Tender/tenderness: Pain felt if touched
Term: State of pregnancy which has completed 37 weeks
Transverse: Lying across
.
.
.
.
Traction: Pulling force
Tubectomy: It is a female sterilization procedure where a part of the fallopian tubes is cut. It is a permanent
method of female sterilization
Umbilicus: A scar where an umbilical cord was attached
Unconsciousness: Person not responding to calls, stimulus
Uterine massage: Gently rubbing the uterus after the delivery of placenta to help the uterus contract
and become hard
Uterine tone: Tightness of uterine muscles
Vasectomy: A surgical procedure performed on males in which the vas deferens (male tubes) are cut. It
is a permanent method of male sterilization
VDRL: Blood test done routinely for syphilis in pregnant women; similar to RPR test
Vertex: Normal presentation of the fetus in which the head lies at the opening of the uterus
Voiding: Emptying the urinary bladder
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Section A
Quality Improvement
Principles and Approaches
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
n
The MNCH Situation and
Response in Karnataka
This chapter describes maternal and newborn mortality in India and the government's response to it. This
chapter also describes the Sukshema Project and the interventions developed to improve maternal and
newborn outcomes through enhancing the quality of MNCH care at PHCs in northern Karnataka. A key
component of the project is the development of a new staff cadre, called MNCH mentors.The broad outline
of MNCH mentoring is described.
1.1 Introduction
High maternal and neonatal mortality is a matter of great concern and a strong indicator of the lack
of attention paid to the health of women and children. The burden of maternal mortality is quite high
in India at 212 deaths per 100,000 live births (Indian Sample Registration System, 2007-09). The five
leading direct obstetric causes of maternal mortality in India are hemorrhage, sepsis, pregnancy-related
hypertension, obstructed
labour and
unsafe
abortion, contributing to about 70% of maternal
B1DAR
deaths, while maternal anemia is a major indirect
contributor. While some of these problems cannot
be reliably predicted, early detection and timely
GULBARGA
management can prevent most of these deaths.
The current neonatal morality rate of 34 per
WJAPUR
YADGtR
iMKOT
RAICHUR
1000 live births accounts for two thirds of infant
’PAL
mortality and half of under-five mortality for India.
The immediate causes of newborn death include
BELLAR)
infection, birth asphyxia, complications related to
premature birth, and congenital anomalies. Most
neonatal deaths can be prevented with simple,
cost-effective solutions that do not depend
■■■_
on highly trained providers or sophisticated
equipment. Nearly two-thirds infant deaths each
................. 7
(..
•' r4
L, 7^
year occur within the first four weeks of life, and
about two-thirds of those occur within the first
|
.
■
■
week. Thus, the first days and weeks of life are
critical; access to skilled care at delivery is essential
for the health of women and their newborns.
Figure 1.1 Sukshema Project Districts in
Northern Karanataka
Mentors' Manual Volume 1
Section A - Chapter 1
Of the four southern states of India, Karnataka has the highest maternal mortality rate and second highest
neonatal mortality rate. In Karnataka, the maternal mortality rate is 178 per 100,000 live births and the
neonatal mortality rate is 24 per 1000 live births. Both these rates are highest in rural northern Karnataka.
The area for the Sukshema project comprises of eight districts (Bagalkot, Koppal, Bijapur, Bellary, Raichur,
Gulbarga, Yadgir, Bidar).These districts together had a population of 15.1 million in 2010, comprising 25%
of the state's population. Female literacy was 42%; urbanization was 25%; and scheduled castes and tribes
comprised 39% of the population in this area.
1.2 Government of India and Karnataka Response
The Government oflndia'sstrategyfor reducing maternal and neonatal mortality focuses on encouragement
of institutional deliveries at PHCs, which are linked through referral to higher level emergency obstetric and
newborn care facilities for all women and newborns. Central to this is the building of a high functioning
primary health care system that provides essential and quality obstetric and newborn care services through
the availability of a skilled birth attendant for every birth.To achieve these objectives, steps have been taken
under National Rural Health Mission (NRHM), Karnataka to appropriately strengthen and operationalize the
24X7 PHCs and designated first referral units in handling basic and comprehensive obstetric and newborn
care respectively.
1.3 The Sukshema Project
The goal of the Sukshema project is to support the state of Karnataka and India to improve maternal,
neonatal and child health outcomes in rural populatipns through the development and adoption of
effective operational and health system approaches within NRHM. To achieve this goal, the project is
designed to integrate and align key aspects of the Bill & Melinda Gates Foundation's MNCH strategy with
the NRHM programme in eight Northern districts of Karnataka namely, Bagalkot, Bellary, Bidar, Bijapur,
Gulbarga, Koppal, Raichur and Yadgir.
Objectives
1. Enable expanded availability and accessibility of critical Maternal, Neonate and Child Health (MNCH)
interventions for rural populations.
2. Enable improvement in the quality of MNCH services for rural populations.
3. Enable expanded utilization and population coverage ofcritical MNCH services for rural populations.
4. Facilitate identification and consistent adoption of best practices and innovations arising from the
project at the state and national levels.
Critical gaps identified during baseline assessment
The Sukshema project had two phases, a planning phase and an implementation phase. During the planning
phase, the project undertook a detailed situation assessment in the project districts to determine the gaps
in the availability, accessibility, quality, utilization and coverage of MNCH services. Areas of concern were
the poor functioning of PHCs, the low levels of knowledge and skills of providers, and the poor linkages
between PHCs, the community and the wider health system. The MNCH mentoring intervention was
developed to address these issues.
|3
I
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
MNCH Mentoring
MNCH mentoring is a Sukshema project intervention developed to improve quality of care in labour, during
delivery and in the immediate postpartum period in the PHCs of Northern Karnataka.
Background and rationale
PHCs in Karnataka are primarily staffed by staff nurses who are responsible for MNCH services. However, in
the PHCs in project districts, not all staff nurses had been trained in skilled birth attendance when the project
began in 2009. In addition, refresher trainings to ensure good clinical practice and maintenance of skills were
uncommon. Even so, while basic training may provide the knowledge required, it often does not provide the
confidence to translate the knowledge into practice, or there may be service delivery issues that hamper staff
ability to practice good quality care.
Health care provider assessments conducted by the Sukshema project in 2009 suggested that knowledge
levels were low, and actual skills and abilities even lower. In the project's baseline assessment of labour
and delivery knowledge, less than 70% of staff nurses knew that AMTSL was essential for all deliveries and
only 28% knew the proper steps in AMTSL. For postnatal care, providers scored only 52% on knowledge
questions, and on observation, their practice was correct in just 31% of provider/client interactions.
Only 13% of providers were able to perform all the components of a postpartum physical exam. Against
this background Sukshema project introduced MNCH mentoring to complement NRHM training to
build competencies and confidence of providers on-site (that is, in the actual context where they are
providing care).
It is well understood that, clinical competency alone is not sufficient to ensure quality service delivery.The
delivery of quality services is also influenced by factors such as staffing patterns and schedules, infection
prevention practices, referral practices to and from the PHCs, equipment and supply logistics, record
keeping, lack of a supportive environment for staff, lack of teamwork, and lack of staff attention to clients'
rights. In particular, there are concerns that linkages with the community and community level health
workers, as well as with first referral units are weak, which compromises the essential care continuum for
mothers and newborns.
Therefore it is required that all staff at the PHC have a common understanding of what it means to
provide a quality service, their roles in providing these services across the continuum of care, and how to
support each other as well as problem-solve to improve services. The MNCH mentors have a role to play
in strengthening these areas of service alongside strengthening clinical competencies.
Focus of MNCH mentoring
MNCH mentoring is provided to the staff in PHCs through a dedicated cadre of nurse mentors. On-site
mentoring for improved clinical care and service delivery will improve the quality of services and continuity
of care, and patients will have better clinical outcomes. The mentoring addresses the issues at four levels.
Mentors'Manual Volume 1
e
Section A - Chapter 1
Table 1.1: Focus of mentoring
❖ PHC facility and operating
systems
Key focus
❖ Individual providers
❖ Community liaison
Additional focus
❖ District systems
PHC facility and operating systems
There is a need to focus on the PHC as a unit to improve systems within the facility that contribute to good
quality service delivery. Included in this are:
❖ Helping implement effective staffing patterns and schedules
❖ Improving infection prevention practices
❖ Ensuring adequate supplies of essential and rational drugs and equipment
❖ Improving referral practices and record keeping
❖ Facilitating a supportive environment for teamwork focusing attention on providers' rights to a
functioning working environment
❖ Facilitating clients'rights to information, safe and competent care, respect and dignity
❖ Enhancing referral processes and follow-up
* These changes at the facility level can be brought about by facilitating self assessments and discussions
around systems improvements, and by addressing the managerial and administrative competencies
among the staff working in the PHCs.
Individual providers
It is also equally critical to improve the clinical competencies of the staff working at the PHC in:
❖ Provision of routine care during labour, delivery and postpartum
❖ Recognition and pre-referral management of common complications during this period.
Community liaison
The Sukshema project recognizes the need for PHCs to liaise with the community, community health staff,
and district level health systems for smooth functioning and provision of quality services throughout the
MNCH continuum. This can be achieved in a phased manner. The communities in the PHC area should
be informed about the enhanced services that are available in order to influence utilization of services
particularly by segments of the population whose needs are often not met. Specifically in relation to
complications, women in the community should be well screened by front-line workers to ensure that
they go the most appropriate level of care, as well as be able to have timely access to emergency services
5
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
at higher facilities which are very critical to achieving positive health outcomes. Hence the PHCs have to
have good linkages with communities, the community front line healthcare workers such as ANMs (Nurse
Midwives) ASHAs (Accredited Social Health Activists), JHFAs (Junior Health Assistant-Females) and AWWs
(Anganwadi workers).
District systems
Many activities of the PHC are dependent on the systems at the district level. For example, the PHCs might
request certain needed drugs, but if district personnel do not respond in time, the functioning of the
PHC is compromised. Several other facility systems such as staffing, population coverage of the facilities,
emergency transport and referral linkages with higher facilities require coordination with systems at district
and higher levels.
Therefore, to improve quality of care for women and newborns, MNCH mentoring involves working with
multiple stakeholders and taking action at multiple levels. The next chapter deals more extensively with
quality improvement in the MNCH context.
6
Mentors'Manual Volume 1
Section A - Chapter 2
|2 Quality Improvement
This chapter explains the concept ofquality improvement, the advantages ofadopting quality improvement
as a process in a health care setting and the key principles that govern the quality improvement process to
help in achievement of the desired outcomes.
2.1 Introduction
Quality improvement (QI) is a process where individuals / organizations make an effort to move from the
current level of'ACTUAL PRACTICE'to a level of'BEST PRACTICE'. This is a continuous process as tomorrow's
best practice becomes actual practice later. In a health care setting, quality improvement encompasses
proper delivery of services that are accessible, safe and affordable to the target society, that leads
to an impact on mortality and morbidity in the area. Quality Improvement is also defined as a distinct
management process which uses a set of tools and techniques to ensure that services consistently meet
the community's health needs and improves the health status of their populations.
The three fundamental principles of Quality Improvement (QI) adapted for Sukshema project are:
Client and Provider Rights
Self-Assessment
Team Work
Figure 2.1: Principles of QI
2.2 Principles of QI
Promotion of client and provider rights
One important principle of QI is that clients'rights to quality services are central to any quality improvement
exercise. To ensure that clients are able to access services, it is important that the PHC is accessible, timings
are convenient for clients and there is a good awareness in the community of the range of quality clinical
services available. The clients should feel confident that they will receive information to take an informed
decision, will be treated with respect and be part of the decision making process, will receive evidence
based diagnosis and treatment fortheir health needs which will be safely provided by competent providers
so that they feel confident to return for continued care.
The PHC providers also have the right to have systems that support them to provide the best possible care
and to be able to fulfill their obligations to their clients.This includes opportunities to practice and develop
7
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
new skills, to be updated on policies and standard operating procedures, have a safe and supportive work
environment and have systems in place that facilitate smooth service delivery.
Self assessment
Self-assessment involves evaluation of one's self or team behaviours and practices, acting on the
evaluation findings more than simply measuring one's own performance. Self-assessment is a low-cost
approach to improving and monitoring the quality of care. Based on interviews and focus groups with
persons who engaged in self-assessment, Marienau (1999) documented that self assessment encourages
learning from experience, facilitates effective functioning, strengthens commitment to competent
performance and fosters self-agency and authority.
Teamwork
A key principle in improving quality is the notion that quality improvement of services is everyone's business
at the PHC and that it is an on-going process. This requires that the staff/health care providers are helped
by the mentors to identify the issues, own those issues, understand the cause of those issues and identify
and implement practical as well realistic solutions to them. The staff within the facility often has answers to
the problems themselves without outside help; a self assessment process can encourage and empower the
providers to continuously stay focused on improving service delivery within the facility.
2.3 Advantages of Adopting Quality Improvement Processes
1. Providers within the PHC feel ownership of quality issues and are encouraged to find solutions at
their facility.
2. All staff are seen as experts which results in high level of confidence and respect among the PHC
health care providers/ staff.
3. Staff are sensitized to understand the mindset and needs of the clients.
4. QI processes teach staff to focus on systems and processes within the PHC rather than finding faults
with an individual.
5. QI encourages staff learning and development in an open way.
6. QI promotes teamwork and cooperation amongst the PHC staff.
In the Sukshema Project A.M.M.A approach is used as the guiding QI approach to improving the quality of
services in PHCs.The A.M.M.A approach is detailed in the next chapter.
REMEMBER!!!
The three principles of quality improvement are:
1. Promotion of Client and Provider's Rights
2. Self Assessment
3. Teamwork
Mentors'Manual Volume 1
Section A - Chapter 3
j 2 The A.M.M.A Approach to
hk Quality Improvement
This chapter introduces the innovative concept of the A.M.M.A approach developed by the Sukshema team
to provide a framework for improving the quality of services at different levels in the continuum of care.
3.1
Introduction
The A.M.M.A approach is a systematic framework for identifying, addressing and measuring problems and
for advocating for quality improvement at various levels of service delivery. Staff/ health care providers
at PHCs will adopt this approach in all areas of functioning from individual clinical practice through to
improving district level linkages. The role of MNCH mentors during PHC mentoring visits is to teach and
help the providers understand and internalize this approach, showcase its usability and benefits, and
ensure providers practice and master the same in every aspect of their work.
"K" stands for assessing and diagnosing problems;
"M" stands for managing these problems comprehensively with sustainable solutions;
"M" stands for measuring the response to interventions and
stands for advocating for quality improvement, a reminder to the PHC team that quality improvement
is an on-going process that involves everyone.
ASSESSED 1
DIAGNOSE |
%
Figure 3.1: The A.M.M.A approach
9
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
3.2 Application of A.M.M.A Approach at Service Delivery
The A.M.M.A approach can be applied at all levels of service delivery (see Table 3.1):
1. At the individual provider level
2. At the PHC systems level
3. At the community level
4. At the wider health systems or district level
At the PHC level - using A.M.M.A approach to improve the PHC facility systems
The A.M.M.A approach helps the PHC team to identify gaps in service provision (using defined standards
of care), by conducting PHC team self assessments that promote the notion of clients'and provider rights.
These assessments, which are done using several tools, identify the gaps in quality service and using the
process of a root cause analysis, diagnose the probable causes of those problems (Assess and diagnose).
The PHC team then identify potential solutions in an action plan and begin to implement them according
to the timing and responsibilities outlined in the action plan (Manage). They will constantly monitor their
progress in addressing issues in the action plan by collecting information and reviewing during regular
meetings (Measure). Success in these efforts will encourage PHC staff, with the mentor's help, to see how
they themselves can make improvements in quality and they will become champions for further quality
improvement in different areas (Advocate).
The role of the MNCH mentor during mentoring visits is to teach PHC providers the A.M.M.A approach and
use of its tools, help them internalize and adopt it in their daily functioning. The actual implementation
of the A.M.M.A quality improvement process will be detailed later in the "how to implement QI using the
A.M.M.A approach"
At the individual provider level -using A.M.M.A approach to improve provider
clinical knowledge and skills
The PHC providers will apply the A.M.M.A approach to comprehensively assess women and babies and
make appropriate diagnosis using case sheets as a job aid (Assess and diagnose), provide routine care
or pre-referral management for complications in a timely manner using the case sheets (Manage) and
then monitor progress by checking the vitals and condition of the client periodically being transported
to the higher facility (Measure). The role of the MNCH mentor is also to equip the PHC providers with the
required clinical knowledge and skills, and motivate them to strive for further improvement in the quality
of patient care in order to create a safe and client centred environment for women and babies (Advocate).
They should also be able to advocate to women and their families why certain quality practices are being
implemented in order to increase demand in the community for such practices and to decrease demand
for unhealthy practices.
In the second year of implementation of the A.M.M.A QI approach, the MNCH mentors will help PHC team
to understand and practice the following two areas.
Mentors' Manual Volume 1
t
88
K
bp■ -:-
Section A - Chapter 3
■I
At the community level - using A.M.M.A approach to improve linkages between
PHC and the community
The A.M.M.A approach can also guide PHC providers to improve linkages between the PHC and
community health workers. This is critical for assuring a quality continuum of care, from pregnancy
through postpartum. Specifically it could ensure that women are appropriately referred to PHCs,
depending on their risk factors, and in a timely manner. It can also ensure follow-up care after delivery.
This approach will help PHC and community staff to work together to assess how these linkages are
currently working, identify the gaps and probable causes for these gaps (Assess and diagnose). The
PHC team will identify solutions to the problems and implement the solutions identified in a timely
and rational manner (Manage) and constantly review the progress (Measure) made in strengthening
communication and linkages. Strengthening of linkages and communication between the PHC and
community health care workers will motivate staff to constantly ensure a continuum of care from home
to facility and back for mothers and newborns (Advocate).
At the systems level - using A.M.M.A approach to improve linkages between PHC
and the wider health system
PHC providers can apply the A.M.M.A approach in identifying problems, and the probable cause/s of those
problems that could be addressed at the facility level and those that need to be addressed at a higher level
such as a referral unit or the district health department (Assess and diagnose). The issues to be addressed
at district level have to be discussed in fora such as monthly review meetings (Manage). Subsequently
anychanges due to action at theTiigher levels need to be constantly reviewed to measure whether there
has been any observable desired result (Measure). The PHC providers and management should constantly
advocate for quality improvement which itself can increase accountability at higher levels (Advocate).
REMEMBER!!!
Use the A.M.M.A Approach at four levels to improve:
1.
2.
PHC functioning as a unit
Individual clinical competency
Linkages between PHC and the community
Linkages between PHC and the wider health systems
.
___
■
Approaches to Improving Quality of MNCH Services in Primary Health Centres
1
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Table 3.1: The A.M.M.A Approach - Assess and diagnose, Manage,
Measure and Advocate
What to
do?
PHC level
Individual staff
level
Assess and
diagnose by
Assess and diagnose
by identifying the gaps screening for
. danger signs
in service provision
ASSESS &
and using the process among women
DIAGNOSE
in labour, during
of a root cause
quality gaps analysis, diagnose the delivery, women
in the postpartum
probable causes of
period and
those problems
newborns
MANAGE
solutions
to address
gaps
MEASURE
progress
ADVOCATE
for client
& provider
rights to
quality
services
Manage by beginning
to identify potential
solutions in an action
plan and implement
them according
to the timing and
responsibilities
outlined in the action
plan
Manage by
providing routine
care or pre-referral
management for
complications in a
rational and timely
manner
Measure by constantly Measure by
monitoring their
monitoring
progress in addressing progress in
issues in the action
improving patient
plan
care
Advocate by
becoming champions
for further quality
improvement in
different areas
12
Mentors'Manual Volume 1
Advocate to
create a safe and
client-centred
environment
for women and
newborns
Community
level
System level
Assess and
diagnose how
linkages are
currently working,
identify the gaps
and probable
causes for these
gaps
Assess and diagnose
by identifying the
problems, and the
probable cause of
those problems
that need to be
addressed at a
higher level
Manage by
identifying
solutions to the
problems and
implement the
solutions identified
in a timely and
rational manner
Manage the issues
to be addressed
at district level these have to be
discussed in a forum
such as monthly
review meetings
Measure by
constantly
reviewing the
progress made
in strengthening
linkages
Measure any
changes due to
action at the higher
levels
Advocate for a
continuum of care
for mothers and
newborns from
home to facility
and back
Advocate constantly
for quality
improvement which
itself can increase
accountability at
higher levels
Section A - Chapter 4
14 MNCH Mentors
This chapter details the various skills and attitudes that mentors should possess, as well as certain tools and
resources that MNCH mentors need to be able to effectively implement the A.M.M.A approach.
4.1 Introduction
MNCH mentoring utilizes QI principles in the A.M.M.A approach (mentioned in previous chapter) to provide
practical clinical training and facilitation for PHC, community and wider system level improvements. To
help providers, the MNCH mentors need to mentor them one on one, on the job, in a very practical way. If
there are no clients available for practical demonstration, then mentors must be able to share knowledge
and show or explain certain practices using didactic teaching or by using models. MNCH mentors need
to be experienced, practicing clinicians/nurses in their own right, with strong teaching skills. Mentoring
should be seen as part of the continuum of education required to create competent health care providers.
To assist in improving systems, mentors need to be able to explain and promote QI; client and provider
rights; facilitate team building as well as team self assessment and encourage non-punitive reflection of
services. The mentors need to adopt often different skills to traditional supervisory staff.
The MNCH mentors will visit the PHCs and attempt to inspire the PHC providers to evaluate their daily work
with a perspective of "I can do things better that will help my team to provide improved services resulting
in higher levels of satisfaction of the clients who visit my PHC"
4.2 Qualities of MNCH Mentors
To achieve this, the MMs must have and display the following qualities:
❖ A strong commitment to the objectives and principles used in the A.M.M.A approach to mentoring
❖ Ability to build trust, promote teamwork and skills to motivate better performance from the PHC staff
❖ Have good interpersonal communication skills
❖ Cultivate in-depth analysis and responsiveness
❖ Have strong QI advocacy skills
❖ Empower the PHC team to develop and practice the A.M.M.A approach at the facility, client and staff
levels
❖ Be competent with technical knowledge in the areas of MNCH services and have the skill to foster
these skills within the PHC staff
❖ Be flexible, expectant and manage change
❖ Be open to new ideas and stay focused on improving the quality of MNCH services
❖ Recognize the influence of external environment and assist the PHC staff to link to larger systems
To undertake the job of an MM, certain knowledge, skills, attitudes, tools and resources are needed, as
explained in the following table (Table 4.1).
13
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
,
■
■
,
Section A - Chapter 4
V
Table 4.1: The A.M.M.A Approach - Knowledge, skills, attitudes, tools and
resources for MNCH mentors to implement the A.M.M.A approach for QI at
different levels
Individual staff
level
Community
level
1. Management of
1. Leading causes
normal labour,
of maternal and
delivery and
newborn mortality
& morbidity
provision of
postpartum
2. Quality gaps at
care including
the PHC level
newborn care
3. Quality
2. Management of
improvement
complications
principles of
during labour,
client/provider
delivery and
rights, self
postpartum I
assessment and
period including
mentoring
newborn care
4. Drugsand
equipment,
record keeping
and infection
prevention
systems
1. ANM/ASHA
roles and
responsibilities
and linkages
PHC level
KNOWLEDGE
What to know?
5. Referral systems
and concepts of
the continuum of
care
Mentors'Manual Volume 1
2. Appropriate
referrals to PHCs
System level
1. Drug and
equipment
procurement
and supply
systems
3. Client rights
2. Use of untied
funds
4. Issues around
continuity of
care before and
after delivery
3. Utilization and
coverage of
schemes and
incentives
4. Referral
5. Community
systems and
interventions
linkages
and tools related
to enumeration 5. Meetingsand
and tracking,
mechanisms for
raising issues
home based
maternal and
newborn care,
family focused
communication,
community
support and
monitoring
—
r
■■■■I ...
PHC level
1. Plan and
coordinate visits
2. Time
management
during visits
3. Facilitate PHC
team self
assessment
(problem
identification, root
cause analysis,
and action
planning)
4. PHC team building
5. Audit case sheet,
register and HMIS
data
SKILLS
What to be
able to do?
6. Identify issues to
be raised at higher
levels
Individual staff
level
1. Be clinically
competent in
all aspects of
routine care and
complications
during labour,
delivery and
postpartum
period including
newborn care
Community
level
1. Liaise and
coordinate
between
different
stakeholders
System level
1. Communication
and negotiating
skills
2. Planning and
prioritization of
issues
2. Liaison and
coordinating
2. Be competent
in case sheet
utilization,
documentation
and audit
3. Use of mentoring
approaches using
good individual
and group
communication
skills to impart
clinical skills to
PHC provider
(observations, one
on one on the job,
coaching, small
group teaching,
case reviews,
demonstrations,
case studies, etc.)
4. Use of onsite
mentoring plan
for PHC staff and
clinical mentoring
guide
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
J
ATTITUDES
How to be and
not to be?
Good attitudes
Poor attitudes
1. Open minded
1. Fault finding/blaming/being critical
2. Having a'can do' attitude
2. Inspecting/policing
3. Trusting, accepting, having confidence
that PHC provider can do a better job
3. Authoritative, expert tone
4. Appreciation of PHC staff
5. Supportive, encouraging, motivating and
helpful
4. Negative feelings and prejudice
about the community, health
workers
6. Innovative
7. Being a role model
PHC level
1. PHC summary
profile
2. Planning,
implementing and
monitoring MNCH
intervention
3. Self assessment
guides
4. Client interview
tool
5. Case sheet review
6. The action plan
TOOLS
What to use?
7. Client and
provider rights
handouts
8. MNCH mentoring
trip report
9. Referral directory
Ttmplate for 24/7
PHCs
10. MNCH mentoring
case sheet audit
11. Case sheet
summary
Mentors'Manual Volume 1
Individual staff
level
1. Self assessment
guides and the
action plan
2. Case sheet review
3. Clinical mentoring
guide for MNCH
mentors
4. Onsite mentoring
plan MNCH for
PHC staff
5. MNCH essential
drug list
6. Teaching materials
(models, case
studies, role plays,
DVDs, handouts,
flipchart and
essential drug
sheet).
7. MNCH mentoring
trip report
Community
level
1. Self assessment
guides
2. Community
liaison self
assessment
tools
System level
1. MNCH
mentoring trip
report
2. Minutes of
district health
meetings
Section A - Chapter 4
1. PHC operating
guidelines
RESOURCES
What to refer
to?
1. Skilled birth
attendant
handbook
2. List of
intervention sites, 2. Medical officer's
contacts, details of
manual
PHC providers and 3. IMNCI manual
other mentors
4. NSSK manual
3. List of referral
centres in the
district
1. Enumeration
and tracking
tool
1. District project
implementation
plan
2. Home based
maternal and
newborn care
tool
2. Sukshema
baseline
assessment
report
3. Family focused
- communication
tool
4. Community
support and
monitoring tool
5. ASHA guidelines
4.3 What are the qualities of an effective MNCH mentor?
This question is at the heart of all mentoring relationships. Some mentor-mentee relationships do well
while others do not do well. Studies have shown that the key reasons for failure in mentor mentee
relationship could be due to the expectations and approach of the mentor. Most of the mentors in the
relationships that failed often have a belief that they should, and could, "reform" their mentees. These
mentors, even at the very beginning, spend at least some of their time, pushing the staff to change.
Almost all the mentors in successful relationships on the other hand believe that their role is to support
staff, to help them grow and develop.They see themselves as a friend to PHC staff.
Rapport building
Rapport building is the single most important aspect of communication for all mentors. All communication
efforts can be futile if mentors do not have rapport with PHC providers. Having rapport is the foundation
for any relationship. Rapport with the PHC staff can be likened to the cement that holds a building together.
Rapport happens at many levels. MNCH mentors can build rapport all the time through:
❖ The way they look, sound, and behave.
❖ The skills they have learned
❖ The values that they live by
♦♦♦ Their beliefs
❖ Their purpose in life
❖ Being themselves
Six quick ways to enhance rapport
❖ Mentors should take a genuine interest in getting to know what is important to the PHC providers.
They should start to understand them rather than expecting them to understand the mentor first.
❖ Pick up on the key words, favourite phrases and ways of speaking that the PHC provider uses and
build these into the conversation.
❖ Notice how the providers like to handle information. Do they like lots of details or just the big picture?
As mentors speak, they should only give as much feedback information as they understand and grasp.
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
❖ Look out for their intention — their underlying aim — rather than what they do or say. They may not
always get it right, but mentors should assume their heart is in the right place.
❖ Adopt a similar stance to them in terms of your body language, gestures, voice tone and speed.
❖ Respect their time and energy.
Clearly, first impressions count. Do you arrive for meetings and appointments hot and harassed or cool and
collected? When you begin to talk, do you mumble your words in a low whisper to the floor or gaze directly
and confidently at your audience before speaking out loud and clear?
In terms of building rapport — you are the message. And you need all parts of you working in harmony: words,
pictures, gestures and sounds. If you do not look confident — as if you believe in your message — people will
not listen to what you are saying. Rapport involves being able to see eye-to-eye with other people, connecting
on their wavelength. So much of the perception of your sincerity comes not from what you say but how you say
it and how you show an appreciation for the other person's thoughts and feelings.
Interpersonal communication skills
MNCH mentors need to have good interpersonal communication skills which directly relate to initiating and
maintaining effective and open communication between them and staff/ health care providers. Following
is the list of twelve interpersonal communication skills. These skills are used in a one-to-one session (face
to face and over the telephone) and in group facilitation.
a. Attending skills
b. Listening skills
c. Observational skills
d. Appropriate use of names
e. Speaking skills
f. Responding skills
g. Exploring skills
h. Giving feedback
i. Summarising skills
j. Problem solving skills
k. Evaluation skills
l. Challenging and confronting skills (conflict management)
a. Attending skills
As an MNCH mentor you will have to be physically, intellectually present in a mentoring session. The staff
will be aware that you are concerned and attending to them wholeheartedly. This will enable them to
interact with you very well. You can remember attending skills by an acronym "ROLES".
❖ Relaxed Posture - When you sit, stand or talk you will have to be relaxed, calm and composed.
❖ Open posture - Try to avoid crossing arms or holding a folder/file. This may indicate that you are
mentally closed to the mentee.
❖ Leaning forward - When you lean forward towards mentee while you talk or listen, it conveys that you
are concerned and interested.
❖ Eye contact - Proper, non threatening eye contact will build rapport.
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❖ Sit or stand squarely - Face your mentee, maintain eye contact and communicate openness between
you and mentee. This will assure your mentee that there is no hidden plan in you.
b. Listening skills
Listening skills are important for you as a mentor. Most of us listen for a short time, after a while, we lose our
attention.The following techniques will help to improve your listening:
❖ Make the effort to listen, remind yourself and stay motivated that you will have to improve listening
during mentoring.
❖ Mentoring in a quiet place (with out any interruption) will help you to listen effectively.
❖ Allow the providers to speak, don't interrupt when the providers speak, listen without any bias or
anticipation, this will improve your listening.
❖ At intervals, paraphrase or summarise what the PHC provider has been saying, this will help the her/
him to understand that you are listening. For example -if the provider told you about lack of gloves
in the PHC. When you summarise you can mention that "you were telling me that you are not getting
enough gloves to use while conducting deliveries. Is that right?"
❖ If the PHC provider is making many points, note them down; it is acceptable to jot down key words
to keep track. While you are taking notes you will not have eye contact, but keep nodding your head
indicating that you are listening.
c. Observational skills
You can use observational skills to get a sense of how PHC providers practice clinical skills and follow SBA
guidelines. You can also observe their ability to accept and learn. Some examples are:
❖ What is the PHC provider's general awareness of SBA guidelines?
❖ Observe how PHC staff perform clinical procedures such as conducting a delivery, counselling a
woman on newborn care? Are they following SBA guidelines?
❖ Observe whether the environment is clean and organised?
❖ Observe whether PHC staff are using the appropriate personal protective equipment for the situation
or the procedure? For example when conducting a delivery, does the provider wear all the personal
protective equipment such as gloves, mask, goggles, apron and closed foot wear?
d. Appropriate use of names
When you call providers by name they will feel that they are important. This will also help you to maintain
rapport very well. Ask your mentees during first visit, how they want to be called and follow accordingly.
e. Speaking skills
As a mentor you will have to speak audibly and clearly. When you speak in a warm tone, and at an audible
volume, the providers will hear well what you say.
f. Responding skills
Responding skills are those skills which allow you to respond directly to what a PHC provider has said to take
the conversation further in a useful direction. When you respond it shows that you have been listening or, if
the response misses the mark, gives permission to the PHC provider to put you back on track.
Respond to content/ facts through paraphrasing, if the provider mentions lack of gloves, for example,
respond saying "you were telling me that you are not getting enough gloves to use while conducting
deliveries. Is that right?" Respond to feelings or facts, for example, when the provider mentions about a
death of a newborn due to lack of oxygen in the PHC, respond to the provider saying "You must have felt
helpless and miserable at that situation".
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
g. Exploring skills (explore what is not clear; clarifying questions)
During mentoring visits, if you do not understand any part of your provider's communication you can
explore or clarify. You can explore by asking clarifying questions, asking open questions like how,
when and what. If the staff tell you that a 20 year old G3P2L2 was found very weak 3 hours after delivery
and was referred after starting IV infusion, examples of such questions include "Can you explain what
happened in the 3rd stage and immediate postnatal period for this woman?" or "What must you monitor
during these periods and why?"
h. Giving feedback
When you give feed back to a provider it ensures that both of you are on track. Feedback is a crucial part
of facilitating and vital to your role as a mentor. This feedback may be of technical nature ("You have
performed aspects of AMTSL correctly"), may relate to general improvement of the PHC provider ("You
have made good progress as a provider"), may relate to the way in which a provider has conducted him/
herself in a mentoring session ("It seems it was difficult for you to hear the negative comments of your
colleagues"). It is important when you give feedback to start and end with good points, and mention points
of improvement in between.
/. Summarising skills
Summaries are essentially paraphrases of a larger amount of information or conversations with the
PHC provider. At the end of mentoring session it is better for you or the provider to summarise what
was discussed and close the session with relevant discussion points and action steps which are to be
Taken in the PHC.
j. Problem identification, examining potential causes and problem solving skills
Problem solving includes root cause analysis (a thorough exploration of all aspects of a problem - using
multiple WHY?) and discussion of potential solutions. As it is done through a self assessment process the
solutions naturally start to emerge. When the problems, root cause and solutions are written in action plan
chart the providers own the solution and work towards it.
k. Evaluation skills
At the end of a mentoring session, you can evaluate how the session went in terms of solutions developed,
and whether amicable and productive relationships were established with providers. This process of
reviewing and evaluating brings a mentoring session to a close.
You can ask following questions to the PHC health care providers to evaluate a mentoring session:
❖ "How did you find the session?"
❖ "Where do you think you can practice these skills?"
<* "What did you take from this session?"
/. Challenging and confronting (conflict management)
Disagree tactfully: During group mentoring or action plan development, if you disagree with something a
PHC provider has said, you can ask the group "what do others in the group feel about this" or you can say
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"there may be another point of view to this issue, and as a group you can take a decision".Take utmost care
that you do not humiliate or embarrass any PHC of the when they voice out different views.
Manage conflicts: During group mentoring and in action plan development, there can be disagreement
on some issues. As a mentor do not take sides, stay impartial and deal with the issue in a professional and
objective manner.
Tools and formats used by the MNCH Mentor
Each of the tools/formats used by the MNCH mentor and its description is summarized in the Table 4.2.
Table 4.2 - Tools/Formats and their purpose
Description
Tool/Format
SI No
This is a guide for the mentor on how to plan MNCH
mentoring visits and details out activities and tools for:
i
Checklist for MNCH mentorto guide
her in managing the MM visits.
• Planning for the PHC visit;
• Implementing the visit;
• Monitoring.
______
This tool provides important information on
PHC
population coverage, enumerates MNCH events and
2
PHC summary profile
complications, and provides a status of the current
staffing of the PHC including vacancies and deputations.
3
Self assessment guides including
the client and provider rights poster These are part of the self assessment tools that the PHC
provider will use to help staff identify gaps at the facility
4
Client interview
5
Case sheet review
level.
The PHC staff will use this template to list the issues
identified as well as the timelines for addressing issues,
the person responsible, etc. This action plan will serve
6
Action plan
as reference for implementing solutions (Manage) as
well as reviewing the progress (Measure) made while
implementing the solutions.
__
This is a format that the mentors will use to report about
7
MNCH mentoring trip report
the visit to the PHC detailing out the people met, activities
conducted, challenges faced, etc.
This tool discusses how clinical mentoring can be
implemented; lists all the teaching topics that need to be
8
Clinical mentoring guide for MNCH
mentors
covered at each visit to the PHC and contain a checklist of
skills/competencies under each of these topics that are
critical to ensure comprehensive coverage of the topic.
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
This is a PHC provider-specific checklist that helps to
9
Onsite clinical mentoring plan for record the topics covered at the PHC. This helps the
PHC staff
mentor to plan micro-teaching for each PHC staff at an
individual level.___________________________________
The mentor will use the MNCH mentoring case sheet
audit checklist to evaluate the practice of providers as
10
MNCH mentoring case sheet audit
too
reflected in the case sheet document. This tool helps
assess how much of technical content taught in the
previous visits has been internalised and practiced.
The NRHM guidelines suggest use of certain essential
drugs related to MNCH in a PHC setting. The PHC
provider should be aware of these drugs, the correct
11
Essential MNCH drug list
routes, dosages, indications and contraindications. The
Sukshema project has prepared a table summarizing
these details and mentors should it supply to all the
PHCs. MNCH mentors will need to refer to this during the
regular teaching sessions.____________________ _____
This template will be used to develop a referral directory
12
Referral directory template for 24/7
PHCs
for each PHC to ensure that the PHC staff knows where
and how to make a referral to depending on the need
of the client The contact details would help PHC staff to
follow up after referral.
The case sheet is a tool used by staff nurses at PHCs for
documenting the cases managed; the case sheets are
user-friendly, act as job aids, indicate diagnosis, give
13
Maternal and newborn case sheet details of management such as drugs and dosages to be
for use at 24/7 PHCs
administered and also assist in performing audits. MNCH
mentors can use these case sheets as a teaching aid as
well as to understand the practice of the providers and
their documentation of events.__________ _____ ____
The case sheet summary, audit of clinical practice and
14
Case sheet summary and audit
essential stocks are the monitoring formats used to collect
of clinical practice and essential
data that reflect changes in the facility infrastructure,
stocks
provider practice as well as certain outcomes over time
as a result of mentoring intervention.
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15 Managing a Mentoring Visit
5.1 Introduction
During each visit of the first year as an MNCH mentor you should use the A.M.M.A approach at two
levels: first at the PHC level to improve service delivery by helping the PHC team to solve problems
related to facility systems that hamper day to day functioning of the PHC. The mentor will encourage
providers to understand that when they work together their collective strength helps to resolve certain
problems. Second, at an individual PHC provider level, the mentor's focus should be to improve clinical
competencies.This chapter describes in detail how the mentors can use the A.M.M.A approach and specific
tools at these two levels.
5.2 Using A.M.M.A Approach to Resolve PHC Level Issues
As a mentor your goal is to help PHC providers improve quality of care at the PHC using the A.M.M.A
approach to:
*•* Assess and diagnose where the PHC staff will first identify the gaps in service delivery and then do the
root cause analysis to arrive at probable causes of those problems.
❖ Manage where the PHC staff will begin to identify potential solutions and implement them as per the
action plan.
.
❖ Measure where the PHC staff will constantly monitor their activities to address the issues as
per the action plan.
❖ Advocate where the PHC staff become the spokespersons for the quality improvement process and
continually strive to perform better.
In order to effectively do this, you should perform the following tasks:
❖ Make pre-meeting plans
❖ Manage the first meeting
❖ Managing the self assessment tools
Pre-meeting planning
The mentors' preparation starts well before the site visit and includes four important steps:
Step 1 If it is the first visit, the mentor should review the data of the PHC that can be obtained from the health
management information system (HMIS) or Sukshema facility mapping data. This will help the mentor to
become familiar with PHC staffing, existing systems, delivery volumes etc. If it is a subsequent visit, the
action plan that has been developed during the previous visit should be reviewed beforehand.
Step 2 Inform the PHC in-charge ahead of time that you would like to visit the PHC. In consultation with the MO
choose two days for your visit that will least disrupt services (e.g. not on an antenatal day).
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Step 3 Discuss with the in-charge that you would like to meet with all clinical and support PHC providers/staff
who are involved in some way in provision of maternal and newborn services at the PHC.This would usually
include all PHC provider nurses, lady health visitors, pharmacists, record keepers, ancillary cleaning staff
and the medical officers (MO), also ANMs if they are available.
Step 4 Be prepared. Know your tools and think about how you can be facilitative during the meetings. Review in
your mind how you need to facilitate meetings. As mentoring date draws nearer, remind PHC provider that
you are coming. Have enough copies of the self assessment guides, pens or pencils, flipchart paper and
pens for action plan. Prepare flipcharts required for writing the action plans.
Managing the start of the a mentoring visit
It is important to understand that sometimes you are entering the PHC and meeting the staff for the
first time. You require time to get to know the staff and make friends with the team. Use the first visit to
develop rapport with the staff and implement some of the self assessment tools. Remember some of the
rapport building skills already discussed. At subsequent visits, you can spend more time on self assessment
exercises and teaching.
This section describes what you should do during a mentoring visit, though not all should necessarily be
done each time:
1. Meet with the PHCin-charge and introduce yourself, the purpose of your visit and that you are visiting
the PHC to work with the PHC in-charge to assist the staff in improving the quality of care and service
delivery. The confidence of the leader in you in very important and this can facilitate a good working
relationship with others.
2. Hold a staff meeting at which you should:
❖
Have introductions and ensure staff inclusiveness and comfort.
❖
Start the meeting by asking if everyone has come for the meeting. Reiterate that you would
like as many PHC team members as possible to come, including providers, paramedics as well
as the support staff. Ensure seating arrangements that are comfortable for all. If possible sit in a
circle so that everyone feels equal. Throughout the day, the MNCH mentors should try to help
the support staff feel included, and try not to let senior PHC provider dominate the discussions.
❖
Introduce yourself and explain what you are there for, how often you will visit and what you
want to achieve. A clear introduction about yourself, your background, the purpose of your
visit, frequency of visits and the process of working with the facility staff is very important.
Gaining the confidence of the staff and having their acceptance of the process is dependent
on your ability to communicate clearly. It is important to spend adequate time in this initial
briefing to ensure that each person is clear about your role and purpose.Talk about quality
improvement. Discuss (again, if not first visit) what you mean by a quality service - what should
clients have as a right to expect and what do PHC providers have as a right to expect in order
to meet clients' rights? What really is a good quality service? If this is a first visit, complete the
exercise below. If it is a subsequent meeting, just have a quick reminder of quality issues.
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Exercise: Hand out two cards to each of the staff present. Ask them to write down on one card
two points that women have a right to expect from the PHC when they come for antenatal care,
or when in labour or in the postpartum period. Ask them to think about what they would want,
what their sisters would want, what they would think are the components of a quality service.
Give them five minutes to discuss about this and to write down their ideas. Collect the cards.
Read out what is on the client rights cards, and sort them into different ideas - you should have ideas about
all the components of the self assessment guides. If you are missing any of the key issues, ask them to think
of anything to add, and formulate questions to solicit more ideas. For example, if they do not mention
timely referral to an FRU, you could ask "what about when a woman has a complication that you cannot
manage here, what do you think she would hope for?" Likewise, if they do not mention confidentiality,
you could ask"how would you feel if the doctor talked about your bleeding problem in a loud voice in the
ward? What would you hope for, expect? For each point mentioned, ask them to give examples of how
these quality issues might be addressed (examples are shown in Table 5.1).
Now request them to look at what they need, to provide these services (what are their rights?) and list ideas
on the other card. Then collect them and read out the provider rights cards and sort them into different
themes. If you are missing any of the key issues, ask them to think of anything to add, and formulate
questions to solicit more ideas. For example, if they do not mention good supervision, ask "how about if
you don't know what the government standards of care are, what do you need?" Likewise if they do not
mention a clean environment ask, "How do you feel as health workers if the compound is dirty, or the walls
are not painted, what do you need?"
j
.t'i
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Figure 5.1 : Talking about QI
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Table 5.1: Client rights and how providers/staff can meet these rights
Client rights
Some examples of how providers can meet these
rights
❖ Practice infection control measures when performing any
procedure for the woman and the baby.
❖ Assess, diagnose and manage complications like shock,
PIN, eclampsia, severe anaemia, etc.
1. Safe and competent services
<♦ Practice the three components of AMTSL.
❖ Administration of MgSO4 for convulsions.
❖ Provide immediate newborn care.
❖ Assess, diagnose and manage preterm & low birth weight,
sepsis, asphyxia, etc.________________________________
2. Access to services and continuity of
❖ Qualified and trained staff available to manage labour and
deliveries.
care
❖ Postpartum woman can stay for 48 hours after delivery.
❖ Lab tests are available at the PHC.
<♦ Provide /arrange transport by ambulance for referral of
woman or baby with complications.
❖ Record of clients available for follow up at each visit.___
<♦ Ensure cleanliness within the PHC, specifically at the
labour room and wards to prevent infection.
❖ ~ Proper management of infectious waste disposal.
3. Safe, infection free services
❖ Staff washes hands with soap and running water.
❖ Between deliveries, tables and contaminated surfaces
wiped with 0.5% chlorine solution.
❖ Maintain privacy/confidentiality.
4.Privacy, confidentiality, dignity,
comfort and expression of opinion
❖ Avoid unnecessary exposure of the woman during vaginal
examination.
❖ Staff do not discuss about personal aspects of the woman
and baby in common areas.
❖ Talk to the woman and her family with respect and dignity.
❖ Staff educate the attenders about complication and why
referral is required.
S.lnformation and informed choice
❖ Staff provide information on FP and allow the woman to
choose the option or advice based on available FP at the
PHC.
Provide information on danger signs* for mother and
neonate at the time of discharge.
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Table 5.2: Provider rights and how to meet their rights
Provider rights
Some examples of how to meet these rights
❖ Equipment available in working condition: radiant warmer, ambu
bag and neonate mask, oxygen, cord clamps.
1. Supplies, equipment and
infrastructure
♦♦♦ Drugs and supplies like gloves, oxytocin, MgSO4, diazepam, Vit K,
insulin syringe are always available.
❖ Towel for receiving baby and placing on mother's abdomen at
birth is. available.
❖ Infection prevention material available.
❖ Lab test kits such as proteinurea test kit available._________ ___
<♦ Current SBA/NSSK/IMNCI guidelines available and pasted in
labour room.
2. Information, training and
development
❖ Trained
in resuscitation,
complications.
pre-referral
management
of
<♦ Trained in infection prevention practices.
❖ Trained to conduct labour and deliveries including use of
partograph.
❖ Staff assess services provided in a team environment.
❖ Management is supportive of team efforts.
3. Facilitative supervision and~
management
❖... Staff and.management assess records and case sheets in.a nonpunitive way.
❖ Staff meet regularly to discuss problems, responsibilities.
❖ Staff review of poor outcome cases at the PHC at regular intervals.
3. Talk about poor quality
Ask the PHC provider, "what is the cost of poor quality?" What are some of the potential consequences
when a PHC does not provide good quality services? Some answers might be:
❖ When women in labour are diagnosed with eclampsia and are having convulsions, if the PHC does not
have MgSO4 then the women may develop serious complications due to lack of treatment, and die.
Thus the women and fetus will be lost due to lack of a drug at the PHC.
❖ Infections can spread to the woman and her newborn during delivery due to the lack of good infection
prevention practices such as cleaning the labour table with 0.5% chlorine between deliveries.
❖ Women do not get treatment on time due to lack of drugs or absence of trained staff to handle complications.
Families do not know how to care for the mother and baby after discharge. This could be due to the
fact that staff did not educate or counsel the woman or family on care at home.
❖ Babies might not be fed properly. This might be due to the fact that the mother is inexperienced
and does not know how to breastfeed her baby. The mother might not have been counselled and
supervised by the staff nurse while breast feeding during the first 48 hours post delivery.
❖ Women and/or babies get sick, even die, due to poor post-delivery monitoring. This could result in
not recognizing danger signs and starting initial management. This could lead to complications and
increased chances of death.
27 I
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
4. Talk about responsibility for quality
Then ask "who is responsible for quality of service"? The answer is that quality is everyone's business, from
the sweeper outside (she is part of the team and contributes when she knows where to send a woman in
an emergency), to the pharmacist (who may understand the importance of keeping adequate stocks of
magnesium sulfate), to the record keeper (who helps the nurses fill in the registers properly), to the ANMs
(who tells a woman about danger signs), to an ASHA (who knows how to advise a woman about feeding),
to a staff nurse (who manages properly a woman with sepsis), to the doctor (who shares new knowledge
with his/her team members, helps with difficult cases, or orders case sheets from the district head
quarters). Quality improvement is not the responsibility of outside quality assurance people; it is the PHC
team's responsibility.
Explain that as quality is everyone's responsibility, all PHC staff have been invited to the meeting and as far
as possible, will participate in working together as a team, to look at quality issues in this PHC.
Then ask this question, "How we are going to improve quality at this PHC and who is responsible?" Explain
to the PHC providers that providers sometimes get frustrated with their working conditions and might
forget clients rights. Ask the PHC provider to tell you "what are some of the things that make staff/PHC
provider feel de-motivated to provide good quality?"
Answers might include:
i
❖ Poor salary, inequities in pay
❖ Long hours, too much work, too many clients
❖ Lack of coordination amongst the PHCtearrt
❖ No encouragement given by supervisors
❖ Staff shortage and staff absences
❖ No equipment, supplies
❖ Lack of training and updates
❖ Poor management and supervision
❖ Staff/PHC provider blame each other
❖ People in the community do not come to use the services
❖ Distance of the PNC and poor transport connectivity
Explain that sometimes staff/PHC providers blameeach other when things go wrong but that does not help
PHC providers to be motivated to do better. Ask PHC provider/staff to think about times they have been
personally criticised and how that made them feel and react. Some may want to give an example. What
helps is an improvement in "systems" - be it training systems, equipment supply systems, time allocation
systems. Explain that sometimes it is difficult to change systems but that we should try to focus on what
we can change in the systems, and not blame individuals who are working under the same constraints
and might have other problems.
Explain that as quality is everyone's responsibility and that nobody likes or reacts well to personal criticism,
the PHC provider will work together to talk about quality, discuss what are some poor quality issues
in this PHC, and come up with ideas of what can PHC provider do about them. PHC providers should
remember not to try to suggest solutions that are outside their control, such as pay scales, or that need
huge resources such as a new ward, but focus on things they can change.
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Figure 5.2: Using self assessment tools
Explain that you, as the new MNCH mentor, will support them to improve quality - you will be here
regularly to help them with clinical skills issues and wider quality issues. Tell PHC providers that you will
be helping them to assess progress themselves, working to improve clinical skills, and trying to help orient
PHC providers to new clinical issues.
.
.
.
-
Explain that they should ask you questions freely and that you are always contactable by phone if they
have a question. But say that quality improvement is their responsibility. Ask them if they are ready to do
that and be advocates for quality!
5. Introduce the A.M.M.A approach
Explain to staff that A.M.M.A is a precious word (discuss the wonder of motherhood in society) and that you
will be using it to help them to improve quality at their PHC. Using a visual, explain what the acronym means
and say that they will learn how to assess and diagnose problems at the PHC, how they will learn how to
manage those problems, how they will learn to monitor progress and how they will become advocates for
quality improvement. You might give an example of an issue that might be identified.
6. Introduce the self-assessment tools
Explain that all PHC providers will now do some work on their own or in teams. Remind them of the Assess
and Diagnose in A.M.M.A approach and inform them that there are three tools that they can use to give
them ideas about what can be improved at the PHC:
i. PHC team self assessment guides
ii. The client interviews
iii. The case sheet review
The PHC staff will work on different things, either individually or in teams over the rest of the day. They will
sometimes have to consult with other PHC providers to help them with the tasks. They will need to identify
problem areas (Assess), but also think about what might be causing those problems (Diagnose).
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The next day, everyone will come back together to present their findings to the group at a meeting where they
develop an action plan to address these problems (Manage). The action planning is a process where the teams
do a root cause analysis for each major problem identified so as to arrive at a realistic and effective solution.
Managing the self-assessment exercises
First explain the tools
a) The PHC self assessment guides
Explain to staff that the self assessment guides reflect essential elements for providing a quality service
and are organized around quality if care themes already discussed.
Explain to the PHC providers how everything will be managed for the QI exercises. Explain the advantages of
a self assessment process and introduce the eight self assessment guides (See Voll: Appendix 3-page 77-90).
Inform the PHC team that if this is the first visit they will review self assessment guides A, B, and C (see
Voll: page 77-84) only and on the second visit they can complete the remaining. Team members should
be asked to divide the tools between themselves, taking areas in which they are most interested or have
expertise - they do not ALL need to work on every tool - they could work in pairs for example; some people
can work on more than one tool - it might be a good idea to have a nurse pair up with a non-nurse.
Ask them to look at, and reflect on all the questions together as a team: if a question has several bullets
in a list, and they think some aspects are problematic, then "x" those so they know what to discuss in
the meeting. Tell PHC providers they can add issues too. The lists are not exhaustive - if PHC providers
can think of other problems, they should add them at the end. Explain that team members jointly review
each of the questions and answer them with either 1 (if the practice is good) or X (if there is a problem)
through discussion among themselves, with their colleagues or direct observation. If some aspect is truly
not applicable, they should write N/A in the column. It is not a test -they should be encouraged to only
mark an "x"against issues they think are important and need to be addressed urgently, otherwise they will
have too many issues. Explain that they can revisit the tools in a few months and identify other issues that
become more pressing. In this way it leaves the door open to revisit issues again later in the year.
Some ways PHC provider can answer the questions are:
❖ Discuss and review standards - PHC provider should discuss and look at copies of standards and
guidelines.
❖ Interview other PHC providers as necessary or check/observe themselves. For example if a team is
unsure whether the PHC has all infection prevention materials, they could ask the people who do the
cleaning.
b) The client interviews
Clients accessing care at the facility can provide critical information on facility, services and the PHC
provider. It is important to understand their perspective and list their opinions on what is going well and
also what they feel should change to ensure that they return to the facility for services. Clients'suggestions
can help improve services but might normally be difficult to get as they are not used to sharing their ideas
openly. Interviewing clients has an additional advantage of the client recognizing that the facility is making
efforts to improve care based on their suggestions.
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During the second visit one of the PHC providers will be asked to volunteer to interview women and
families in the facility. Try to interview people after they have had service. As there might be few women
in labour or in the postpartum ward, these interviewees can be antenatal women or those seeking care for
children or women in the postpartum ward. If none of these people are available, they should interview
any other clients in the facility and focus on general quality issues. They should interview 5 or 6 clients.
Explain why they are doing this - not to get specific information but to start a dialogue with community
members, to show that they are serious about quality improvement and to get some ideas about what
could be improved at the PHC.
PHC providers should introduce themselves to the clients and ask the questions shown in Appendix 4
(see Vol 1: page 91 -93).The interviews should be friendly and casual. PHC providers should feel free to have
a general chat with clients about their experiences and ask genuinely for ideas. Be open to criticism, in fact,
invite criticism, and don't be upset or feel threatened. Only by seeking other perspectives can we learn
what to improve. Tell PHC providers to be ready to share findings with the group.
c) Case sheet review
It is very important to look critically at the way we manage the cases and how we document our practices
in the case sheets that we fill. Case sheets can give us an actual idea of the providers' knowledge and
practice related to clinical protocols. One or two PHC staff will be responsible for reviewing the case sheets
to understand the current practices and identify areas for improvement.
Tell the PHC providers to examine 10 case sheets and look at al[ the elements described in the table in
Appendix 5 (see Vol 1: page 94-95).They should mark each box either with a check mark as given in page 29
(4th para Sth line) if something was done, with an X if not done or with a'T if they are not sure. They should
make a note of things that are not there for a good reason (e.g. if the baby died you would not check its vital
signs on discharge).Then tally the data. The PHC providers should come back to the group with a summary
sheet, adding up the rows and be prepared to share with the group, identifying areas for improvement. You
might have to delay this activity until case sheets have been introduced at the sites.
Organize groups
After you have explained the three tools (self assessment guides, client interview and case sheet review) and
depending on how many people are participating, you should divide up the PHC providers into smalljeams
so that some of them work using tools in Appendix 3 - A, B, C (see Vol 1: page 77-84); Appendix 4 (see Vol 1:
page 91-93) and Appendix 5 (see Vol 1: page 94-95). Depending on their interest, one or two people can
interview clients and one or two people can review case sheets. Teams should consist of a mixed level of
PHC provider but should include some clinical PHC providers who will be able to answer the more technical
or medical questions. Each team will identify a note taker who can present findings to the rest of the group
in the form of an action plan. The small groups or the individuals should discuss some of the problems they
observe and develop a draft action plan as described below.
Explain root cause analysis
While carrying out the various assessments if something is not being done, or is a problem, team members
should discuss why it is not being done, or what is the root cause of the problem? In analyzing root causes,
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staff should focus on gaps in the systems and processes and not blame individuals. What is the root cause
of the gap? One of many problem solving techniques is call the WHY-WHY-WHY analysis to help discern
root causes. In this technique when presented with a problem you keep asking "why?" until there are no
more answers.This allows you do "drill down" until you discover the performance that is at the root cause of
the problem and then can focus interventions on real reasons for the performance gap.
In looking for root causes, recognize that there are several factors that affect quality and can lead to
performance gaps. Too often people tend to think the root cause of the problem is lack of knowledge and
skills and that more training is needed but often, it could be other factors that need to be addressed. Some
gaps might have more than one root cause and more than one solution might be needed to address them.
Explain ways to find solutions
Once problems have been identified, then the small groups should brainstorm about possible solutions to
address the problems. Groups can also learn from the processes that are working well in other departments
within the facility. For example, the pharmacy department might not have a supply problem but the lab is
often out of reagents. What could lab services learn from the pharmacy department about how to ensure
adequate supplies?
Explain the development of an action plan
Initially the smaller groups can brainstorm on the possible solutions before bringing it to the larger
group during the action planning meeting where further discussions can take place and more ideas can
be gathered to solve problems. Team members must find a solution for each root cause identified. They
should prioritize solutions, taking into consideration such issues as client or PHC providers safety and
the ease with which the problem can be solved using local resources or ingenuity. Then the team should
assign someone responsible for implementation and completion dates that reflect the priorities. This is
the M (Manage of A.M.M.A). An example of an action plan is given in Table 5.3.
Table 5.3: Sample action plan
Problem
Staff do not
Root causes
Staff are not aware
know treatment
for eclampsia
convulsions
of new eclampsia
management
PHC has no case
sheets
None available at
district level
Solution
Arrange a short
refresher training
By who
Jyoti will ask MM to
give a short refresher
session
M.O to arrange and
pay for using untied
for better long term funds and ask district
for some at the
supply
Photocopy some
sheets and arrange
earliest
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By when
31 August 2012
29 July 2012
Section A - Chapter 5
Staff do not
transfer clients in a
timely manner
Staff do not
understand the
importance of
timely referral
Staff do not have
a referral display
to know where to
refer based on the
need
There is no
ambulance in the
village
Not all staff know
how to resuscitate
a baby
MgSO4&VitK
including Insulin
syringe
Administration is
Have a short
meeting about
the importance of
timely referral
Usha to facilitate the
meeting
Usha will collection
the information and
Develop the referral develop the Referral
Directory
Directory for the
PHC with contact
MO to organize a
details, etc.
meeting with VHC
Have discussion
with the
community about
how to transport
women quickly
Problem Root
causes Solution
By who By when
15 August 2012
20th August
2012
30 August 2012
Arrange to
contact NRHM
for immediate
procurement
MO to organize
MM (or any staff
member already
trained) to give
mini lecture and
demonstration
Jyoti will get MM to
conduct the session
tomorrow
Lack of Supply of
these drugs to the
PHC
Arrange for these
drugs and supplies
with the use of
untied
MO will purchase and
bring tomorrow to
the PHC
8th Aug 2012
Since 2 years
Funds
MO and Pharmacist
5th Sept 2012
will raise this at their
(MO review
district meeting
meeting by
There are no
ambu bags
Staff have never
been trained
not available at
Pharmacist and
the PHC in case of
MO will raise this
emergency
10 Aug
8th August 2012
DHO)
supply issue at
their district level
meeting with
DHO and other
concerned officials
Staff do not use
There are no
Make some from
Uma to work with
puncture proof
puncture proof
any thick plastic or
maintenance person
containers for
containers in the
metal container
sharps
PHC
Orient all staff
Staff do not know
to importance
importance
of proper sharps
Geeta
15 Aug 2012
15 Aug 2012
disposal
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Discuss and decide on a good time the next day to come back and discuss the
results
What mentors can do while the PHC providers work on the self assessment (SA) tools:
During the day, you should be walking around observing the self assessment process or sitting with
the PHC providers to see if they understand the exercises and are properly completing the tasks. They
might have a little difficulty at first but will soon learn how to do it. Don't worry if they don't do it
perfectly the first time - one objective is to get them working together, thinking about quality issues,
thinking about problem solving and thinking about their clients. You are there to model facilitation,
teamwork and non-judgemental sharing. While observing them filling the self assessment guides you
might have to stop to discuss why they put a tick for skill components like Active Management Third
Stage Labour (AMTSL); ask them what they practice for AMTSL at their PHC. If they do not do all the
three components then remind them that the SBA guideline mentions them and encourage them to
change it to an X mark.
When the teams are busy administering SA tools, audit 10 case sheets using MNCH mentoring case sheet
audit format (Appendix 10 - See Vol 1: page 113-119).This helps to specifically know if the PHC staff practice
specific things. You will conduct the case sheet audit at every mentoring visit to the PHC. This is discussed
further in the next chapter. Remember that this is different from the earlier case sheet review which was
done by the PHC teams as a part of self assessment exercises. The initial case sheet reviews done by PHC
staff may not highlight all the gaps and it might take a while before the staff are comfortable in auditing
their own practices. Hence, you as a mentor will have to audit few case sheets to get an understanding of
gaps in the practice and plan your teaching sessions.
Ensure that you observe any woman in labour or deliveries - tell staff to come and inform you. Also observe
practices in the postpartum ward. Pay attention to infection prevention practices, record keeping, use of
case sheets and labour monitoring. Spend more time chatting with the in-charge, with laboratory staff,
with pharmacy staff and support staff.
If the teams are coping well on their own, take some time yourself to do some of your other MM tasks, such
as collecting monitoring data or checking supplies, or talking yourself to clients.
Instruct the PHC team that these self assessment guides can be filed and kept in their PHC for internal
review at a later time.
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REMEMBER!!!
If there are a lot of clients or especially during any emergency, then PHC staff
should attend to the emergency in a timely manner. If a woman comes in labour,
or if there are women in the postpartum ward, then take time to observe what is
going on there and give gentle feedback and coaching to the PHC provider as they
work.
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Facilitate the collective action planning meeting
A moment's reflection
When you come back together at the agreed time, make sure that everyone is here and that all are seated
comfortably. To warm u p the meeting, ask people to reflect on how they found the experience of doing the
exercises - did they feel happy, sad, excited, overwhelmed or depressed, bored, energized, hopeless? Be
sure to let everyone have the chance
Guidelines for reporting back
Ask the team spokespersons to report on what they found. Use the A3 size laminated posters of these
self assessment guides for all the PHC staff to see. Reiterate that they need to focus on root causes, not
superficial causes so as to not go off in the wrong direction when seeking solutions. They also need
to focus on rational, realistic solution, in a realistic timeframe. Advise them not to expect the same
person to fix everything.
Ensure that they can speak without interruption, but do not let them talk for too long - stress that they need
to make their points quickly and concisely. Ask the rest of their team if they have anything to add. Then
invite other people or teams to comment. Ask people to rephrase points if the rest of the PHC providers
do not agree or have other ideas of what root causes might be, or what potential solutions might be, or of
they think other people should be responsible or if the time frame should be changed. Ask all the groups
to report back. Where there is overlap, add issues together.
Put the action plan together
Some of your own observations can be included in the follow-up action plan meeting. But remember, the
main aim of the exercises is self assessment, and letting PHC providers find out for themselves what their
limitations are, so you should not let your findings (or your recommendations) dominate the meeting,
otherwise PHC provider will feer'inspected"and criticised.
When the action plan is finished, and if there are many items, ask PHC providers if they would like
to prioritize and focus on just a few in the next 1-2 months, and leave harder things for later (quick
results will give impetus to the process). Ask PHC provider to commit to following up on the issues
they have brought up.
Identify a site QI coordinator
Ask them if they would like to nominate someone who can be responsible for checking in with everyone
listed as responsible for certain items. This person will measure if the action plan is being implemented
as planned and will communicate within the PHC team and with the MNCH mentor on successes and
difficulties encountered.
During the whole process if you have observed that a particular PHC provider has understood the QI
process well and had good suggestions to contribute, talk to the person and understand his/her role in
the centre and appreciate his/her effort. In the last part of the meeting gently suggest to the team if this
person could help coordinate within the PHC team. Explain that this person will also be a contact person
for you as the MNCH Mentor for the PHC. Tell the PHC provider that you are available by phone if they want
to discuss anything later.
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Make sure you have made notes of items on the action plan so you'll know how to fill in the mentor's trip
report (Tool 5) to be submitted to the District Program Specialist of Sukshema project in the district and for
preparation ahead of your next visit.
REMEMBER!!!
Use the A.M.M.A Approach while addressing PHC level issues. This will help the
PHC staff follow a stepwise approach to problem assessment and diagnosis,
management, measurement and advocacy for QI
5.3
Using A.M.M.A to Help Improve Provider Clinical Knowledge
and Skills
You may remember that as a MNCH mentor you will have to use A.M.M.A approach at all levels of quality
improvement in PHC. During your mentoring visit you will mentor the staff/PHC provider to be clinically
competent in those key aspects of labour, delivery, postpartum and newborn care that most significantly
affect morbidity and mortality. PHC providers need to know what they can manage at a PHC and exactly
how to do that They also need to know what they cannot manage at a PHC and when referral is necessary.
The PHC provider should be helped to use A.M.M.A approach to provide quality clinical care to the
woman and newborn as outlined below:
❖ Assess and diagnose by screening for danger signs among women in labour, during delivery, women
in the postpartum period and neonates, using case sheets and partograph.
❖ Manage by providing routine care or pre-referral management for complications in a rational and
timely manner using the case sheets.
❖ Measure by monitoring progress of client's clinical condition after initiating management.
<♦
Advocate to create a safe and client centred environment for women and neonates.
Broadly, you could address clinical competencies of the 24/7 PHC staff through the following ways:
❖ Introduction of the new case sheet for use at 24/7 PHC
❖ Identify onsite clinical mentoring needs of providers
❖ Provide on the job coaching and address providers'clinical competencies
Introduction of the new case sheet for use at 24/7 PHC
A very critical component of the mentoring program is the ne^v case sheet developed by the project in
consultation with providers and government officials. You need a thorough knowledge of the'why'and
'what' of the new case sheet in order to explain it well to the PHC teams during your first visit and gain
a good acceptance of the case sheet. It is a good idea to have a discussion of the case sheet by initially
eliciting provider's responses on the advantages of case documentation or that of a case sheet.
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Mentors'Manual Volume 1
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Figure 5.3: Mentoring on the use of the new case sheet
Why (the need for a new case sheet)
The project during the initial assessments found out that the case sheet documentation was poor in all the
PHCsduetomanyreasonssuchaslackoftrainingororientationonimportanceanduseofcasesheet;thecase
sheet did not serve as a job aid to remind the provider of all the critical steps (protocols, drugs, dosages, etc)
to be followed from the time of arrival to discharge or referral, if there was a complication; earlier case sheet
did not provide opportunity to audit provider's practice as they were open ended andinvolved descriptive
documentation.The project introduced the modified case sheet, along with 8 separate complication sheets
for each of the most commonly diagnosed complications, as a job aid to the staff attending deliveries. This
job aid aims to help the PHC staff in providing a comprehensive and quality care to the woman during initial
assessment, labour, delivery and immediate postpartum period and to the newborn. More specifically,
it (1) reminds the sequence of the different steps to be followed at each stage (2) reminds the correct
diagnosis of complications (3) reminds the appropriate procedures and drugs for the initial management
of complications before referral and (4) facilitates easy and quick documentation for future audits for
quality improvement.
What (the components of the new case sheet)
Once you explain and convince the PHC teams of the need for a new case sheet, now you have to do the
most important job of introducing the different components of the case sheet. A good presentation can
inspire the staff nurses to accept the case sheet and start using it. Hand over a copy of case sheet to each
staff so that they can refer to the different parts of it as you talk about it. Clarify in the very beginning that
the new case sheet is to be used for only those women who have crossed 20 weeks of gestation and arriving
at the PHC for labour or for any complications.The case sheet needn't be filled for antenatal women visiting
the PHC for a routine check up.
❖ First, you talk about the broad sections of the case sheet - initial assessment, labour monitoring with
simplified partograph, delivery notes with fourth stage of labour, postpartum care, outcomes sheet
followed by the complications management and referral sheets.
❖ Next, you take up each section and go through the details in it; emphasize the rationale behind each
section and each parameter and why it is important in knowing and documenting everything in the
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
case sheet, and how the sequence of steps in each section culminates in assessing and diagnosing
the condition of the client (A) and also guiding the next steps of management (M); then, there are also
vital parameters that one has to watch out for to measure (M) the effects of management, if the client
is recovering or not.
❖ Highlight that complications can be detected at any point in time and it is only our watchful attitude
that can help us pick them up early and take action. The case sheet is essentially designed to help a
provider in doing this.
❖ If at any point in time, a complication is detected, remind them that they need not proceed with
detailed documentation, but to switch over to the specific complication case sheet (as denoted by the
code for easy identification of complication case sheet) and start using it.
• Each complication case sheet helps the provider to reassess and confirm the diagnosis (A), manage
(M), measure (M) and refer to the higher facility.
• The complication case sheet captures the referral details including the outcome of referral and
thus there is a comprehensive documentation of every case that is admitted in the PHC.
❖ Another very important aspect is that the case sheets are printed in duplicates so that at the time of
referral, the referral copy (coloured) can be separated and sent to the higher facility along with the
woman or newborn. Encourage the staff nurses to use the case sheets as a job-aid when providing
care and simultaneously document without postponing to a later time and date. Meticulous
documentation can go a long way in improving the quality of care provided in the PHC (Refer to the
Vol 1: Annexure 13; page 128-147 Annexure 13 for case sheet details).
Anticipate the challenges related to case sheet use
Certain circumstances can affect the providers' practice as well as the documentation and thereby
affects the overall quality of care in the facility. It is important for you as a mentor to understand these
circumstances which can be systems related where you and the teams have to jointly explore solutions to
overcome these challenges. For eg: PHCs with high delivery volume or OPD (outpatient) load, PHCs with
inadequate number of staff nurses, etc. It is important to address these issues through self assessment and
action planning with the PHC teams. You could explore task sharing with the ANMs or any other strategy.
Very often advocacy with higher officials can be useful. Sometime, it is simply the providers'attitudes and
resistance to change that can affect their learning and use of case sheet also. You have to be sensitive to
this, spend more time to build rapport, try to win their confidence, periodically communicate and convince
that following evidence based protocols and using case sheets can make a difference. You may have to take
the help of the medical officer or your line manager (DPS) to address these situations.
Identifying onsite clinical mentoring needs of providers
As detailed earlier during the first visit to the PHC, you will focus attention on developing rapport with the
PHC staff and administer Self Assessment guides (A, B, C). During this visit should a clinical event arise at
the PHC (such as a delivery or a postpartum mother), allow the staff to attend to it.Then you will proceed
to provide clinical mentoring to the PHC staff attending to the event. As much of your time during first
visit will be dedicated to knowing the PHC, developing the rapport, administering the self assessment
tools; introducing and reinforcing the use of new case sheet, you may not have enough time for organizing
any teaching sessions. You have to plan in your second visits, a more systematic clinical mentoring with a
pre-determined teaching plan that revolves around the critical MNCH skills. In addition, you will ascertain
the clinical mentoring needs at the PHC through the discussions during administration of self assessment
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exercises and case sheet reviews. During the administration of self assessment guides and case sheet
reviews, providers may identify certain gaps in practices and skills. You can discuss the finding during team
meetings and staff may actually request for a teaching session.
Observations of clinical practices and facility systems
Whenever possible, try and observe the actual practice of the providers at the PHC at all stages of the
continuum of MNCH care including observing assessment of a woman in labour if she has just arrived,
monitoring of labour using partograph if the woman is admitted, assessing active management of
third stage of labour to see if all the three steps are performed, etc. If there are women and newborns in
postpartum wards, observe if monitoring of mothers and newborns is performed as per the protocols.
The observations can be noted down to guide the clinical mentoring plan.
Auditing of MNCH mentoring case sheets
This is done by using audit format annexure 10 (see Vol 1: page 114-119). The case sheets used by the
PHC providers are job aids to guide their clinical management. Additionally they also help you understand
the practice and documentation of PHC providers related to MNCH services. You have to audit about 10
case sheets that are most recently filled up, review them carefully using the case sheet audit checklist and
document whether a specific task in management of a condition is done or not. After auditing the 10 case
sheets, you will have the firsthand information of the actual practice and gaps in specific competencies.
While working alongside the PHC providers you will also observe their skill in case sheet documentation
practices. Very often the gaps in documentation could be because the PHC providers may not have realized
the importance of documentation. You will have to ascertain this and actually reinforce the importance
and advantages of documentation. You can also use the case sheet as a job aid for conducting a mini
teaching session along with use of other teaching aids as appropriate.
Provide on the job coaching and address providers'clinical competencies
Having assessed the clinical mentoring needs of the PHC providers, your task as a mentor is to create
opportunities during your visit to enhance their clinical competencies. You have to plan and prepare well
both in terms of knowledge of the topics that you have to cover as well as the specific mentoring skills that
can effectively enhance participants learning. Certain tools and checklists will come in handy to support
you in this regard. Make sure that you spend good time practicing and rehearsing in the planning meetings
with your line manager.
Pre-defined topics that are part of the critical MNCH services package for PHC staff
Use the Clinical Mentoring Guide for MNCH mentors (see Vol 1: Appendix 8 - page 101-107).This tool guides
you about the topics to be covered during each visit and has a detailed guide/checklist of content within
each topic that needs to be emphasised.These topics are in line with the essential MNCH package focused
by the intervention and have to be taught over several MM visits.This is only a guide to tell you what topics
and skills have to be covered. But as far as the content is concerned, you have to refer to the mentors'manual
(Vo! 2 and Vol 3) that you were provided during your training. These manuals are very important for you to
read and re-read till you are thorough with the knowledge.The clinical content is presented in a systematic
manner in the Appendix 9 (see Vol 1: page 109-112) and document whether a specific task in management
of a condition is done or not. After auditing the 10 case sheets, you will have the firsthand information of
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
the actual practice and gaps in specific competencies. While working alongside the PHC providers you
will also observe their skill in case sheet documentation practices. Very often the gaps in documentation
could be because the PHC providers may not have realized the importance of documentation. You will
have to ascertain this and actually reinforce the importance and advantages of documentation. You
can also use the case sheet as a job aid for conducting a mini-teaching session along with use of other
teaching aids as appropriate.
Use of teaching aids
You can enhance the learning of the participant by use of certain teaching aids. A dry lecture without any
aid can often be less effective as they may not elicit enough participation and interest. Be alert and never
get into a monotonous lecturing mode. In order to support you in this regard, you can make use of case
sheets that can be an excellent aid both for teaching as well as for learning. Carry your manuals and refer
to them while you deal with these topics. The 24/7 PHC essential MNCH drug list (see Vol 1: Appendix 11page 120-124), is useful when you are referring to various drugs that need to be used in this context. Use of
models through demonstration and asking for a re-demo, or use of case studies that are given to you along
with the manuals can be very effective teaching aids.
Methods of clinical mentoring
As a MNCH Mentor it is important for you to understand some of the adult learning principles and
strategies that will help the PHC staff learn and absorb technical content. You will also keep in mind that
teaching opportunities will present themselves in a variety of settings that will not allow for a classroom
style teaching. As a skilled mentor during routine work you will be able to create learning opportunities
for the PHC staff. During your mentoring visit, you can use the following different methods of clinical
mentoring and the same structure can be adopted during your teaching sessions. Each chapter starts
with importance of the topic, the components under the topic, the requirements in terms of key skills,
equipments, supplies and attitudes to practice, the associated do's and don'ts and finally ends with the key
messages for the topic.
Immediate Responsive Methods
❖ Responsive Coaching
❖ Modelling
While you as a MNCH Mentor work alongside PHC staff, opportunities will present themselves to provide
mentoring right at that time and these are called Immediate Responsive Methods. You may choose to
assess knowledge and then provide mentoring or you may choose to model the procedure correctly and
allow the PHC staff to observe and directly learn from this observation without having to teach them Modelling.
To understand this let us look at some examples of how this is practically done:
An example of a situation of pregnancy induced hypertension immediate responsive method
<♦ If magnesium sulfate is not prescribed for pregnant women with pregnancy induced hypertension
(severe pre-eclampsia and eclampsia) when indicated, then you as a mentor may use the work place
opportunity to provide additional knowledge on this aspect using a one-minute preceptorship or
incidental learning by providing responsive immediate coaching.
❖ During rounds when you observe that a client's blood pressure is not measured, you may use the
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opportunity to immediately ask "Why is measuring blood pressure in pregnancy important?" going
on to explain that PIH is a common cause for maternal morbidity and mortality, as well potentially
leading to complications for the newborn such as prematurity. This brief exchange of words between
you and the PHC staff could easily lead to a discussion of the relevance of blood pressure recording,
identification of PIH and the role of magnesium sulfate in successful management.
❖ If you find that there are additional issues that prevent the utilization of magnesium sulfate such
as pharmacy stock outs, non-availability outside working hours or even that the staff nurse/medical
officer has apparently no knowledge or protocol in place for medication in eclampsia, then additional
steps may be needed.
❖ You may decide upon reinforcement even through team/small group discussions. You may discuss
the finding during team meetings, request for a mini-lecture on the management of the PIH/
eclampsia either by you but preferably by other team members asking them to review texts, literature
or existing national guidelines from existing trainings. Providing clinic aids like posters for the wards
and explaining the protocols on them will also assist in learning.
An example of hand washing
If hand-washing by the PHC staff is uncommon in the labour room or between examining newborns in the
post-delivery ward, then it could be the source of infection - both maternal and newborn. The challenge
here would be the need for knowledge of various aspects of hand-washing from the why, to the how and
the when of hand-washing.Talking about hand-washing may not be adequate, but actually demonstrating
hand-washing protocols in the workplace situation or modelling followed by reinforcement through the
team meeting and small group discussions with clinic aids may be one possible method of enabling learning
amongst the PHC staff. Additional iong term feedback would.be documenting the number of neonatal
and maternal sepsis attributed to poor hand-washing practices and demonstrating changes in trends with
initiation of hand-washing protocols. Similar methods of modelling and one minute perceptorship may be
used to enhance the learning of the affective/attitude related counselling.
Delayed reinforcement methods (Planned small group teaching session)
When issues identified are widespread in the facility or are cross cutting across all professional team
members (e.g. hand-washing, initiation of exclusive breastfeeding, lack of management protocols, etc.),
there may be a need to refresh provider knowledge and skills in a relatively more planned and formal way.
Suggested methods could be:
Case based discussion and the mini-lecture
A small group discussion with PHC staff could be scheduled in consultation at the team meeting at a date
or time convenient to most usually during follow-up visits. It is always a good idea for you to suggest that
it will be an update which will be brief focusing on the task. Active participation by PHC staff and you
is recommended. Dividing subsections among each PHC member to be presented by 10 minute mini
lectures prevents boredom and increases active participation and learning of all the staff. Adult learning
principles should be the cornerstone of any such plan.
It is always interesting and demonstrates relevance in the context of the PHC staff if a client's case
details from actual case sheets are discussed. You can concentrate on the WHY, HOW, WHEN questions
to trigger discussions and interactions between PHC staff.
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Case sheet/ register review discussions
Discussions based on review of case sheet/ registers, can focus on brief audits of specific issues such
as the completion of BCG vaccination at birth and those with missed opportunities, referrals, etc. You
can identify some of these issues from the case sheet self audit that the PHC staff carried out or from
the case sheet audit that you conducted. You can use statistics from registers to trigger for small group
discussions focusing on issues/challenges/ideas/solutions to reinforce good practices and plug gaps
within the PHC practices.
Hr f
KI
. . .f -
f-
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Figure 5.3: Skill Demonstrations
Skills demonstration:
You can use lectures and demonstrations for identified psychomotor skills that need reinforcement
to improve learning. Hand-washing, bag-mask-ventilation of a newborn, AMSTL for prevention of
PPH, etc. would be some examples of skills requiring some learning of theory but certainly a focus on
demonstrating skills.
Role plays/ video clips:
Role plays or video clips can be useful teaching tools to demonstrate feelings, empathy, kindness and an
understanding of the situation and need. You can use a role play or video clip that may be dramatized or
viewed by the PHC team who in turn discuss the strengths and weaknesses of the communication and
interaction. For example, you can select topics for role plays on counselling of exclusive breastfeeding, danger
signs, immunization, etc.
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Workplace aids:
You can help PHC staff to develop posters of standardized protocols based on guidelines; even simple clinic
aids including checklists do make their task easier and more structured. Case sheets, essential drug list,
standard protocols for management of complications are some of the workplace aids that can be kept as
ready reference for all PHC staff.
Distance mentoring
Use your mobile phone in providing mentoring support to the PHC staff by giving them your number for
them to call you when they are in doubt. The advantage of telecommunication is that phones are readily
available and offer an opportunity for PHC staff to interact directly with you. However they are often not
accustomed to presenting cases over the phone. Train providers in how to present cases clearly, in order
and comprehensively over the phone.
You and the PHC staff need to have a clear agreement on when to call for advice. It is also important for
you to let the PHC staff know that to convey the fact, calling frequently is good and not bad. PHC staff are
often not accustomed to seek advice and may have had negative experiences when calling for advice.
You may also have to initially call the PHC staff regularly, to find if they had any problems, discuss cases
and follow up on cases and problems discussed during previous site visits.
REMEMBER!!!
A.M.M.A approach can also be used to improve providers'clinical competencies. You
have to plan and prepare well. Do not forget to use the appropriate teaching aid
during your mentoring sessions. Case sheet is an excellent teaching aid and always
refer to them when you take a session.
Adult learning principles
1. Adults learn only if they feel the need to learn (internally motivated and self
directed)
2. Adults learn bring life experiences and knowledge to their learning situations
3. Adults learn if they know why and think it is important for them (relevancy
oriented)
4. Adults learn if they think it would help them in real life task (goal oriented)
5. Adults learn better by doing or practicing in the real world (practical)
6. Adult learners like to be respected
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5.4 Summary meeting and subsequent visits
Manage the summary meeting with the PHC staff
This has to be done at the end of the visit after you have sufficiently dealt with both the PHC systems issues
as well as provider clinical skills. It will be important to always have a summary meeting with all the staff to
ensure you get an opportunity to:
❖ Update them on what has taken place during the entire visit
❖ Thank the PHC providers for all their hard work
❖ Compliment them for what they were already doing well at the PHC
❖ Compliment the staff on the immediate changes they have made at the PHC. This will give you a
chance to appreciate those who have made a special effort to improve the quality of service at the
PHC like MO purchasing drugs and supplies
❖ Highlight the new learnings of how to handle complications the next time they are
encountered in the PHC
❖ Mention the topics of clinical mentoring that were covered during this PHC Mentoring visit
❖ Ensure that the PHC knows that you are available on the phone should they need your
help - Distance Mentoring
Managing subsequent mentoring visits
" In each subsequent mentoringVisit, mentors should meet with the fulT team to review status of the action
plan, discuss and resolve challenges and brief the team on how mentor and staff will interact for remainder
of that visit. In the second mentoring visit to the PHC the remaining self assessment tools will be filled by
the PHC staff and the Action Plan will get updated with these new areas that need to be worked on. Ensure
that the uncompleted tasks from the earlier Action Plan need to be revisited during the current visit.
The PHC team should repeat the self assessment exercises during the subsequent visits (preferably during
4th and 5th visits) as this will give them an opportunity to assess the progress made in improving the PHC
systems and staff capacities.
Mentors'Manual Volume 1
Section A - Chapter 6
Other Responsibilities of
UK MNCH Mentor
6.1 Introduction
Apart from what has been covered in previous chapters, there are a few additional responsibilities that
have to be taken care of by the MNCH mentors. This chapter explains them briefly.
6.2 Liaisonof PHCs with Community
Improving quality of care in PHCs is dependent on factors within the community. The knowledge levels
and attitudes of communities can influence their health seeking behaviour. Very often one observes that
the women come to the PHCs very late in labour (8 or 9 cm dilatation) and deliver within a short span of
time after arrival at the PHC. Use of partograph for labour monitoring is limited in these circumstances and
the PHC provider may fail to recognise the complication early enough. Sometimes, the women may fail
to recognize the danger signs themselves and may come actually very late to the PHCs. These challenges
can be addressed when the PHC teams and the front line workers realize that they have to work as a team.
Mentors have a role to play in facilitating this linkage. Mentors may have to address the knowledge gaps of
the front line workers if needed and ensure that the team works in coordination.
6.3 Liaison of PHCs Higher Systems
During the self assessment exercises, you may find that some facility gaps are best addressed at
higher level e.g. filling the vacant positions within the PHC or strengthening the supply chain,
strengthening linkages between PHCs and higher facilities, high delivery volume setting that needs
additional staff, etc. The MNCH mentor will make a note of these issues and encourage the PHC MO
to raise these at their monthly meetings with the DHO. The mentor can then also inform the DPS to
work with the DHO to address these concerns for the respective PHC.
6.4 Reporting to the Sukshema District Program Specialist
MNCH mentors report to the respective DPS at the end of each month.TheTable 6.1 lists the various reports
that need to be submitted.
6.5 Attending Meetings with other MNCH Mentors
It is important for all of you (MNCH mentors) to meet together after completing every two PHCs during the
first and second round of visit to share and evaluate what is going well and what needs to be strengthened.
Use this as an opportunity to share experiences, successes and challenges faced during the month. This will
encourage cross learning and exchange of ideas within the team.
6.6 Monthly Review Meetings with Program Officers
Your DPS who is your line manager, will facilitate monthly review meetings to bring together all of you
( mentors) and the government program officers face to face to discuss issues and solutions that need to
be initiated at the district level.
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
6.7 Clinical Practice at Taluka/ District Level First Referral Units (FRU)
To ensure that you as a mentor maintain a high standard of clinical acumen, it is critical that you continue
to practice skills on a regular basis. Sukshema project will facilitate opportunities for you to practice your
skills at a clinical setting with high delivery volume.
Table 6.1: Various reports to be submitted by MM
Client interview guide
Take a copy of these tools after they have been
Case sheet review guide
filled up by the PHC provider
Action plan
Mentoring trip report template
Onsite mentoring plan and training monitoring
tool for PHC staff
Take a copy of the action plan that has been filled up
by the PHC provider to monitor its implementation
This is a report format that the mentors will use to
report back on the visit to the PHC
These documents guide mentors in planning
clinical sessions as well as for documenting the
topics and skills covered during any visit
References
1. EngenderHealth (2003) COPE Handbook: A process for imporving quality in health services.
EngenderHealth, NY, USA
2. Jackson SC, Murff EJT (2011) Effectively teaching self-assessment:Preparing the dental hygiene student
to provide quality care. Journal of Dental Education. 75(2): 169-179
3. Marienau (1999) Self assessment at work: Outcomes of adult learners' reflections on practice. Adult
Education Quarterly. 49 (3): 135-146. doi: 10.1177/074171369904900301
4. MENTOR/National Mentoring Partnership (2005) How to build a successful mentoring program. Using
the elements of effective practice. USA
5. Stephen J and Lewin S(2012)Mentoring skills - Participants workbook. Medical education cell, St. John's
Medical College, Bangalore www.uonbi.ac.ke/sites/default/files/chs/chs/Mentoring
6. Student supervisors toolkit- basic prinicples of adult learning www.qotfc.edu.au/resource/documents/
reference_document_3_1 .pdf
7. WHO (2006) WHO recommendations for clinical mentoring to upport scale -up of HIV care, anteretroviral
therapy and prevention in resource-constrained settings. WHO, Geneva
Mentors'Manual Volume 1
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Section B
PHC Systems Issues
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
>1 Infection Control Practices
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This chapter explains the importance of infection control at PHCs, different components of infection
control specific to PHCs and how a mentor can actually apply the A.M.M.A approach to set up or
strengthen the infection control practices in a PHC.
1.1 Introduction and Need for Infection Control Practices
Any person seeking services from a PHC or their family members or the PHC staff can be a source of
infection. All objects that come in contact with any of them in the PHC should be considered to be
potentially infected and capable of transmission of infection. The main objectives of infection control is to
prevent the occurrence and minimize the risk of transmitting infections including blood borne infections
such as Hepatitis B, C and HIV between persons within the health facility. Risk for infection is high when
exposed to body fluids. The risk is even higher when health care providers are not careful enough take
adequate precautions. Hence infection control practices must be followed by the staff always since it is
not possible to tell who is infected and who is not infected.These are called Standard Precautions. With
correct infection prevention practices at the right time and place, we can prevent cross infections i.e.
from one person to another, prevent infection after an invasive procedure such as episiotomy suturing,
and lower the costs of health care since prevention is cheaper than the treatment of infections and their
related complications.
1.2 Components of Infection Control (Standard Precautions)
You as a mentor should be aware of different components of infection control so that you can orient the
PHC staff and encourage them to practice these effectively. There are six components in infection control
namely, (1) Hand hygiene (2) Use of personal protective equipments (PPE) (3) Processing of instruments
and other items (4) Proper handling and disposal of sharps (5) Maintaining a clean environment (6) Waste
segregation and disposal. All these components are described below. In addition the PHC staff have to be
aware of the post exposure prophylaxis protocols as a part of broader infection control procedures which
is explained subsequently.
Hand hygiene:
The hands can get contaminated when performing various procedures. The correct technique of hand
hygiene is important since microorganisms could be concentrated in the skin folds between fingers and
around the thumb. Practicing hand hygiene is one of the most important procedures to prevent cross
infection (infection spread from one person to another). A health care provider must be able to perform
hand hygiene at the following times:
❖ Immediately after arriving at work
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❖ Before and after examining each patient
❖ After contact with blood, secretions, excretions or articles that have been used for patients
After handling specimens
❖ Before putting on and after removing gloves
❖ Before leaving work
Preparing for hand hygiene
❖ Remove jewellery (rings, bracelets) and watches before washing hands
❖ See that the nails are clipped short
❖ Roll the sleeves up to the elbow
Hand hygiene technique
❖ Wet the hands and wrists, keeping hands and wrists lower than the elbows (permit the water to flow
to the fingertips, avoiding arm contamination).
❖ Apply soap and lather thoroughly.
❖ Use firm, circular motions to wash the hands and arms up to the wrists. Cover all areas including
palms, back of the hands, fingers, between fingers and lateral side of fifth finger, knuckles, thumbs,
nails and wrists (see Figure 1.1).
❖ Rub for minimum of 10-15 seconds.
❖ Repeat the process if the hands are very soiled.
❖ Rinse hands thoroughly, keeping the hands lower than the fore arms.
❖ Dry hands thoroughly with disposable paper towel or napkins, clean dry towel, or air-dry them.
❖ Discard the towel used, in an appropriate container without touching the bin lids with hand.
❖ Use a paper towel, clean towel or your elbow / foot to turn off the tap to prevent contamination.
If there is no running water available:
❖ Collect water in a bucket daily.
❖ Ask someone for help to pour water on your hands using a mug.
❖ Follow the same steps as given.
❖ Collect used water in a basin and discard in a sink, drain or toilet
❖ DO NOT dip your hands in to the bucket as this will contaminate the water.
❖ DO NOT keep a basin with disinfectant solution in the ward to use for cleaning hands. This will not
disinfect the hands. It will only contaminate them further.
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Duration of the entire procedure: 40-60 seconds
Wet hands with water,
Ap^y enough soap to cover
all hand surfaces;
Rub hancis palm to palm;
Right palm over left dorsum with
mtertaced fingers and vtce versa;
Pahi to palm with fingers Intartacad;
Backs of fingers to opposing palms
with fingers mtertodced;
Rotational rubbing of left thumb
clasped in right pahi and vice versa;
Rotational rubbing, backwards and
forwards with clasped fingers of right
hand m left pafcn and vice versa;
Rinse hands with water;
Dry hands thoroughly
with a single use towel;
Use towel to turn off faucet;
Your hands are now safe.
Figur 1.1: Step of hand washing/hygiene washing
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Use of personal protective equipment (PPE):
PRE is designed to protect the skin and the mucous membranes of the eyes, nose, and mouth of healthcare
providers (HCP) from exposure to blood or other potentially infectious material (amniotic fluid, vaginal
secretions, urine, stool etc.). This includes the use of gloves, mask, apron or gown, goggles, footwear etc.
The use of these will depend on what the chance of contact with infectious body fluids would be. If the risk
is very high then all PPE must be used (See Table 1.1)
Table 1.1 - Use appropriate PPE during maternal and newborn common procedures
Type of Equipment
When to wear
Points to keep in mind
/ Remove gloves before leaving the
patient's bedside
Handling sterile supplies
Sterile gloves
Doing invasive procedures
/ Change gloves between patients and
procedures
/ Wear correctly fitting gloves
X Don'tusegloves with holesortears
X Do not reuse disposable gloves
/ Remove gloves before leaving the
patient's bedside
Handling blood or body
/ Change gloves between patients and
procedures
Fluids or secretions
/ Wear correctly fitting gloves
Clean gloves (not sterile)
X Don't use gloves with holes or tears
X Do not reuse disposable gloves
X Do not use them to touch patients,
patient care items, or anything near
patients.
/ Use the same utility gloves for the
Utility gloves
Cleaning or managing waste
(thick gloves, not sterile)
same tasks
/ Use separate gloves for dirty and clean
tasks.
/ Wash with soap and bleach and leave
to dry at the end of the shift
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Type of
Equipment
Points to keep in mind
When to wear
/ Cover both the nose and the mouth
during proceduresand patient-care
activities
Protect mouth and nose from potential
Masks
(cloth and paper)
splashes of infectious fluid
/ Change for each procedure
Use when:
/ Replace if wet or contaminated
- Handling patients with respiratory
infections
- Doing an invasive procedures
/ When removing, hold masks by the
strings/ties as the centre of the mask
is most contaminated
/ Dispose immediately after use
- Conducting a delivery
/ Wash hands after disposing the
mask
Use eye wear when it is anticipated that
infectious body fluids may splash and
come in contact with the eye.
Eye wear (goggles,
visor, face shield)
/ The eyewear surrounds the rim of
the whole eyes without any gap
/ Should not restrict the vision
Use when:
/ Disinfect if there is a splash of
potentially infectious fluid on it
- Conducting delivery
Assisting / performing surgery
/ Wash thoroughly before reuse'*
- Cleaning contaminated articles
Protect skin when risk of
•
Splashing or spraying of blood or
body fluid
• Contact is expected using
impervious/plastic gowns
Gowns and aprons
•
Prevent spiling of clothing during
procedures that may involve contact
with blood or body fluids
Use when:
/ Gowns need to be thick enough so
that blood will not soak through
easily
/ Cotton gowns are inappropriate as
the cloth absorbs dirt very easily and
needs to be disinfected and
/ They must be cleaned daily
/. Aprons need to be water resistant
preferably made of plastic
/ Wash hands after removal of gowns/
aprons
/ Disinfect as per standard protocol
- Conducting delivery
/ Soak in bleaching solution (1 %) for
- Performing surgery
20 minutes, then wash and sun dry
Used to keep the hair and scalp covered
Caps
so that flakes of skin and hair are not
/ Should be large enough to cover all
hair
shed into the wound during surgery
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Type of
Equipment
Footwear
When to wear
Points to keep in mind
Worn during procedures and patient
/ Slippers are not sufficient protection
care activities when large-particle
droplet spatter or sprays of blood or
/ If foot wear does not completely
cover the foot then put a plastic
cover over it and secure this with a
rubber band
body fluids is anticipated
Use when:
/ Footwear should be fluid proof
- conducting delivery
/ They should be washable and easily
disinfected (Plastic or sandal)
- performing surgery
Processing of instruments and other items
All instruments that are to be reused (e.g. episiotomy scissors, cord cutting scissors, artery clamp etc.) must
be decontaminated first, washed thoroughly and sterilised before using them again.
❖ Decontamination is needed to kill the viruses and bacteria present on articles and make it safer for
health care providers to handle articles for cleaning.
❖ Cleaning reduces visible dirt, oils, grease, blood or any secretions that could be present on the
instruments.
❖ Sterilisation removes all the bacteria and viruses including endospores from the instruments and
makes them safe for use again.
Steps to be followed for decontamination, cleaning, sterilisation and storage are mentioned below:
Decontamination
❖ Put on utility gloves or surgical gloves.
❖ Place all instruments (forceps, scissors etc.) in 0.5% chlorine solution for 10 minutes immediately after
completing the clinical procedure.
❖ Dispose of waste material and put in a leak proof container.
❖ Decontaminate labour room table or other surfaces contaminated during the procedure by wiping
with 0.5% chlorine solution.
❖ Remove instruments from 0.5% chlorine solution after 10 minutes and place them in water.
❖ Remove reusable gloves by inverting and soaking in 0.5% chlorine solution for 10 minutes. If wearing
utility gloves do not remove till cleaning instruments are finished.
Cleaning
❖ Place the instruments in basin with clean water and mild detergent.
<♦ Completely disassemble instruments and or open jaws of joint items.
❖ Wash all instrument surfaces with brush or cloth until visibly clean (hold instruments under water
while cleaning to avoid splashing).
❖ Thoroughly clean serrated edges (rough surfaces of artery forceps or thumb forceps) of instruments
using a small brush.
❖ Wash surgical gloves in soapy water, cleaning inside and out.
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
❖ Towel dry instruments or allow them to air dry.
♦> Hang surgical gloves up to allow them to air dry, and once first side is dry, reverse them to dry
completely.
❖ After cleaning all items, remove utility gloves and allow to air dry
❖ Wash hands thoroughly.
Sterilisation
❖ Arrange instruments in tray or cloth wrapping using appropriately clean material.
❖ Wrap items using envelope or square wrap technique.
❖ Place packs in drums or trays for autoclaving.
❖ Arrange items in autoclave chamber to allow free circulation and penetration of steam to all surfaces.
❖ Sterilise for 30minutes for wrapped items; 20 minutes for unwrapped items at 121 °C or (250°F) and
(15lbs/in2)
❖ Wait for 20-30 minutes (until the pressure gauge reads zero) before opening the lid or door to allow
the steam to escape.
❖ Allow packs to dry completely before removing.
❖ Place sterilised drums or packs on a surface padded with paper or cloth.
❖ Allow them to reach room temperature before storing.
❖ Record sterilisation condition (time, temperature and pressure) in log book.
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Storage
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❖ Place sterilised instruments in the cupboards based on date of sterilisation (earlier dates to
be used first)
❖ See that the room or cupboard is cleaned regularly
❖ It is thus important to keep enough stock of these instruments so that there is always more than the
required amount. For example if in a day an average of two deliveries occurs, then it is important
to keep an additional two sets of instruments so that what has been used could be processed
before they are reused.
Processing of gloves
Syringes, needles, gloves, masks are for one time use.
❖ Washing gloves with soap, water can cause micro punctures, may allow liquids to penetrate through
undetected holes in the gloves. Therefore washing of gloves is generally not recommended.
❖ In case of extreme shortage of glove supply at the PHC, the gloves can be reused by processing the
gloves as mentioned below:
❖
Grab the cuff of one of the gloves to turn inside out and pull halfway off of the hand. Pull the other
glove at the cuff to turn inside out and pull halfway off the hand. When both gloves are halfway off
the hands, pull both gloves off from the inside at the same time. Never touch the outer portion of the
gloves with your skin.
❖
Soak the gloves in 0.5% chlorine solution for at least 10 minutes.
❖
Wash gloves in soapy water inside and out and rinse fully. Test for holes or tears by placing the gloves
under water. If any air bubbles appear, throw the gloves away immediately. If no air bubbles appear,
let the gloves air dry.
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♦ Turn the cuffs of the gloves inside out a few inches and place five to fifteen pairs of gloves onto each
steamer pan and cover with the lid.
♦ Steam the gloves for 20 minutes at a rolling boil.
♦ Air dry the gloves in the steamer pan for four to six hours before use and remove with forceps into a
disinfected container with a lid.
Source:httpy/www.ehow.com/how_8280564_sterilize-rubber-gloves.html
Proper Handling and Disposal of Sharps
Sharps include needles, and scalpel blades. These are single use items and must be handled carefully and
disposed correctly once used.
Follow strictly the points given:
❖ Use disposable needle and syringe only once.
❖ Make needles unusable after single use by burning them in a needle burner / or using a hub cutter
that cuts the hub of the syringe
❖ Dispose of needles and syringes in a puncture-proof container.
❖ DO NOT use disinfectants for cleaning needles and syringes.
❖ DO NOT separate the needle and syringe after use.
❖ DO NOT recap needles before disposal.
❖ Dispose needles and broken vials in pit or tank and send syringes and unbroken ampoules for recycling
or to a landfill as per the policy of the government
t
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c
X
Figur 1.2: Destroy a needle with needle burner Figur 1.3: Dispose syringes in appropriate bin
or cutter
Maintaining a clean environment
The general cleanliness and hygiene of the PHC could help in preventing spread of infection from one
person to another. It is thus very important that all efforts are made by the PHC nursing staff to ensure
cleanliness in, patient care areas in the outpatient department (antenatal clinic, dressing room or injection
room, postnatal clinic), inpatient care areas (labour room, wards). Patient care areas are to be cleaned every
day and as often as needed. Use of the following cleaning solutions is recommended
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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❖ Plain detergent and water: Scrubbing with plain detergent and water can remove dirt and organic
material such as grease, oil and other matter.
❖ Disinfectants (0.5% chlorine solution): This is used to clean up spills of blood and other body fluids
❖ Disinfectant cleaning solution (contains detergent, disinfectant and water): such solutions like phenol
and Lysol are used for cleaning areas such as labour rooms, injection or dressing rooms, toilets etc.
Waste segregation and disposal
It is important to follow waste segregation and waste disposal methods recommended by the government for
biomedical waste (BMW)to:
❖ Prevent the spread of infection to health care providers (doctor, nurse, lab technician and even
cleaner) who handle waste.
❖ Prevent of spread of infection to the local community.
❖ Protect those who handle waste when disposing it from an accidental injury such as needle stick /
prickinjury ora cut.
Table 1.2: Steps of waste segregation and disposal include proper and correct segregation,collection of
waste and storage, transportation and disposal
Step 1. Segregation
y Separate infectious and non-infectious waste at the
source always
/ Follow recommended Schedule I and II
f.....
Step 2. Collection and storage
/ Collect waste in covered bins always
/ Fill the bin only to three quarter level
/ Clean the bin regularly with soap and water or 0.5%
bleaching / chlorine solution
X Never store waste more than 48 hours
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Step 3. Transportation
B
k
/ Use a dedicated trolley / bin for transportation
Correct
/ See that it is covered when transporting waste
X Never transport waste for collection bins with
sterile equipment
Wrong
Step 4. Treatment and disposal
/ Decontaminate and shred waste before its final
disposal
/ Follow Schedule I and II for how to treat and
dispose waste(see Table 1.3 and 1.4)
X Never throw infectious waste with general waste
without any pretreatment and shredding
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Table 1.3: Schedule I implementation plan for biomedical waste management in
PHC and small scale hospitals in rural areas
Category
1
6
4
Waste
Requirement
Treatment and
disposal
Human
anatomical
waste
Deep burial pit
Treatment is not required
Yellow bin/bag
Handover the yellow bin or
bag to the transporter of
common biomedical waste
treatment facility (CBMWTF)
or deep burial
Soiled waste
Deep burial waste
Treatment is not required
Yellow or red bin/
bag
Hand over the yellow bin
or bag to the transporter of
CBMWTF or deep burial
Needle cutter/
burner
Destroy the needle and
disinfect
Sharp pit
White puncture
proof translucent
container
Handover the container to
transporter of CBMWTF or
dispose them in sharp pit
Waste sharps
1% sodium
hypochlorite
solution_______
7
5
8&10
Scissors/knife for
mutilation
Destroy or shred the plastics
and disinfect
1 % sodium
hypochlorite
solution
Blue bin/bag
Handover the bin or bag
to transporter CBMWTF or
store in bigger container and
dispose by sale to authorised
recycling industry
Discarded
medicines
Secured landfill
Treatment is not required
General waste
like paper
Green bin
No treatment required, put in
secured landfill
Liquid waste
and chemical
waste
Disinfection
chemical treatment
Treat the waste and disinfect
Solid waste
(Plastic)
Mentors'Manual Volume 1
Secured landfill see that it is
out of reach
_____
For liquid waste allow it to
reach the drain and for solid
waste put it in black bin and
then into secured landfill or
hand over to the DM&HO
Post disposal
If deep burial then
cover it with soil and
lime
If deep burial then
cover it with soil and
lime
If it is put in sharp pit
then close the pit and
lock it
■
- ------A
• - •'
BmBHHKI
■i
Hi
HM
Table 1.4: Schedule II colour coding and type of container for disposal of
biomedical Waste
Colour coding
Yellow
,
Treatment options as per
Schedule 1
Plastic bag
Category 1,6
Incineration/deep burial
Dsinfected container/
Plastic bag
Category 6,7
Autoclaving/
microwaving/chemical
treatment
Category 4,7
Autoclaving/
microwaving/chemical
treatment and
destruction /shredding
Category 5,10 (solid)
Disposal in secured
landfill
General waste (domestic)
Disposal in a landfill
Plastic bag /puncture
Blue/ White / Translucent
proof container
|
Waste category
Type of Container
Black
Plastic bag
Gree.
Plas.c bag
Notes
1. Colour coding of waste categories with multiple treatment options as defined in Schedule I shall be
selected depending on treatment chosen, which shall be as specified in Schedule I
2. Waste collection bags for waste type needing incineration shall not be made of chlorinated plastics
3. Category 8 and W(liquid) do not require container/bags
Precautions in the event of specific situations
Management of spills
❖ Wear gloves
❖ Place cloth/cotton over the spill
❖ Flood with freshly prepared sodium hypochlorite solution <0.5-1 %)
❖ Wipe thoroughly
❖ Discard cloth in appropriate waste container
❖ Wipe surface with disinfectant solution
❖ Incinerate wastes
❖ Remove gloves and wash hands
Handling laundry and linen contaminated with infectious body fluids
❖ Handle soiled linen with gloved hands
❖ Prepare bleach solution in a bucket
❖ Place all soiled line into the solution
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
❖ Soak for 30 minutes and then wash along with other linen Soaking for a long time will damage the
clothes/linen
❖ Heavily soiled linen should be soaked overnight (at least 8 hours)
1.4 Occupational Exposure and Post Eexposure Prophylaxis (PEP)
All health care providers are at risk of acquiring the infection. When the health care providers acquire
infection due to their job related tasks it is called occupation exposure. The risk for occupation exposure is
dependent on infection prevention practices in the PHC.
If accidental occupational exposure has occurred post exposure prophylaxis for HIV can help prevent health
care provider from being infected with HIV.
Crisis management
❖ Counsel HCP about the chance of exposure to HIV if there is an accidental exposure to blood and
body fluids. Remember it can be frightening or anxiety proving experience.
❖ Explain the protocol and benefits of following instructions.
❖ Encourage the HCP to take measures to report the incident.
Immediate care: give first aid depending on type of exposure as given in Table 1.5.
Table 1.5: First aid for occupational exposure__________________________________________
❖ Wash for 10 minutes with soap and water or antiseptic
For Needle pricks, cuts:
•»
❖ Cover with waterproof dressing e.g.Band-Aid. Don't attend to patients
until the wound is covered
❖ DO NOT put the pricked finger into mouth
For splash to nose / mouth
♦> Flush with water
For splash to eyes
❖ Rinse thoroughly with plenty of running water or irrigate copiously by
running a pint of normal saline over 10 minutes, with the eye being
held open by another person.
Reporting and recording
♦ HCP must report to the person in charge of such situations in the hospital (medical officer/ authorities
/ infection control officer) regardless of the patient's HIV status.
♦ Others must motivate the concerned HCP to seek help if there is a delay in reporting the incident.
Complete the "Needle stick or occupational exposure register" with information such as:
♦ Type of injury,•
♦ The category of the staff;
♦ The time;
♦ The place;
♦ The circumstances of the injury.
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Risk assessment
A person is considered to have more risk if any of the following factors are present:
❖ Prick with large bore Needle - No. 18 gauge and below (for adults) No.22 gauge and below
for newborn;
❖ Blood was visible on the tip of the needle;
❖ Deep muscle injury occurred with the needle stick injury;
❖ Source patient or person is HIV positive or HIV status is not yet clear; but high prevalence of HIV.
Testing and counselling
❖ Check if the source person is positive for HIV by doing the antibody test after obtaining
informed consent.
❖ Give pre test counselling.
❖ Test the HCP for HIV after obtaining informed consent to check if the HCP is positive already. The HCP
will not require PEP then, but must be assessed in an ART centre whether eligible for ART.
❖ Perform other investigations before starting PEP medication such as: hemoglobin / platelet count /
reticulocyte count / WBC - Total and differential counts / renal function tests / liver function tests /
random blood sugar.
❖ Do follow up / post-test counselling.
PEP medication
PEP means taking precautionary measures and antiviral medications as soon as possible after
exposure to HIV, so that the exposure will not result in HIV infection. PEP medication is available in all
government facilities.
Indications for PEP
PEP reduces the rate of HIV infection from workplace exposures by 79%.This does not mean that it provides
100% protection against the infection. PEP is to be prescribed by a doctor who will first do an assessment
and then determine whether it is needed. Table 1.6 gives a broadoutline of how the doctor can decide
about need for PEP.
Table 1.6: Categorization of occupational exposure and PEP regimen
Small Volume
Few drops of blood/ body fluids/ other
potentially infectious materials
C
Basic Regimen
Short duration
Zidovudine(AZT) + Lamivudine
Solid needle (no bore in it)
Less Severe
Superficial scratch
(3TC) twice daily for 4 weeks
(28 days)
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
SEESESSSSSS^BSESSESSSBBSSBSSE
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Several drops of blood / body fluids / other
Large volume
potentially infectious body fluids
Advanced Regimen
Long duration
Large bore hollow needle
More severe
Deep puncture
AZT +3TC twice daily+
Indinavir every 8 hours for
4 weeks (28 days)
Visible blood or needle used in person artery/
vein
When should PEP be initiated?
❖ PEP should be started without waiting for the index person or source's laboratory results.
❖ The HCP case can stop PEP if the result is negative.
<♦ PEP must be started within 1-24 hours and for best results it must be started within 1-2 hours.
❖ Initiating PEP after 72 hrs of exposure is not useful or recommended.
Follow up
❖ Follow up is recommended at 6 weeks, 3,6 till 12 months.
❖ Laboratory tests recommended include HIV antibody test at 6 weeks, 3 months, and 6 months-post
exposure. This can be rechecked at one year.
-
❖ If the HIV test is found to be positive at anytime within 12 weeks, the HCP should be referred to ART
centre for treatment.
1.5 A.M.M.A Approach for Infection Control in the PHC
Your role as a mentor is very critical in setting up or strengthening already existing infection control practices
within the PHC. Prepare well by reading the manual, rehearse the teaching session in your meetings with
other mentors, carry enough copies of tools (self-assessment tool D, action plan format, etc.)
❖ During your visit, the self-assessment exercises will help you get an assessment of current status of
infection control practices (see Vol 1: Annexure 3D - page 85). Assess, if the staff nurses are practicing
hand hygiene correctly by using the checklist or hand hygiene chart; if there are colour coded bins
at the labour room, dressing room, injection room and nurses' station; if staff are segregating waste
correctly in the colour coded bins; if the staff have correct knowledge about the PPE correctly; if
the patient care areas are clean and free from dust and dirt; if there are sufficient surgical articles /
instruments and sharps for use; if waste is transported correctly and if sharps are disposed correctly.
During the action plan development meeting, facilitate detailed discussions around how to address
the gaps with appropriate solutions in this regard (Assess and Diagnose).
❖ Plan a group teaching session to all the PHC staff at their convenient time during the 2nd or 3rd day
of your visit. Ensure that all the PHC staff are available as all have a role to play in implementing the
infection control practices at their PHC. See to that you cover each component of infection control
as discussed above. You may use the manual or your notes as convenient. Emphasise again that this
is a team work. At the end of the session, help staff to organise the labour room so that there is
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place to keep the waste disposal bins. Reinforce how important each one's role is to prevent spread
of infection in the PHC. Keep posters in places where the activity is happening e.g. hand washing
poster, by the sink; waste segregation poster just above the place where the waste bins are kept.
Take a session for the staff nurses on infection control practices, teach the cleaners how to clean the
environment, and transport waste to the final disposal area, demonstrate or model good infection
control practices when you are in the PHC. Some examples of topics for demonstration include:
washing hands correctly, using the correct PPE, wearing protective foot wear when walking into the
labour room, segregating waste correctly and disposing needles soon after use in the puncture proof
container, etc. (Manage).
❖ During every subsequent visit, interact with the staff and observe the infection control practices.
Check if equipment are available and in working condition e.g. check if the autoclave is working
correctly; or if inventory register is maintained about articles / instruments availability or before of the
maintenance of autoclave. Monitor the practices of the staff nurses while they are providing care for
the patients (Measure). Plan your next steps accordingly. If the gaps persist, a refresher and reminder
session can be useful. Sometimes, advocacy with higher facilities may be needed to gain the support
of higher facilities which can be taken up at the district level meetings.
❖ Over a period of time, if the PHC staffs are successfully following the infection control protocols,
facilitate discussions to refine and further improve the systems. You continue to advocate for
constant refinement by appreciating the teams'efforts and helping them appreciate the impact of
their work (Advocate).
*
REMEMBER!!!
♦ Infection control practices or standard precautions must be followed for ALL
patients
♦ Use of infection control practices or standard precautions could reduce the risk
of blood borne and airborne infections
♦ All health care providers have a key role to
♦ Follow standard precaution protocols
♦ Educate other health care personnel
♦ Prevent occupational exposure
♦ Protect self by getting vaccinated for Hepatitis B
♦ Educate others about prevention of blood borne pathogens including HIV
♦ PEP can reduce greatly the chance of HIV transmission from occupational
exposure
<♦ Existing PEP protocols should be followed
<♦ Exposed health care providers should be monitored for side effects and
adherence
__
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
|
Referral System at
Primary Health Centre
u
This chapter explains the need for a referral system at PHCs, what constitutes an effective referral system
and how a mentor can actually apply the A.M.M.A approach to set up or strengthen the referral system.
2.1 Introduction and Need for Referral System
The continuum of care for reproductive, maternal, newborn and child health includes integrated service
delivery for mothers and newborns from pre-pregnancy to delivery, the immediate postnatal period and
newborn period. PHCs are located between the community and higher level health facilities; unless the
referral linkages are strong enough, ensuring continuum of care is a challenge. Delays in seeking treatment,
reaching a health facility and delay in receiving quality care often lead to increased maternal and newborn
mortality. Timely access to emergency maternal and newborn services can reduce significant proportion
of deaths and hence there is a need to develop robust referral system between PHCs and other service
delivery systems.
2.2 Components of an Effective Referral System in the 24/7 PHCs
It is important to know what constitutes an effective referral system so that you as a mentor can facilitate
the setting up of thts system in your PHCs.
Knowledge about the incoming admissions and referrals
In general, the PHC staff should be aware about the broad health needs of the community and the major
causes of morbidity and mortality, the practices and behaviors within the community and the providers
within the PHC area who offer maternal, newborn and child health services.This knowledge may be useful
in being prepared to handle the cases that come to the facility. This may also be helpful in sensitizing
the providers toward what services are available in the PHC and when to refer in case of any emergency.
Having a prior knowledge of whether a woman belongs to high risk category or not is important to plan
for admission beforehand.
Establish a referral directory of the MNCH services at the PHC
Very often in emergency situations, a lot of time is wasted in identifying the appropriate referral facility
and in deciding if the facility has adequate resources to handle the complications. If the PHCs refer cases
blindly without ascertaining the availability of services at the higher facility, the patients when they reach
the higher facilities will be further referred to other facilities and thus will lose precious time in the process.
All these gaps can be overcome by setting up a referral directory and following certain protocols within
the PHC before making a referral. The PHC staff can set up a referral directory through the following ways:
❖ First, getthe contact details ofall the higher referral facilities that are closely located to the PHC. Check
if the referral centre has the required resources to handle a complication. For example for referrals in
case of obstructed labour, make sure that there is facility for conducting caesarian section i.e., a skilled
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obstetrician, an operation theatre with all equipment. For referrals of LBW baby less thenl 000 grams,
make sure that neonatologists, incubators, ventilators are available in the higher centre.
❖ Prepare a referral directory that mentions the name of the referral facility, location and contact details.
❖ Display details in a designated place within the PHC (near the telephone). The referral directory should
be boldly visible to all PHC staff and clients (women and their families).
❖ Frequently update the status of referral centres as the status might change and the PHC staff should be
aware of them (for example the specialist might get deputed or may go on long leave; the higher facility
might be under renovation, etc). In these circumstances, the PHC staff should explore alternate options.
Facilitate a formal linkage and develop protocols for referral from
PHC to higher facility
It is very important that the PHC establishes a formal linkage with the higher facilities as this can facilitate
a committed response when the referrals are made. This can be achieved by an initial formal meeting
between the PHC in charge and the chief medical officer (CMO) of the higher facility to discuss the need
to work together, need to follow certain protocols to ensure continuum of care. The PHC staff should be
sensitized to follow the required protocols when referring a woman or newborn or both. The complication
case sheets have these protocols for complication management and referral. For example if a woman with
hemorrhage is to be referred do the following:
❖ Call the referring centre
❖ Check if there is a bed available
❖ Check about transportation availability - whether they would pick up the woman and if not arrange
for transport (108 or private transport using funds available with MO etc.)
❖ Check for availability of service for hemorrhage - blood, IP facility, specialist
❖ Inform details of what treatment was given at the PHC and when the woman will reach the facility
Help PHC staff handle emergencies skilfully
A critical component to reducing mortality and morbidity is skilled management of complications before
referral. The complication case sheets assist the staff in this regard. You as a mentor should make sure that
the staff are knowledgeable as well as confident in managing complications through appropriate teaching
sessions during your visits (Refer to chapter 6 on implementing A.M.M.A approach at provider level).
Document comprehensively and send referral sheets to higher facility
Complete the documentation in the complication case sheets with details of what initial management
was done. The coloured copy of the case sheet (both the normal and complication part) is the referral copy
and that has to be sent to the higher facility along with the woman or newborn or both. The details of
management at the PHC can guide the staff at the higher facility accordingly. Also fill up other documents
at the PHC such as referral register. Always have enough stock of case sheets, complication sheets and
referral registers.
Follow up on all referrals
Every case referred by the PHC should be followed up to know the status of referral. The staff nurse who
referred the correct as woman or newborn should take this responsibility. This is important as the PHC is
primarily responsible for the health status of the community and will assist in planning appropriate follow
up with the community through the front line workers. Following steps can be followed in this regard:
Ms ]
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
❖ Check with referral center whether the woman or newborn reached the centre and what is the status
of the woman or newborn (whether discharged/referred further/ refused treatment).
❖ Keep track of referral back to the community with the help of the ANM / ASHA.
❖ Appraise the front line workers through telephone, of the cases discharged from the facility.
2.3 A.M.M.A Approach to Setting up Referral Systems at the PHC
Your role as a mentor is very critical in setting up or strengthening already existing referral system within
the PHC. Prepare well by reading the manual, rehearse the teaching session in your meetings with other
mentors, carry enough copies of tools (self assessment tool C, action plan format, referral directory template,
complication case sheets, etc) and use case study 2.1 to practice how to do a referral with staff
❖ During your first visit, the self assessment exercise - client rights to access services and continuity of
care (see Vol 1: Appendix 3C- page 83-84) will help you get an assessment of current status of referral
systems. During the action plan development meeting, facilitate detailed discussions around how to
address the gaps with appropriate solutions in this regard (Assess and Diagnose).
❖ Plan a group teaching session for all the PHC staff at their convenient time during the 2nd or 3rd day
of your visit. Ensure that all the PHC staffs are available as all have a role to play in making a referral
and to develop referral as a system. Use the case study 2.1 (see Vol 1: page 66) on referral system as
that can make everyone think and internalize the problem. See to that you cover each component
of referral systems as discussed above. You may use the manual or your notes as convenient. Discuss
who could perform different roles when it comes to making a referral. Emphasise again that this is
a team work. At the end of the session, invite the team to develop a referral services directory for
the PHC. Share the template that you carry. Involve the medical officer in developing the directory
as his knowledge and existing rapport with higher facilities can be very useful in developing
a directory. Allow them to decide the right place for displaying the directory. Remind that the
complication case sheets assist the staff in handling the emergencies correctly and in following the
referral protocols (Manage).
❖ During every subsequent visit, interact with the staff; audit the complication case sheets and referral
registers to understand how the referral system is working (Measure). Plan your next steps accordingly.
If the gaps persist, a refresher and reminder session can be useful. Sometimes, advocacy with higher
facilities may be needed to gain the support of higher facilities which can be taken up at the district
level meetings.
♦♦♦ Over a period of time, if the PHC staffs are successfully following the referral protocols and are
convinced of the functioning of the referral systems, facilitate discussions to refine and further
improve the systems. You continue to advocate for constant refinement by appreciating the teams'
efforts and helping them appreciate the impact of their work (Advocate).
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Case study 2.1 on referral systems
Kala who is a 20 year old, primigravida and delivers a live female baby weighing 2.2 kgs at the 24/7 PHC. Post
delivery, she bleeds continuously. The staff nurse detects low BP and high rising pulse. She gets nervous and
quickly asks the family members to take the woman to the taluka hospital. In an hour, the woman is taken to
the hospital. The hospital staff do not admit the woman saying that they do not have blood transfusion facility
and so they refer to a private facility.
Few questions for reflection:
❖ If you were the staff nurse at the 24/7 PHC, how would you have done things differently?
❖ If you detect a complication, what is the first thing that you have to do?
❖ Whenever you refer any complication, what do you want to ensure?
❖ What is your major learning from this experience?
❖ How do you want to be prepared to better handle these situations?
❖ As a mentor, how would you like to support the staff nurse in this regard?
REMEMBER!!!
v
\
\
I
A.M.M.A approach is useful in strengthening the referral systems in the PHC. Get
the PHC teams to realize that this is a team work and that all have-to come together
in setting up a system. Emphasise the use of complication case sheet and referral
directory in adhering to the referral protocols.
____ _______ _ _______ _____________________ __________ |
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
13 Drugs and Supplies Management
This chapter explains about the importance of strengthening the management of drugs and supplies in
the PHC, the components of an effective drugs and supplies management system and how the mentor can
actually support the PHC staff in setting up an effective system
3.1 Introduction
Drug and supplies management within a PHC involves setting up systems to ensure uninterrupted availability
of drugs and supplies so that the staff do not feel handicapped in care provision. Stock out situations of
essential drugs due to poor health systems can adversely affect quality of care, thus increasing the number
of maternal and newborn deaths . This becomes vital in the face of any emergency during intranatal or
postnatal periods when the chances of occurrence of complications are high. For example in a situation
where a woman in labour gets an eclamptic convulsion and the staff nurse suddenly realizes that she does
not have magnesium sulfate and finally ends up referring the woman without the pre-referral management
is actually putting the woman's life in serious danger. Magnesium sulfate in this case can be life saving drug;
just the knowledge and skill of administering the drug is not enough, but also a regular uninterrupted supply
of essential drugs as well.
3.2 Components of Drugs and Supplies Management
You as a mentor should be knowledgeable of what constitutes an effective management of drugs and
supplies in a 24/7 PHC. World Health Organization suggests that all health care centres can follow 4 steps
in this regard namely drug selection, procurement, distribution and use. While the training manual largely
refers to the drugs in particular, most aspects can be applied to general equipments and supplies as well.
Selection of drugs, equipment and supplies
The national policies and guidelines prescribe certain drugs, equipments and supplies needed to be used at
the primary care level. The SBA, IMNCI and NSSK guidelines suggest certain essential MNCH drugs needed
at the level of the PHC which are compiled into a essential MNCH drug list, (see Vol 1: Appendix 11 - page
120-124)
Procurement
Drug procurement procedures depend on estimated requirements (to avoid 'stock out' or 'excess
situations/ wastage') as well as other factors such as population being catered, disease pattern and its
variations, monthly consumption rates, delivery time (or lead time - the time taken for the drug to be
delivered and receipted at the stores), time lag between placing and receiving orders, re-order level
(request indicator - the level at which fresh order has to be made in order to avoid stock out situation in
future). This is largely concerned with higher supply chain management systems and not so much to the
PHCs, yet the knowledge of these higher systems is useful in planning drug movements within the PHC.
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Requisition, supply and receipt
Drugs and supplies that are ordered for use in the health centre should be approved first within the PHC. In
the context of 24/7 PHC, they should be the drugs listed in the essential MNCH drug list, the requirement
should be estimated by joint discussions between the providers (medical officers, staff nurses), lab
technicians and the pharmacist.lt is important to request for drugs regularly in order to avoid stock out
situations. If there is a request format suggested by the health systems, it is advisable to use the same and
the form should have the following details such as name of drug, dosage, unit of issue and quantity, cost
per unit and total cost, requisition number, name of PHC and date of request, name and signature of the
staff requesting, signature and endorsement of the PHC in charge. Similarly every supply from the higher
stores should be accompanied with a delivery form which should be cross checked by the PHC staff when
the stocks received at the PHC. Any discrepancies should be immediately informed and documented; verify
the stocks for any expired stock, damaged or spoiled drugs, drugs soon to expire, excess stock and plan
for immediate transfer. A transfer voucher should be prepared and sent along with the stock if you are
transferring immediately. All that the pharmacist receives in the PHC should be documented in detail in
the registers meant for drugs and supplies such as the names of the drugs and supplies, doses, quantities,
expiry dates and date of receipt.
Storage and arrangement
Storage is a very critical part in the whole cycle. Specifically designed space in the PHC should be identified
in order to protect the stocks from deterioration or contamination, avoid disfiguration of labels, maintain
integrity of packaging, reduce pilferage, thefts or losses and prevent infestation of pests or vermin. The
storage environment should possess adequate temperature, sufficient lighting, clean conditions, humidity
control, cold storage facilities, adequate shelving to ensure integrity of the stored drugs. A well-arranged
store enables easy identification ofdrugs and saves time when picking a drug from the shelves. The rule of
FIRST IN FIRST OUT (FIFO) should be applied always. So, drugs that were received first should be used first,
except where the new stock has shorter expiration dates than the old stock. In this regard, the principle of
FIRSTTO EXPIRE FIRST OUT (FEFO) should apply.
Dispensary
Retain a daily drug use record in the dispensary. In the context of MNCH, where most of the activities
happen in the labour ward and postnatal wards, stock adequate quantities of drugs in easily accessible
areas. Display the essential MNCH drug list in the labour room as that provides ready reference to the
names ofdrugs, dosages and routes ofadministration. In the context of emergencies, these readily available
details can save the time for providers.
Distribution
Drug distribution can refer to dispensing the drugs to patients in a rational manner. In this regard, the
evidence should guide the providers while dispensing the correct medicines as compiled in the essential
MNCH drug list. Distribution also refers to writing a comprehensive and clear prescription and packaging
the medicines properly. The other aspect of distribution of drugs at the health centre is the return of
overstocked and nearly expired drugs to the medical store as discussed earlier.
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Drug use
Rational use of drugs requires that a particular patient with a specific problem receives drugs according
to appropriate dose and dosage form, appropriate route and frequency of administration, appropriate
duration, and appropriate information to the patient and follow up.
3.3 A.M.M.A Approach to Strengthening the Drug and Supplies
Management System at the PHC
Your role as a mentor is very critical in strengthening the drugs and supplies management system within
the PHC. Prepare well by reading the manual, rehearse the teaching session in your meetings with other
mentors, carry enough copies of tools (self assessment tool B, action plan format, essential MNCH drug
list, complication case sheets, etc). Use case study 3.1 to facilitate a discuss can among staff on supplies
management.
❖ During your first visit, the self assessment guide B (see Vol 1: Appendix 3B - page 80-81) will help you
get an assessment of current status of supply systems. During the action plan development meeting,
facilitate detailed discussions around how to address the gaps with appropriate solutions in this
regard (Assess and Diagnose). Reiterate that it is staff's right to access essential drugs, equipments
and supplies and all have to work as a team to fulfil their right and how this can significantly affect
quality of care. The pharmacist's role is crucial and has to take a lead in addressing these issues in
regular consultation with the key providers. If the pharmacist's position is vacant, one of the staff
nurses should take up this responsibility (Assess).
❖ Plan a group teaching session to all the PHC staff at their convenient time during the 2nd or 3rd day
of your visit. Ensure that all the PHC staff, especially the providers (medical officer, staff nurses), lab
technicians and pharmacist are available. Use the case study 3.1 (see Vol 1: page 70) on supply chain
as that can make everyone think and internalize the problem. See to that you cover all components
of drugs and supplies management as detailed above. Discuss the roles of each one when it comes to
planning for indent. Emphasise that it is important for the pharmacist to be continuously interacting
(on a daily basis) with staff nurses or the lab technician to update the drug registers, assess the
reorder level, monitor the movements of drugs nearing expiry and to make a timely indent. Involve
the medical officer actively as h/she being the leader can take decisions related to use of untied funds
for addressing stock out situations quickly or to have discussions with higher official to process the
requests promptly. Share the essential MNCH drug list with the group; review the drugs, dosages and
routes of administration for various indications, remind the staff to constantly refer to this list and
hence display this in the labour ward. Also emphasise that the complication case sheets remind the
staff of the different drugs and dosages associated with provision of MNCH care (Manage).
❖ During every visit, interact with the staff; audit the complication case sheets, drugs and supplies
registers to understand how the system is working (Measure). Plan your next steps accordingly.
A refresher and reminder session can be useful when there is a need.
❖ Over a period of time, if the PHC staff are successfully following the agreed upon protocols and are able
to see the results for themselves in terms of reduced stock out situation or less wastage of drugs and
supplies, it is important to recognize their efforts. You continue to advocate for constant refinement
by appreciating the teams' efforts and helping them appreciate the impact of their work (Advocate).
7 '0 I
Mentors'Manual Volume 1
Section B - Chapter 2
Case study 3.1 on drugs and supplies management
On the night of 1st of August 2012 at 8:00 pm, Belagola PHC receives a woman with history of labor pain.
The staff nurse on duty during the initial assessment finds out high BP (150/100 mmHg) and proteinurea
(2+). She decides to refer the woman to a higher facility and attempts the pre-referral management. She
runs to the pharmacy and finds out that inj. hydralazine is not found. Later she remembers pharmacist
mentioning that inj hydralizine has been in nil stock since a week. She panics and now tries to find cap
nifidipine. nifedipine which is an alternative. She does find few boxes of nifedipine, but discovers that the
entire batch had expired almost two months ago. By now, the woman's BP shoots further up and develops
convulsions. The staff nurse quickly administers 10 gm of inj magnesium sulfate and refers urgently to the
higher facility.
Few questions for reflection:
♦ Did the woman receive good quality service in this PHC?
♦ What could have contributed to nil stock situation of Inj Hydralazine?
♦ How could we have prevented this?
♦ What contributed to expiry date situation of Tab Nifedipine?
♦ How does a staff nurse get prepared to avoid getting into this situation?
♦ How do you think this instance will impact on the mindsets of family / community?
♦ As a mentor, how would you like to support the staff nurse in this regard?
71
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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APPENDICES
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Appendix
Checklist for WINCH Wlentor to
Guide the NIWI Visits
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Checklist for MNCH Mentor to Guide her in Managing the MM Visits
Planning MM visits (In the beginning of each month and before each PHC visit,
check if you are prepared as follows)
1. Scheduling the visit for each PHC considering the timelines, access, backlog, etc
2. Finalize the schedule and freeze the dates after informing MO
3. Familiarize yourself with:
a.
PHC profile before the visit
b.
PHC situation/ gaps based on action plan of previous visit
c.
The tools to be administered during the visit (refer to visit checklist)
d.
Topics/ sessions to be covered (refer to visit checklist)
4. Equip with the following:
a.
Adequate no of copies of formats - self assessment tools, audit checklist, onsite training plan, action
plan formats
b.
Teaching aid - Models, CDs, case sheet
c.
Flip charts, Markers
d.
Posters - A.M.M.A, client and provider rights, action plan, MNCH drug list, referral chart
e.
Mentors'Manual
f.
Stationary
5. Refresh your knowledge and skills of topics to be covered
a.
Read Mentors'Manual
b.
Practice using teaching aids
c.
Decide the topics for Day 1 and Day 2 and time to be taken for sessions
d.
Decide the effective teaching method
e.
Familiarize yourself with the use of case sheets, audit checklists
6. Plan your summary/how to end the visit
Tools to be used for planning:
1.
Planning checklist
2.
Visit specific list of tools and topics
3.
Monthly planning format
4.
PHC profile format for MM
5.
Last visit action plan
6.
Last visit trip report
7.
Clinical mentoring guide for MNCH mentors
74
Mentors'Manual Volume 1
Appendix 1
Implementing MM visits: (During the visit, adhere to the broad steps listed below)
1. Start with a meeting with PHC staff to refresh or review the previous action plan.
2. Administer SA tools (specific to the visit) and help PHC teams develop action plan. Use posters and flip
charts while facilitating self assessments.
3. When the teams are busy administering SA tools, audit 10 case sheets using case MNCH Mentoring
sheet audit format. This helps to specifically know the PHC staff specific gaps.
4. Provide clinical mentoring using the teaching aid as planned. Emphasize on the gaps that were
observed while auditing case sheets. Focus on the do's and don'ts.
5. Document in the onsite training plan, the sessions that are covered.
6. Meet again with the team to give a debrief before leaving the PHC.
Tools to be used for implementing:
1. SA tools
2. Case sheet review tool
3. Client interview
4. PHC summary format
5. Action plan
6. Case sheet audit format
7. Clinical mentoring guide for MNCH mentors
8. Trip report
Monitoring MM visits:
(You need to constantly monitor whether your activities during the month are going as per the plans. The
list will guide you in regularly monitoring your activities and make mid course corrections)
1. Check if the schedule of PHC visits is implemented as per the plan; if faced with any difficulties, report
to DPS.
2. During the visit, the following will assist in the monitoring of PHC performance:
a.
b.
Review if the action plan items are addressed;
Fill up and review PHC summary information (casesheet and selected quality indicators);
c.
Perform case sheet audits to check on the practices related to the topics handled during previous visit.
3. Follow-up with site co-ordinator referring to the action plan.
Tools to be used for monitoring:
1. Schedule
2.
PHC summary
3.
4.
Case sheet audit format
Action plan
5.
Clinical mentoring guide for MNCH mentors
75 j
Approaches to Improving Quality of MNCH Services in Primary Health Centres
’;^,.J’.. J. 'i
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6^30#
>lsSw <;
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•
Appendix
PHC Summary Profile
' ,!'K
Appendix 2
PHC SUMMARY PROFILE (Update this every 3 months with the help of M&E specialist)
Name of PHC
Name of Mentor
Name of Taluk
Name of Medical Officer
Contact number
Population served by PHC
it SC served by PHC
# Villages served by PHC
Name of nearby FRU
Distance from FRU
Average time to reach 108 Vehicle
PHC got functioning Ambulance
PHC Statistics (Number = #)
In Year
In Month
# ANC registered
# ANC registered within first trimester
# Pregnant women received 3 ANC check ups
# of deliveries conducted at PHC
# home delivery in PHC Area
'# of live births
# of still births
# Newborns having weight less than 2.5 kg
# Abortion (spontaneous/induced)
# Women receiving post partum check-up within
48 hours after delivery
# PNC maternal complications attended at PHC
# In-patient
# OPD attendance
# Tests for Hb__________
# Women having Hb < 7 gm/dl
Staff Details
# Sanctioned
Posts
i
Available
Available
but on
Deputation
Medical officer (allopathic)
Medical officer (ayurvedic)
Staff nurse
Jr. health assistant female
Jr. health assistant male
Lab technician
Pharmacist
Group-D
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Vacant
s
....
.iait
Appendix
3
The Self Assessment Guides
s
Visit#
District
Taluka
Name of PNC,
Date/s of visit.
Name of MM
Tick V'if yes
A. Clients' Rights to Safe and Competent Care
1.
or
fill X if no
Do staff fully and accurately document the woman's history and details of
lab tests, vaginal and pelvic exams on client case sheets?______________
2.
Do staff fully and accurately document all complications (assess, diagnose,
manage and measure outcome of treatment) on the complications sheets?
3.
Do staff monitor and document the process of labour fully and accurately
4.
on partographs?_____________________________________________
Do staff monitor all women and newborns post delivery and document on
5.
the case sheets?______________________ _______________________
Do staff ensure that women in 2nd stage are never left alone?___________
6.
Do all staff know how to assess, diagnose, manage and measure outcome of
treatment of women in shock?__________________________________
7.
Do all staff know how to, and practice AMTSL including appropriate use of
oxytocin for delivery of the placenta (but NEVER for labour augmentation)?
8.
9.
A re all staff able to recognize severe anemia and refer wh e n necessary?
Are all staff able to assess, diagnose, manage and measure outcome of
treatment of PROM, obstructed and/or prolonged labour?_____________
10.
Are all staff able to assess, diagnose, manage and measure outcome of
treatment of antepartum and postpartum hemorrhage?_______________
11.
Are all staff able to take BP and assess, diagnose, manage and measure
outcome of treatment of pregnancy induced hypertension, pre-eclampsia
12.
and eclampsia?______________________________________________
Do all staff know to, and practice administration of magnesium sulphate for
13.
________________________
Are all staff able to assess, diagnose, manage and measure outcome of
treatment of preterm labour?
________
14.
Do all staff know and practice administration of corticosteroids according to
convulsions?
guidelines (how much, when and where) in preterm labour?____________
15.
Are all staff able to assess, diagnose, manage and measure outcome of
treatment of the different causes of maternal sepsis?
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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16.
Do all staff know not to do episiotomies unless absolutely necessary and
17.
not to augment labour at a 24/7 PHC?_____________________________
Do all staff know how to assess, diagnose, manage and measure outcome of
18.
treatment of fetal distress?______________________________________
Do all staff know how to, and practice: Neonatal resuscitation; Cord care;
Eye care; Thermal protection and Kangaroo Care; Immediate breastfeeding
support; Appropriate vaccinations and Vitamin K for newborns before
discharge? _________________________
19.
Are all staff able to assess, diagnose, manage and measure outcome of
20.
treatment of prematurity and low birth weight?_____________________
Are all staff able to assess, diagnose, manage and measure outcome of
21.
treatment of neonatal asphyxia?_________________________________
Are all staff able to assess, diagnose, manage and measure outcome of
22.
treatment of newborn sepsis?____________________
________
Do all staff know how to help a woman to breastfeed and how to manage
23.
problems?__________________________________________________
Do all staff know how, and practice all the steps, and timings of postpartum
and newborn monitoring and what danger signs to look for?_______
24.
Do staff, before discharging postpartum clients, know how what advice to
give new mothers about themselves and the newborn?
Comments
80 ■
Mentors' Manual Volume 1
:
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Date/s of visit.
Visit #
Appendix 3
District
Taluka
Name of PNC.
—
Name of MM
B. Staff's Right to Supplies, Equipment and Infrastructure
Tick'^' if yes
or
fill X if no
i.
Is there a good system for repair/maintenance of equipment, so
services are not interrupted? ____________________
2.
Is there a functioning system for monitoring and ordering of drugs and
supplies so services are not interrupted?
_____________
3.
Have there been situations when a required drug was not available to
manage complicated cases including PPH, pre-eclampsia, eclampsia, etc?
4.
Are the following available (in working order) in the examination room
and labour room?
a.
Examination table
b.
Labour table
c.
Adjustable light
d.
BP apparatus
Fetoscope (Manual or Doppler Fetoscope)
e.
f.
gh.
5.
Speculum
.
. ...
Forceps (Cheatle and Sponge)
New Case sheets
_________________________ _______________
i. Registers
In the labour room, is there a newborn corner with the following?
a.
b.
c.
d.
e.
f.
g.
h.
Table or flat surface
Clean dry blanket or towel for warmth
Thermometer (Pediatric and Adult)
Baby weighing scale
Radiant warmer
Neonatal ambu bag and mask for term and preterm newborns
Oxygen; Nasal catheter; Mucus extractor; Cord ties/clamps
Infant stethoscope
81 J
Approaches to Improving Quality of MNCH Services in Primary Health Centres
/ pproach as to Improving Quality of MNCH Serviees In Primary H.alth Centres
A
3
6.
Are all the following drugs available or readily accessible 24/7?
a. Anti-convulsants (magnesium sulfate) and calcium gluconate for
drug reaction or diazepam (can be used for severe pre-eclampsia
and eclampsia)
b. Uterotonics (oxytocin or misoprostol) for AMTSL (NOT for
augmentation)
c.
d.
e.
f.
g.
h.
i.
jk.
7.
8.
Anti PPH uterotonic (oxytocin)
Antibiotics (gentamycin, ampicillin, metronidazole) for sepsis/
sepsis prophylaxis
Cioxacillin, Erythromycin for breast abscess
Diazepam (for retained placenta)
Methergin, carboprost or misoprostol for atonic uterus and delayed
PPH
IV fluids: Ringer lactate / Normal saline
Anti-hypertensives (nifedipine or hydralazine)
Corticosteroids (betamethasone or dexamethasone)
Chlorhexidine
l. Vitamin K
m. All needed vaccines____________________ ________________
Are all infection prevention materials available including labour room?
a.
Soap and running water
b.
c.
Surgical gloves
•
-*
Utility gloves for cleaning instruments
d.
Buckets with chlorine (0.5%, with lids), renewed every day
e.
Sharps disposal containers
f. Waste buckets for medical and other waste___________________
Is the pharmacy always ready, stocked and open for clients with
complications 24/7?
Is there always an emergency tray with all needed drugs in the labour
room?
13_______
Mentors' Manual Volume 1
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9.
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Annondiv 3
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Appendix
Is the lab always ready, with staff and all reagents and equipment
needed to perform basic tests 24/7?
a.
b.
Hemoglobin
c.
Urinalysis for proteins
d.
Urinalysis for bacterial infections
e.
HIV tests
RPR/VDRL
HBsAg
f.
g.
Urinalysis for sugar
If the lab is closed, are staff able to access HIV rapid tests and urine
dipsticks for protein testing?_________________________________
10.
Is the instrument processing area fully equipped at all times withthe
following?
11.
a.
Working autoclave or boiler
b.
Deep sink and running water
c.
d.
e.
Brushes
Detergent
Chlorine
f.
Basins
|I
____________________ z
g. Utility gloves Does the PHC have a deep pit for burying waste?
Comments
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Date/s of visit
Visit #
District.
Taluka
Name of PHO
Name of MM
C. Clients' Rights to Access to Services and Continuity of Care
Tick'/'ifyes
or
fill X if no
1.
Do clients have access to labour and delivery services 24/7 (24hrs everyday)?
♦ Qualified staff available to offer labour and delivery services (doctors,
nurses, labs staff, pharmacist)?
♦ Are there always supplies available to provide labour and delivery
services?
♦ Is there always emergency transportation service available for referrals?
2.
Do staff reduce procedures and financial barriers to care for clients?
(e.g. requirement that clients obtain a male family member's permission to
receive services, have easy access to services without having to pay or purchase
L
supplies or drugs)
________ __________________________ _
Are all women in labour evaluated within 15 minutes of arrival at the PHC? _
4.
Do the community ANMs and ASHAs refer on time women with or without
5.
complications, to thg PHC?
_
,
._____ _
Do staffs encourage all postpartum women to stay in the PHC for 48 hours post
6.
delivery?__________________________ ____ ______________________
Are all nursing staff able to do the following always?
a.
b.
Set up an IV drip
c.
i.m Injection of oxytocin for AMTSL and PPH
Intravenous antibiotic administration
d.
i.m Inject magnesium sulphate
e.
7.
Repair a simple tear
Are all necessary supplies, drugs and equipment available 24/7?
a.
b.
c.
8.
Supplies (e.g. gloves, IV fluids, oxygen)
Drugs (e.g. antibiotics, anti-hypertensives, anti-convulsants, uterotonics)
and
Equipment available 24/7 without barriers (e.g. locked doors or cabinets
or unavailable keys)
_ _______________
Does the facility:
Have all needed case sheets and registers?
Do all staff know what is expected of them in terms of recording?
84
Mentors'Manual Volume 1
•' Si
Appendix 3
9.
Do staff do the following for women or newborns who need referral?
a.
Provide or arrange transport within one hour of identification of need to
refer?
b.
Communicate with the referring facility to which the woman/newborn is
being referred to and inform them about this referral?
c.
Complete all paperwork about the person being referred including history,
details of tests performed, drugs given, diagnosis?
d.
Know about and record the outcome of the person referred?
e.
Ensure the person referred is also then referred back to the ANM and ASHA
in her community?
85
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Date/s of visit
Visit #
District
Taluka
Name of PHC
Name of MM
Tick'^'if yes
or
D. Clients' Rights to Infection-free Services
fill X if no
1.
Do staff ensure they do not do procedures that can increase the risk of
infection? e.g: too frequent vaginal exams, routine IV, routine episiotomy
2.
Do staff initiate treatment of all suspected or confirmed sepsis with ampicillin,
gentamycin and metronidazole?
3.
Do staff wash their hands with soap and running water in the following
situations?
a.
b.
c.
4.
Does your facility have the following protective wear for staff?
a.
b.
c.
d.
e.
f.
5.
Before each clinical procedure
After each clinical procedure
Before and after each client contact_______________________________
Aprons
Caps
Eyewear
Face masks
Shoe covers/boots
Sterile gloves_____________________________________ ____________
Do staff change gloves if they become contaminated?
i.e. between clients and with the same client if glove gets contaminated
6.
Between deliveries, do staff clean the tables and contaminated surfaces in
every room with 0,5% chlorine solution?______________________________
7.
Do staff know how to, and follow all correct steps of instrument processing?
a.
b.
c.
d.
e.
8.
9.
___
Do staff always disposal of sharps properly in a puncture-resistant container?
Do staff sort and dispose of all medical waste according to guidelines?
a.
b.
c.
d.
10.
Decontaminated immediately after use in 0.5% chlorine solution
Washed in running water
Sterilization or HLD
Drying
Storage
anatomical waste
swabs and
sharps
containers
Are the following areas always clean?
a.
b.
c.
labour room
ward and
toilets
Comments
•86
Mentors'Manual Volume 1
•
Name of PNC
Visit #
Taluka
Date/s of visit
District
Name of MM
E. Staff's Right to Information, Training and Development
Tick V if yes
or
fill'XTfno
1.
Are current NRHM and SBA / NSSK guidelines available and accessible to all
2.
Are all staff trained to manage labour and deliveries as per SBA standards?
3.
Are all staff trained to deal with pre-referral management of complications
staff?_________________________________________
of labour and newborns?__________________________________ ____
4.
Is a sufficient number of nursing staff trained to check the following?
5.
1. BP
2. insert a Foley's catheter
3. administer IV fluids
4. antibiotics
5. oxytocin
6. magnesium sulfate and
7. corticosteroids
In cases of newborn resuscitation are all staff sufficiently trained?
and ALWAYS available, to perform newborn resuscitation?
6.
Are all staff trained in infection prevention?
7.
Are all nursing staff trained and able to do the following
a. urine dipstick tests for protein
b. HIV rapid tests__________________________ ___________________
8.
Does the pharmacist:
a. Know what drugs are essential for labour?
b.
c.
d.
9.
Know what drugs are essential for delivery?
Ensure all emergency drugs are in the labour room during labour?
Does s/he (and nurses) know what drugs (e.g. oxytocin)
req u ire cold chai n ?
______________________
Do all staff know the list of possible hospital options for referral of women
who have complications that cannot be managed at the PHC?_____ _
10.
Do all staff know how to refer a woman / newborn?__________ ______
11.
Has any of your staff received EmOC training?___________________
Comments
Approaches to Improving Quality of MNCH Services in Primary Health Centres
■■■■
Approaches to Improving Quality of MNCH Services in Primary Health Centres
i ______________________________
~___________________________
District.
Taluka
Name of PHC
Name of MM
Date/s of visit
Visit #
Tick
F. Clients'Rights to Privacy, Confidentiality, Dignity, Comfort and
Expression of Opinion
1.
during examination or their discussions heard by other clients and staff?
2.
Examination rooms
b.
Labour and delivery rooms
c.
Counselling areas
Do staff keep the women exposed for a minimum time and extent during
vaginal exams and delivery?_________________________________________
3.
Do staff avoid talking about clients with people who are not directly involved
4.
When client records are not in use, do staff store them in a secure place (e.g.
in her care?___________ ____________________________ ___________
with access strictly limited to authorized staff)?_________________________
5.
6.
Is each of the following areas always clean and comfortable?
a.
Examination rooms
b.
Maternity wards
c.
Labour and delivery rooms
d.
Toilets
e.
Waiting areas
_______ ___________________________________
Does your PHC provide the following for clients and those who come with
them?
7.
a.
Clean drinking water
b.
Clean toilets
c.
Nourishing food_______________________________________________
Do staff always provide pain medication for those that need it, and
emotional support during labour and in the postpartum period?
8.
Do staff provide counselling and emotional support to clients and their
families in the case of complications ?
a.
maternal orfetai death
b.
severe morbidity
c.
foetal abnormalities
Comments
88
Mentors'Manual Volume 1
or
fill X if no
Does each of the following areas offer privacy where they will not be seen
a.
if yes
.. JsSiiS
Name of PHC
Taluka
Date/s of visit.
Visit #
Appendix 3
District.
Name of MM
TickV'ifyes
G. Clients'Rights to Information and Informed Choice
or
fill'X' if no
1.
After clients with complications have been stabilized, do staff inform them
and their families about the following?
a.
b.
2.
diagnosis
need for treatment or procedures and
c. possible outcomes_______________________ ___ _____________
Before discharging postpartum women and babies, do staff know about,
and provide information on family planning?
3.
Before discharging postpartum women and babies, do staff know about,
and provide information on infant feeding and the importance of exclusive
breastfeeding for 6 months?
4.
Before discharging postpartum women and babies, do staff know about,
and provide information on danger signs in the mother?
5.
Before discharging postpartum women and babies, do staff know about,
and provide information on danger signs in the newborn?
6.
Before discharging postpartum women and babies, do staff provide
information on how to contact the ANM and ASHA in her area?__________
7.
When a woman/newborn is referred, do staff explain why it is important to
go to a facility that can manage the complication?____________________
Comments
Approaches to Improving Quality of MNCH Services in Primary Health Centres
*
ri
"
Approaches to Improving Quality of MNCH Services in Primary Health Centres
_________ .
Date/s of visit.
Visit #
District.
Taluka
Name of PHO
flassilBiiSifisW
____________________
Name of MM
Tickif yes
H. Staff's Right to Facilitative Supervision and Management and safe and
secure work environment
1.
Do off-site supervisors or technical experts visit the facility regularly and do
the following?
a.
b.
f.
Assess services
Recognize success
Work with staff to solve problems
Provide constructive feedback on clinical skills
Provide constructive feedback on general management of services
Provide information on government MNCH and SBA guidelines
g.
Provide new knowledge through mini-trainings
c.
d.
e.
2.
h. Review management of complications of labour with you
Do you together, as staff, regularly assess the services you are providing
(such as observing your infection prevention practices)?
3.
Do you together, as staff, review emergency protocols?
4.
Do you together, as staff, review the following to assess your progress?
a.
b.
Case sheets
Registers and records
5.
Does PHC management meet with staff regularly to discuss problems?
6.
Does PHC management encourage the following?
a. Staff to work together as a team,
b. Respecting all staff and their roles (including ancillary staff, nurses,
pharmacists, lab technician, doctors, record keepers)
7.
Does everyone have clear job descriptions and know their responsibilities?
8.
Are referral protocols and referral facility contact information readily available
and protocols understood by all staff?
9.
Is there a system for ensuring transport to a referral facility for clients 24
hours and all days that ensures transport within one hour?
Mentors'Manual Volume 1
or
fill'X'if no
““““
■■I
10.
Does the PHC keep and post on the wall a statistics chart with monthly
information on the following?
a.
b.
11.
Number of deliveries
Number of referrals
Are all complicated cases and cases with poor outcomes regularly reviewed
at staff meetings?
(i.e. maternal or neonatal morbidity or mortality)_____________________
12.
Does PHC management share information about the performance of the
PHC (e.g. service statisticsz findings from district quality team visits, etc.)?
13.
14.
Are there well functioning processes for determining the following
a.
b.
staff schedules
managing coverage during leaves and absences
c.
filling vacant positions
Are there adequate levels of security at the facility so that staff and clients
feel safe at all hours?________________________________________ __
15.1
Are there supportive systems and means of redressal in place if staff
experience gender based violence or harassment at work?______________
Comments
.__ _____ _,. ,r____ D
Approaches to Improving Quality of MNCH Services in Primary Health Centres
-I
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Appendix
Client Interview
lliliilfiflll
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Client Interview
Interview 5 or 6 client and/or their family members. Focus on MNCH clients, but if not available, then you
can interview any clients about the quality of PHC services.
Name of clinic
Person interviewed - Male/female
.Date
Hello, namaskar. My name is
and I work here at this PHC. The staff here are trying to make services
better for everyone and so I am going to ask you a few questions about what you think of the services and
get some ideas from you about what we could do better to serve the community. So can you tell me:
1.
Can you tell me why you are here today?
3.
Did you get the services you came for? Yes/No.
4.
What type of information were you given while you were here?.
5.
Did the provider give you all the information you needed? If no, what else did you want to know?
6.
Were you able to spend enough time with the provider/s? Yes/No
7.
Were the staff respectful? Yes/No
8.
What have you heard from your family or friends or others in your community about the quality of
services at this clinic?
9.
Have you been here to this PHC before in the past 6 months? Yes/No. If yes, do you think services for
women and children have:
a. Improved
2. Inpatient/Outpatient (specify.
.)
If not, why not?
b. Stayed the same
c. Got worse
10. What has changed ?
11. If you could afford it, would you go somewhere else for services? Yes/No. Why?
12. What do you like most about this clinic?
11. What do you like least about this clinic? Is there anything you think could be done to improve services
here (for example to make them cleaner, safer, more comfortable?
I would like to answer any questions that you have before you leave. Is there anything about the services
here that concern you, or anything that I can help you with? Thank you for your help and ideas.
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MUCH Services in Primary Health Centres
________________ _______ _________
Appendix
Case Sheet Review
Case Sheet Review
It is very important to look critically at the way we collect information and the way we use that information
for improving services. Use the following template to look at your in-patient obstetric client case sheets
and report back to the group whatyou find. If something is present, mark with a . If something is missing/
not done correctly, mark with an X. If there seem to be good reasons why something was not done (e.g.
baby died), make a note of this. If you do not know the answer, mark with a ? Select 10 records at random.
2
Item recorded
3
4
5
6 I
7
8
9
10
All client ID information
Date & time of admission_____
Date & time of discharge
Full medical history taken with
results noted
Pelvic exam with results noted
Lab tests results noted
Danger signs on admission
asked and noted
Partograph fully completed
Exams in labour done on time
Mother delivery notes
completed
Baby delivery notes completed
AMTSL done and recorded
Exams in 2 hour postpartum
period (4th stage) done on time
All maternal danger signs
checked and noted before
discharge
Abdominal exam done and
results noted before discharge
All baby danger signs checked
and noted before discharge
Discharge forms completed
If a complication, were actions
recorded and was it properly
managed
If the mothef/baby needed
referral, was a referral sheet
correctly filled_______ •
If referred, was time recorded
and was it less than one hour
All entries legible
:
Staff always sign their name
Comments on records reviewed (write on back if necessary)
.95
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Appendix
The Action Plan
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Action plan
Area of
Improvement
Root causes
Solution
By who
By when
Status
Approaches to Improving Quality of MNCH Services in Primary Health Centres
■
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Appendix
WINCH Mentoring Trip Report
...
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131
.........
MNCH Mentoring Trip Report
District
Taluka
Name of PHC
Date/s of visit
Name of MM
Name of accompanying persons and designation
Namesand
designation of
staff working at
PHC
Present at 1st
Present at last
Participated in
Attended
One on
group meet?
group meet?
SA exercises?
If so, what
exercises?
any group
teaching? If so,
one clinical
mentoring
what subject?
done? (attach
checklist)
Code as below:
A=PHCteam
self assessment
guides,
■ ■
B= Client
interviews
C= Case sheet
review.
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
Appendix 7
Trip report details
1. Were the trip dates as planned? If not, what happened?
2. Who came with you, and why, and what did they do?
3. How did you spend your time at the PHC? What went well, what didn't go well? What needs more
attention?
4. What are your observations about the meetings and self-assessment exercises? What went well, what
didn't go well? What needs more attention?
5. Did you help develop an action plan? What went well, what didn't go well? What needs more attention?
6. What are your observations about any group talks you gave? What went well, what didn't go well?
What needs more attention?
7. What are your observations about any clinical mentoring you did? What went well, what didn't go well?
What needs more attention?
8. What are your observations about the evaluation data you collected? What went well, what didn't go
well? What needs more attention?
9. Is there anything else happening in the area or in the PHC that impacts your mentoring work?
(Please use extra sheets if necessary, add any other useful information, and attach clinical checklists,
action plans and evaluation data)
0_____
Mentors'Manual Volume 1
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Clinical Mentoring Guide for
MNCH Mentors
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Appendix 8
Clinical Mentoring Guide for MNCH Mentors
You as a MNCH Mentor (MM) during the mentoring visit will ascertain the clinical mentoring needs of the
PHC teams and develop an onsite mentoring plan using the format given. These sessionswill be in line with
the essential MNCH services focused by the intervention and have to be delivered over several MM visits.
The staff mentoring needs can be ascertained through the following ways:
❖ Discussions during administration of self assessment exercises and record reviews
❖ Actual observations of clinical practices and facility systems
❖ Auditing of case sheets using audit format
You can provide clinical mentoring using many techniques / skills picked up in the MM training program.
Hence, you have to constantly refresh your mentoring skills in order to execute them during the need. You
have to be on the top of your knowledge and skills by a thorough reading of MM manuals, being familiar
with the use of case sheets and more importantly through regular clinical practice. You should refer to
the section of "ideas for mentoring" that is listed under each topic in the participant manual. Broadly, the
following will aid the teaching:
❖ Use videos (CD/DVD) for demonstration of procedures
❖ Use of models (pelvis and doll)
❖ Use of case studies that are provided in the manual
❖ Use of case sheets, drug check list for teaching
❖ Use of Mentors' manual to teach in a systematic way; always emphasize the do's*and don'ts at a PHC
Approximately, you should plan for about 4-5 hours for clinical mentoring during each visit. It is important
for you to plan the session well in advance, communicate clearly and have the PHC teams free during
the teaching sessions. At the same time, you also have to be flexible; for e.g. though a teaching session is
planned, yet some opportunities may crop up for discussing another specific issue/skill and this need to
be handled and documented. If there are specific areas that need more emphasis, the same needs to be
addressed till the staff feel confident and the same is reflected in their practices. Sometimes, you may have
to be available to the staff over phone for any discussion and clarifications. Any session that is handled
should be documented in the onsite mentoring plan.
You may have to give special emphasis to the mentoring in relation to facility systems such as referral,
supply chain and infection prevention. This should be in line with the administration of self assessments.
For e.g. if the self assessment related to continuity of care (or) supply/infrastructure has been completed
and the gaps identified; this should be followed up with discussion and mentoring around the issues ideally
in the same visit or the subsequent visit. Also the charts (referral directory or the essential MNCH drug list)
should be shared with PHC teams and should be displayed.
102
Mentors'Manual Volume 1
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Session Plan
Visit#
1st and 2nd
visits
Sessions
1. Normal labour - initial assessment, labour monitoring, conducting delivery/handling
newborn, postpartum period, discharge
2. Continuity of care (referral)
3. Supply chain
3rd visit
1. APH
2. PPH
3. PROM, Prolonged / Obstructed labour
4. LBW
5. Newborn asphyxia_________________________________ _________________
4th visit
1. Preterm labour
2. PIHZ Pre-eclampsia/ Eclampsia
3. Maternal sepsis
4. Newborn sepsis
5th visit
5. Infection control_______________________________________ ______ ______
1. Monitoring of labour, delivery and postpartum period
2. APH, PPH
3. PROM, Prolonged / Obstructed labour
4. LBW..
-
......
5. Newborn asphyxia
6th visit
...
________________
1. Preterm labour
2. PIHZ Pre-eclampsia/ Eclampsia
3. Maternal sepsis
4. Newborn sepsis
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
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15
_______________
Sessions
Normal labour - initial assessment,
Key skills/ competencies to be focused
Initial assessment and labour monitoring
labour monitoring, conducting
♦ Calculation of gestational age
delivery/handling newborn,
<• Taking of vital signs including pulse, blood pressure,
temperature
postpartum period, discharge
♦ Interpreting basic investigations
♦ Blood sampling for Hb%
♦ Urinalysis for protein
♦ Rapid HIV testing
♦ Examination of the heart and lungs
♦ Abdominal examination including symphsis fundal height,
foetal heart rate and presentation, tone
Pelvic examination including cervical dilation, effacement,
station, presentation and status of membranes, colour of
liquor
♦ Determining true labour from false labour
<♦ Plotting and interpretation of the partograph
♦> Ability to recognize signs of impending delivery or
obstructed labour
♦ Conducting delivery
♦ AMTSL
♦ Delivery of the newborn including perineal support and
infection prevention
♦ Examination of placenta
♦ Basic newborn care
♦ APGAR
♦ Immediate routine care of newborn if stable
♦ Clamping and cutting the cord
♦ Providing eye care
♦ Administering Vitamin K intramuscularly
Mentors' Manual Volume 1
<♦ Fourth stage
♦ Measurement and interpretation of vital signs in mothers
♦ Estimation of blood loss
♦ Examination of uterine tone and height
♦ Examination of the perineum
♦ Identification of different types of perineal tearsRepair/
suturing of first and second degree tears
Postpartum period
♦ Taking of vital signs including pulse, blood pressure,
temperature
♦ Abdominal examination including uterine height and
tone
♦ Counselling skills
♦ Newborn assessment
♦ Filling case sheets__________________
Shock management
APH
♦ Monitor vitals including FHR
♦ Insert IV line, calculate fluid rate
♦ Insert Foleys catheter
♦ Administer oxygen
♦ Abdominal examination
♦ Case sheet documentation________________
<♦ Shock management
PPH
♦ Monitor vitals including FHR
♦ Insert iv line, calculate fluid rate
♦ Insert Foleys catheter
♦ Administer oxygen
<♦ Administration of uterotonics
♦ Manual removal of placenta
<♦ Bimanual compression of uterus
<♦ Repair of tears
Packing of vagina
♦ Case sheet documentation
PROM, Prolonged / Obstructed labour
♦** Interpreting partograph
❖ Case sheet documentation
Preterm labour
<♦ Calculation of EDD
Administering steroids
<♦ Case sheet documentation
I
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality 6f MNCH Services in Primary Health Centres
Appendix 8
•_______________________________ ___ _________________
<
PI H/ Pre-eclampsia/ Eclampsia
♦ PIN/Pre-eclampsia/Eclampsia
♦
Urinalysis for proteins
♦
Administration of Magnesium Sulfate\
♦
Administration of antihypertensives
♦
Start IV infusion
♦
Rectal Administration of diazepam
♦
Estimation of urine output
♦
Performing deep tendon reflexes
♦♦♦ Check gestational age
<• PV examination if term and in labour
♦ Case sheet documentation________ _
Maternal sepsis
♦ Shock management
♦
Monitor vitals including FHR
♦
Insert iv line, calculate fluid rate
♦
Insert Foleys catheter
♦
Administer oxygen
<♦ Abdominal examination
♦ Perineal examination
Breast examination
♦ Case sheet documentation
Newborn sepsis
♦ Checking temperature
♦ Feeding the baby
♦ Give first dose of antibiotics
♦ Referral and transport of newborn
<* Case sheet documentation
<♦ Checking weight of newborn
LBW
♦ Classifying newborns based on gestational age
♦ Classifying newborns using physical criteria
♦ Kangaroo mother care
<♦ Feeding a LBW baby
♦
Assessment of method of feeding for a LBW or preterm
newborn
♦
Feeding by paladai
♦
Feeding by Katori
♦
Feeding by spoon
♦
Feeding by orogastric tube
<♦ Checking temperature
Use of radiant warmer
♦> Referral and transport of newborn
<♦ Case sheet documentation
—
Mentors' Manual Volume 1
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❖ Checking equipment in newborn corner
Newborn asphyxia
❖ Provide bag and mask ventilation
❖ Insertion of orogastric tube to remove secretions and air
in stomach
❖ Give chest compressions
<♦ Refer those who required bag and mask and more
intensive resuscitation measures
❖ Referral and transport of newborn with complications
❖ Case sheet documentation_______________
Continuity of care (referral)
❖ Referral directory
❖ Documentation in case sheets
❖ Pre-referral management protocol
❖ Follow up after referral___________________________
Supply chain
❖ Indenting
❖ Documentation
❖ Stocking/arrangement
❖ Checking regularly for expiry drugs
❖ Use of essential drug list_________________________ _
<♦ Hand washing
Infection control
<* Use of personal protective equipment
.
Preparation of bleach
I
-
❖ Processing of instruments
❖ Waste segregation in colour coded bins
♦** Proper handling and disposal of sharps
PEP
.........
.........
....—.........
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Appendix
Onsite Clinical Mentoring Plan
for PHC Staff
■■■
110
......
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Onsite mentoring plan for the PHC staff for the year
Name of MM
Name of the PHC
Name of the taluka
Name of the District.
Staff mentored (Mention name)
Key skills/ competencies (record "Vz/or
wx")
SN1
SN2
SN3
MOI
to
MO2
Others Others Others
2
Initial assessment and labour
monitoring____________________
Calculation of gestational age
Taking of vital signs including pulse, BP,
temperature
Interpreting basic investigations
Blood sampling for Hb gm/dl
Urinalysis for protein
Rapid HIV testing
Examination of the heart and lungs
Abdominal examination including
symphsisTundal height, fetal heart rate
and presentation, tone
Pelvic examination- cervical dilation,
effacement, station, presentation and
status of membranes, colour of liquor
Determining true labour from false
labour
Plotting and interpretation of the
partograph
Ability to recognize signs of impending
delivery or obstructed labour
Conducting delivery_____ ______
Active management of third stage -
Uterotonic, controlled cord traction,
uterine massage
Delivery of the newborn including
perineal support and infection
prevention
Examination of placenta
Approaches to Improving Quality of MNCH Services in Primary Health Centres
3
1
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Staff mentored (Mention name)
Key skills/ competencies (record "V"
or"x")
Basic newborn care____________
APGAR____________________
Immediate routine care of newborn if
stable________________________
Clamping and cutting the cord_____
Providing eye care_______________
Administering Vitamin K
intramuscularly_________________
Checking temperature
Assisting in initiating breastfeeding
Fourth stage__________________
Measurement and interpretation of
vital signs in mothers
Estimation of blood loss
Examination of uterine tone and
height________________________
Examination of the perineum
Identification of different types of
perineal tears__________________
Repair/suturing of first and second
degree tears___________________
Postpartum period
Taking of vital signs including pulse,
blood pressure, temperature
Abdominal examination including
uterine height and tone
Counselling skills
Newborn assessment
Case sheet documentation
Referral system_______________
Referral directory
Documentation in case sheets
Pre-referral management protocol
Follow up after referral
■i
Mentors'Manual Volume 1
SN1
SN2
SN3
MOI
MO2
Others
Others
Others
2,
3,
7tr-
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MMM
Staff mentored (Mention name)
Key skills/ competencies (record
/zV"or"x")
SN1
SN2
SN3
MOI
M02
Others
Others
Others
2
3
Supply chain___________
Indenting
Documentation
Stocking/ arrangement
Checking regularly for expiry drugs
Use of essential drug list
APH_______________________
Shock management
1.
Monitor vitals including FHR
2.
Insert iv line, calculate fluid rate
3.
Insert Foleys catheter
4.
Administer oxygen
Abdominal examination
Case sheet documentation
PPH________________________
Shock management^
1.
2.
Monitor vitals including FHR
3.
4.
Insert Foleys catheter
Insert iv line, calculate fluid rate
Administer oxygen
Administration of uterotonics
Manual removal of placenta
Bimanua I compression of uterus
Repair of tears
Packing of vagina______________
Case sheet documentation
Approaches to Improving Quality of MNCH Services in Primary Health Centres
1
Appendix?
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Staff mentored (Mention name)
Key skills/ competencies (record
"V"or"x")
PROM/Prolonged/Obstructed
labour__________ ___
Jnterpretingpartograph________
Case sheet documentation
LBW________________________
Checking weight of newborn__
Classifying newborns based on
gestational age
______ _
Classifying newborns using
physical criteria_______________
Kangaroo mother care
Feeding a LBW baby_____
Assessment of method of feeding
for a LBW or preterm newborn
Feeding of newborn
❖ Feeding by paladai
❖ Feeding by Katori
❖ Feeding by spoon
Feeding by orogastric tube
Checking temperature
Use of radiant warmer
Case sheet documentation
Newborn resuscitation
Checking equipment in newborn
corner
Provide bag and mask ventilation
Insertion of orogastric tube to
remove secretions and air in
stomach
Give chest compressions
Refer those who required bag
and mask and more intensive
resuscitation measures
Referral and transport of newborn
with complications
Case sheet documentation
i12
Mentors'Manual Volume 1
SN1
SN2
SN3
MOI
MO2
Others
Others
Others
2
3
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Appendix
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Approaches to Improving Quality of MNCH Services in Primary Health Centres
10
MNCH Mentoring Case Sheet
Audit tool
Appendix 10
Approaches to Improving Quality of MNCH Services in Primary Health Centres
MNCH Mentoring Case Sheet Audit
Name of the taluka
Name of the PNC
Name of MM,
Name of the District.
A. AUDIT OF CASE SHEETS FILLED FOR PREGNANT WOMEN GREATER THAN 20 WEEKS GESTATION
(Pick up 10 case sheets of pregnant women more than 20 weeks who visited the PHC in the last month and
check if the following parameters were documented. Follow the specific instructions and record" V" or"x" as
appropriate). Fill up the thayi card (TC) no for each sheet_______ _________________ ________________
SI
no
1
SECTIONS
AUDITED
Case
Section
1 (initial
assessment)
la
Presenting
All presenting
complaints
complaints
documented
1b
Menstrual
Expected date
and obstetric
of delivery (EDD)
history
documented
correctly
1c
Investigations
All investigations
listed are
completed
Id
Examination -
Following are
general
documented:
♦♦♦ Pulse
* BP_________
<♦ Temperature
1e
CASE SHEET
PARAMETERS
Examination -
Following are
abdominal
documented:
❖ Fundal
height
Presentation
<♦ Contractions
FHR
Mentors' Manua! Volume 1
Case
Case
Case
Case
Case
Case
Case
Case
Case
sheet
sheet
sheet
sheet
sheet
7
8
9
10
IC
TC
K
No
No
No
sheet
sheet
sheet
sheet
sheet
1
2
3
4
5
6
IC
TC
IC
IC
IC
IC
No
No
No
No
Nfi
No
NS
■
.
.
IBBSBhBRBMHHhII
If
Examination
-vaginal
Following are
documented:
❖ Cervical
dilatation
❖ Cervical
effacement
❖ Status of
membranes
❖ Presenting
part
ig
Overall initial
assessment
Complication
case sheet filled
correctly (if
present)
1h
r
Correctly
documented
(verify with
history/
examination
findings)
2
Section
2 (labour
monitoring)
2a
Latent phase
Correctly and
completely filled
(check with time
of admission and
time of delivery)
2b Active phase
Correctly and
completely filled
(check with time
of admission and
time of delivery)
2c
Plotting started
only in active
phase( 4 cm)
and on line A
2d
Partograph
All graphs
correctly and
completely
documented
(Crosscheck with
active phase
documentation)
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
2e
Overall
labour
assessment
2f
Correctly
documented
(verify with
partograph/
labour monitoring
section)_____ __
Complication
case sheet filled
correctly (if
present)
3
Section 3
(delivery
notes)
3a
Particulars of
delivery
Following are
documented:
❖ Mode of
delivery
❖ Amniotic
fluid status
♦♦♦ Three steps
of AMTSL
❖ Placenta
Estimated .
blood loss
3b
Particulars of
the baby
Following are
documented:
❖ Sex_________
<♦ Weight
<♦ Maturity
<* Resuscitation
details as
appropriate
<♦ Correct dose
of inj Vitamin
K
<♦ Initiated
breast
feeding
within half an
hour
3c
Fourth stage
of labour
Correctly and
completely
documented
Mentors'Manual Volume 1
Appendix 10
--
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3d
Post-delivery Correctly
assessment
of mother
documented
(verify with
sections of
particulars of
delivery and
fourth stage)
3e
Complication
case sheet filled
correctly (if
present)
3f
Post-delivery
Correctly
assessment
of newborn
documented
(verify with
sections of
particulars of
baby and fourth
stage)_______
Complication
3g
case sheet filled
correctly (If
present)
4
Section 4
(postpartum
4a
period)
Maternal
All parameters
assessment
are monitored
completely and
timely
4b
Newborn
All parameters
assessment
are monitored
completely and
timely
4c
Counselling
All parameters
are addressed
completely and
timely
Approaches to Improving Quality of MNCH Services in Primary Health Centres
■
-■
Approaches to Improving Quality of MNCH Services in Primary Health Centres
■
4d Postpartum
Correctly
assessment
documented
of the
(verify with
mother
sections of
maternal
assessment)
Complication
4e
case sheet filled
correctly (if
present)______
4f
Postpartum
Correctly
assessment
documented
(verify with
of the
newborn
sections of
newborn
assessment)__
Complication
4g
case sheet filled
correctly (if
present)______
5 ^Outcomes
sheet_
5a
Background
information
All details are
completely
documented
5b
Outcomes
Maternal and
newborn
outcomes are
documented
correctly (verify
with case sheet
sections)_____
5c
Follow
up in the
All details are
community
completely
documented
Mentors'Manual Volume 1
Appendix 10
B. AUDIT OF COMPLICATION CASE SHEETS
(Pick up all the complication sheets of cases that were managed and referred in the last month
and check if the following parameters were documented. Follow the specific instructions and record
"V" or"x"as appropriate)
SI no
6
Sections
Parameter to
be audited
Background
Documented
information
completely
7a
Diagnosis
documented
7b
Assessment
criteria for
Specific
7c
Mention the complication case sheet type below in
Comments
the first row
and fill up the respective column
the diagnosis
documented
diagnosis
completely
and initial
Corresponding
management
documentation
in the sections
1/2/3/4 (as
appropriate) is
complete
Appropriate
management
7d
completely and
correctly done
8
Condition at
the time of
referral
Documented
completely
9
Referral
details
Documented
completely
Approaches to Improving Quality of MNCH Services in Primary Health Centres
liSBl
Approaches to Improving Quality of MNCH Services in Primary Health Centres
f
________
Appendix
Essential WINCH Drug List
Essential MNCH Drug List
MNCH indication
Active
Name of drug -
Initial
Name of drug
first choice(with
management
-second choice,
contraindications)
(prior to referral
to be given only
(if multiple drugs
from PHC)
when first drug is
are used, list all)
Dose / route (if
not available (with
multiple, list all)
contraindications)
10 IU Intra
Misoprostol
Oxytocin
Management of
Dose / route
800mcg (4 Tabs)
rectally/orally
muscularly (IM)
the Third Stage of
-evidence is
Labour (AMTSL)
strong for oral not
rectal (max dose
IQOOmcg)______
20 IU in 1L RL/DNS
Methergin/
0.2mg IM (up to a
Hemorrhage (PPH)
bottle at 60 drops
Ergometrine
total 5 doses)
- Atonic uterus
per min
(Not given in high
Post partum
Oxytocin
BP)____________
Prostaglandin
0.25mg IM (uptoa
-carboprost
total 8 doses)
(Not given in
asthma)
Misoprostol
600mcg (3 Tab)
rectally/orally -
evidence is strong
for oral not rectal
PPH - Retained
Oxytocin
20 IU in IL RL/DNS
placenta/ placental
bottle at 60 drops
fragments (if
per min
unable to perform
manual removal)
PPH - Retained
placenta/ placental
fragments prior to
20 IU in IL RL/DNS
Oxytocin
Antibiotics (3)
bottle at 60 drops
per min
manual removal of
- Ampicillin and
Igm IV or orally
Ampicillin -
placenta
- Metronidazole
400mg orally Or
Cloxacillin
and
500mg IV
combination
- Gentamicin
80mg IM or IV
PPH -Perineal/
Antibiotics (2)
Cervical tears
- Ampicillin and
500 mg orally
Ampicillin -
- Metronidazole
400mg orally
Cloxacillin
(only 4th degree
perineal tears)
Igm iV or orally
500mg orally
combination
I
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Appendix I I
___
PPH - Delayed PPH
with foul smelling
discharge
Oxytocin
10 IU IM
Misoprostol
-Ampicillin and
Igm IV or orally
- Metronidazole
and
400mg orally Or
SOOmg IV
Ampicillin
- Cioxacillin
combination
- Gentamicin
80mg IM or IV
Smg IV
Severe Pregnancy Anti hypertensive
- Hydralazine
Induced
Hypertension (P1H) (give only if BP
>160/110)_______
Severe
pre-eclampsia
Anti hypertensive
- Hydralazine
Eclampsia
(give only if BP
>160/110)
5mg IV
Magnesium sulfate Total 10 gms(20
ml) IM
(If toxicity - RR
Sgm or 10 ml each
less than 16/min
buttock
or deep tendon
SOOmcg (4Tab)
rectally/orally evidence is strong
for oral not rectal
Igm IV or orally
Anti hypertensive Nifedipine
5mg orally
Anti hypertensive
- Nifedipine
5mg orally
Diazepam
lOmg IV over 2
minutes or 20 mg
rectally in a 10 ml
syringe
Ampicillin
- Cioxacillin
combination
Igm IV or orally
Ampicillin
-Cioxacillin
combination
1 gm oral or IV
reflexes are
absent, stop Mag.
Sulphate)
Preterm labour
with or without
rupture of
membranes and
with fever
Preterm labour
with or without
rupture of
membranes and
no fever
Antibiotics (3)
-Ampicillin and
Igm IV or orally
- Metronidazole
and
400mg orally Or
SOOmg IV
- Gentamicin
80mg IM or IV
- Paracetamol
SOOmg orally
(Not given in
renal and hepatic
impairment)
Antibiotic -
Ampicillin
■ni
Mentors'Manual Volume 1
1g oral or IV
HHMM
HHHI
Si
. . .. . —~
■Mi
Preterm rupture
Antibiotics (2)
of membranes
- Erythromycin
without labour and and
without fever
-Amoxycillin
Preterm rupture
Antibiotics (3)
of membranes
-Ampicillin and
without labour and
- Metronidazole
with fever
and
Prematurity,
preterm
(threatened or
active)
250mg orally
500mg orally
Ampicillin
Cloxacillin
combination
Igm IV or orally
12mg IM
Corticosteroid Dexamethasone
6mg IM
Igm IV or orally
Ampicillin
- Cloxacillin
combination
Igm IV or orally
Ampicillin
- Cloxacillin
combination
2 gm IV or orally
Igm IV or orally
400mg orally Or
500mg IV
-Gentamicin
80mg IM or IV
Paracetamol
500mg orally
(Not given in
renal and hepatic
impairment)
Corticosteroid Betamethasone
Mt-
> 24 weeks and
<34 weeks
Severe infection or
prophylaxis
Antibiotics (3)
• Obstructed/
prolonged labour
-Ampicillin and
• Rupture of
-Metronidazole
membranes more
and
than 12 hours
-Gentamycin
• Rupture uterus
• Amnionitis in
pregnancy,
Paracetamol
• Endometritis/
puerperal sepsis
400mg orally Or
500mg IV
80mg IM or IV
500mg orally
(Not given in
renal and hepatic
impairment)
• Wound infection
(abscess)
Severe infection septic shock
Antibiotics (3)
- Ampicillin and
2 gm IV or orally
- Metronidazole
and
400mg orally Or
500mg IV
- Gentamicin
80mg IM or IV
Approaches to Improving Quality of MNCH Services in Primary Health Centres
R|
a
Approaches to Improving Quality of MNCH Services in Primary Health Centres
__________________
Severe infection Pyelonephritis
Newborn infection
(sepsis)
All Newborn
Appendix 11
___
Antibiotic (2)
-Ampicillin and
2 gm IV
-Gentamicin
80mg IM or IV
Paracetamol
500mg orally
(Not given in
renal and hepatic
impairment)
Ampicillin
- Cioxacillin
combination
2gm IV or orally
Antibiotics (2)
- Ampicillin and
50mg /kg IM
- Gentamicin
5 mg/ kg IM
Vitamin K
For newborns
>1500gms
Inng
For newborns
<1500gms
0.5mg
Ongoing management in PHC
Mild infection mastitis
Mild infection breast abscess
Antibiotic Cloxacillih
500 mg orally four
timerdaily for 10
days
Erythromycin
250mg orally three
times daily for 10
days
Ampicillin
500mg orally three
times daily for 10
days
Antibiotics (2)
Ampicillin and
Metronidazole
Paracetamol
Mentors'Manual Volume 1
Ampicillin
- Cioxacillin
400mg three times combination
daily orally
500mg four times
daily orally
500mg orally
(Not given in
renal and hepatic
impairment)
500mg orally four
times daily
* ■-'■■■■■
■
*—
—■
-
-
—■
-
•
■
Approaches to Improving Quality of MNCH Services in Primary Health Centres
----
Appendix
Referral Directory Template for
24/7 PHCs
Reference: SBA Guidelines, NSSK Guidelines and WHO Guidelines
SB
Approaches to Improving Quality of MNCH Services in Primary Health Centres
HppeilUlA IZ
REFERRAL DIRECTORY TEMPLATE FOR 24/7 PHCs
Name of the PHC:
....... Name of the MO:
PHC Contact number:
Taluka:
Services offered in the
referral facility
Address of the referral
facility
Labour induction
Labour augmentation
Dilatation and
Curettage
Cesarean section
Intensive Care Unit
Blood transfusion
Surgical facility (abscess
drainage, repair of major
tears, hysterectomy)
Sick newborn care unit
123 |
Mentors'Manual Volume 1
District:
Contact number of the
Contact person in the
referral facility
referral facility
'1;-: ’'A'’
,
'■
^;':
'W'_
./I,
Appendix
13
Maternal and Newborn Case
Sheet for 24/7 PHCs
Approaches to Improving Quality of MNCH Services in Primary Health Centres
Appendix 13
MATERNAL AND NEWBORN CASE SHEET FOR USE AT 24x7 PHCs
The simplified Case Sheet, along with 8 separate Complication Sheets for each of the most commonly
diagnosed complications are especially designed for use at 24/7 primary health centres. The case sheet has
to be filled for all women over 20 weeks of gestation reporting labour pain or any complication. The case sheet
functions as a job aid and helps the PNC staff in providing a comprehensive and quality care to the woman
during initial assessment, labour, delivery and immediate postpartum period and to the newborn. More
specifically, it (1) reminds the sequence of the different steps to be followed at each stage (2) reminds the
correct diagnosis of complications (3) reminds the appropriate procedures and drugs for the initial
management of complications before referral and (4) facilitates easy and quick documentation for future audits
for quality improvement.
General instructions
1. Use ball point (black or blue) for recording on the Case Sheet.
2. Put a 0 as appropriate on the boxes provided.
3. Use one case sheet for every woman over 20 weeks gestation visiting the PHC with reported labour pains
or any complication.
4. Read and follow the detailed instructions under each section and sub-section of the Case Sheet.
5. Read and record on all sections of the Case Sheet, either before or during or after an examination or a
procedure.
6. Use all related Complication Case sheets if multiple complications are diagnosed.
7. Whenever a Complication Sheet is used, tear off the pink pages of the sheet and send them to the facility
where the woman/newborn is referred to.
Mentors'Manual Volume 1
J.™—
.. .........
■
.................................................................................................................... ........................ ................................ ........................................................
■
CASE SHEET FOR WOMEN ARRIVING TO THE PHC FOR DELIVERY
SECTION 1: INITIAL ASSESSMENT
A.FACILITY IDENTIFICATION
District
PHC Location.
Taluka
BBACKGROUND INFORMATION
daymonthyear
Date of arrival
Name
Husband’s name.
Time of amvalhrsl
] minsAM/PM[
Age yrs [
BPLY
N nThayi card available Y
daymonthyear
Date of initial assessment [
N
Thayi card number [
] minsAM/PM [
Time of initial assessmenthrs[
Address
Contact number L
C. PRESENTING COMPLAINTS (Put a Elon Y box If present and a Bon N box if not present, for each compiainlf
Breathlessness at rest or on mild exertion YD ND
FeverY D N D
Pain in abdomenY D N
Swelling of faceY D N D
Contractions YD ND
HeadacheY D N D
Watery discharge per vagina/rupture of membranes YD ND
Blurred visionY D N D
Bleeding per vaginaY D N D
Vomiting YD ND
Foul discharge per vagina Y D ND
Fits/seizuresYD ND
Decreased / No foetal movement YD ND
Difficulty in passing urine/ less urine YD N D
Any other (specify)
Palpitation YD ND
Severe weakness/tiredness Y D N D
D. MENSTRUAL AND OBSTETRIC HiSTORY (Ask the woman and/or refer to Thayi Card)
..gI
I p|
LMPday I
I aI
I
I
Gestational agewks I
I L,
I CyclesJRegular□ IrregularD
month
I
year
I days I
]
I
III
i r
Lengthpf the cycle
I
EDD |
|
| daymonth I
I
J year L
n
] if gestational age is between 24-34 weeks, Manage and refer using Complication sheet
EGestational type Single pregnancy DMultiples D__________________________ -________________________________ E.PREVIOUS OBSTETRIC HISTORY (Record particulars for each pregnancy outcome in separate lines. If primigravida, skip to section F)
Outcome (Record
Complications during pregnancy/
Year of
Mode of delivery(Record
Place of
ABORTION, STILL BIRTH,
delivery/MTP(Rec delivery/postpartum(Record NONE, APH,
delivery/ NORMAL, INSTRUMENTAL,
LIVE BIRTH, NEONATAL
PIH, PRE-ECLAMPSIA, ECLAMPSIA, PRE
ord SC, PHC, CHC,
abortion CESAREAN,
DEATH, INFANT DEATH)
SPONTANEOUS ABORTION,
TERM LABOUR, PRE-TERM RUPTURE OF
TH, DH, PVT,
or MEDICAL TERMINATION
MEMBRANES, FOETAL DISTRESS, MALHOME, or OTHER)
OF PREGNANCY)
PRESENTATION, SEPSIS, PPH, NEWBORN
COMPLICATION and OTHER(specify)
F, OTHER HISTORY_______________________________
Medical history Diabetes Y D N DAnaemia Y D N
DHypertension Y D N DHeart disease Y D N DOther Y D ND
(specify)
Surgical history
Any allergies Y D N Dlf yes, specify
Medications during thjs pregnancy
Injection TT given 1 D2 DBoosterDNone D
Taking any medications Yes D NoDlf yes, IFA D
Other D(specify)
Approaches to Improving Quality of MNCH Services in Primary Health Centres
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