GOVERNMENT OF MIZORAM

HEALTH & FAMILY WELFARE DEPARTMENT

…….

N O T I F I C A T I O N

Dated Aizawl, the ­22nd January, 2016.

No.B.12011/17/2015-HFW:In pursuance of National Health Mission RoP, 2014-15 and in the interest of public service, the Governor of Mizoram is pleased to constitute a State Level and District Level Quality Assurance Committee consisting of the following members with immediate effect and until further orders.

STATE LEVELQUALITY ASSURANCE COMMITTEE (SQAC):

  1. Principal Secretary, Health & Family Welfare Department :Chairman.
  2. Mission Director , National Health Mission :Vice-Chairman.
  3. Director of Health Services:Convener
  4. Joint Director of Health Services, Family Welfare:Member
  5. Director of Hospital & Medical Education:Member
  6. Director, Administrative Training Institute (ATI):Member
  7. Medical Superintendent, Civil Hospital, Aizawl:Member
  8. Head of Department, Obs. & Gynecology,C.H.,Aizawl:Member
  9. Head of Department, Surgery, Civil Hospital, Aizawl:Member
  10. Head of Department, Anaesthesiology, C.H., Aizawl:Member
  11. Head of Department, Paediatric Medicine, C.H., Aizawl:Member
  12. Head of Department, Medicine, C.H., Aizawl:Member
  13. Chief Medical Officer, Aizawl East:Member
  14. Chief Medical Officer, Aizawl West:Member
  15. Registrar, Mizoram Nursing Council:Member
  16. Director, Presbyterian Hospital, Durtlang:Member
  17. Law Officer from State Law Department:Member
  18. President, Indian Medical Association, Mizoram State Branch:Member

TERMS OF REFERENCE :

SQAC is a body for the Policy decision & directions. This is also responsible for all QA initiative, its success & shortcomings. The primary role of the committees at the state level will be to provide overall guidance, mentoring and monitoring of QA efforts in the districts. Some of the ToRs reflected here are operational in nature and shall be implemented by the SQAC, which is the operational and implementation are of SQAC.

  1. Developing the Quality Assurance Policy & Guidelines for the State:

Using National guidelines, the SQACs will develop/adapt QA the Guidelines specific to their States.

  • Composition of the state and district QACs & QAUs.
  • Recruitment of consultants for QA at state and district levels.
  • Empanelment of state QA assessors who may be retired/serving, part time/full time as per the state specific need.
  • Expanding the scope of QA process as per the states’ requirements.

Note : The Recruitment committee should include one nominee from the Ministry of Health &

Family Welfare, GOI.

  1. Ensuring attainment of the Standards for Quality of Care by Public Health Facilities:
  • The committee will develop ‘road- map’ for achieving the national standards.
  • Assessment of need of Technical Assistance (TA) by the facilities and mobilization of such TA.

  1. Monitoring the state/district level units :
  • Ensuring that state/ district level orientation and other trainings are conducted timely in a meaningful manner.
  • The support of the technical team at the national level may be taken to prepare a pool of master-trainers at the state/district.

  1. Periodic Review of the progress of QA activities :
  • Will conduct review meetings at six monthly interval.
  • Review of Quality scores, attained by different categories of Public Health Facilities.
  • Take decisions for corrective actions and preventive actions
  • Defining targets and road maps

  1. Review and adjudicate compensation claims : Under the NationalFamily Planning Indemnity Scheme for cases of deaths, complications and failures following male and female sterilization procedures. (for detailed procedures to be followed please refer to the manual on “Family Planning Indemnity scheme 2013”, Ministry of Health & Family Welfare, Government of India”).
  1. Supporting quality improvement process :
  • Take visionary decisions for continuous quality improvement and its sustenance.
  • Sanction funds for implementation and improvement of quality.
  • Reflects funds requirement for Quality Assurance in the annual State PIP along with justification
  • Operationalisation of incentive scheme.

  1. Reviewing Key performance indicators of quality :
  • The suggested KPIs for District Hospitals are given in the Annexure ‘A’. The SQAC may add additional indicators in KPIslist.
  • Performance of health facilities as assessed by the KPIs would also be discussed during review meetings of CMO/CS/CMHO/DHO.
  • RMNCH score card can be used for assessing the performance of the facilities.
  1. Reporting :
  • The committees’ review report should be put on the State’s website.
  • The reports would also be shared with all district committees and other stakeholders.

PROCESS OF SQAC :

  1. The state quality assurance committee will meet at least once in six months.
  2. The convener will issue meeting notice at least seven working days before the scheduled date of meeting with the approval of the chairperson/vice chairperson.
  3. While every attempts should be made to ensure that the chairperson and/or the vice-chairperson are able to attend the meeting, however, in the absence of the chair, the Convener shall have the right to convene the meeting and conduct it according to the set agenda. Under such circumstances, the minutes of the meeting should be sent to the chairperson and vice chairperson for information and ratification.
  4. The member secretary will ensure the preparation of the agenda notes for meeting, minutes ofthe last meeting and Action Taken Report(ATR), which will also be circulated in advance to all committee members, at least seven days before the scheduled date for the meetings.
  5. An attendance by at least one-third of the Committee members will constitute the quorum required for a valid meeting.
  6. Member secretary will ensure follow-up actions with responsibilities and timelines for the same.
  7. The “State Family Planning Indemnity Subcommittee” would meet as often as warranted at least three members would constitute the quorum of this subcommittee.

DISTRICT LEVELQUALITY ASSURANCE COMMITTEE(DQAC) :

  1. Deputy Commissioner :Chairman.
  2. Chief Medical Officer:Convener
  3. District Family Welfare Officer(if any):Member
  4. Medical Superintendent of District Hospital :Member
  5. In-charge of CHC & PHC (one each, by rotation).:Member
  6. Seniormost Gynaecologistof Dist. Hospital:Member
  7. Seniormost Surgeon of Dist. Hospital:Member
  8. Seniormost MedicalSpecialist of Dist. Hospital:Member
  9. Seniormost anaesthesiologist of Dist. Hospital:Member
  10. Seniormost Pediatrician of Dist. Hospital:Member
  11. Nursing Superintendent ofDist. Hospital:Member
  12. One of the Govt. Advocates of the District:Member

TERMS OF REFERENCE :

  • Dissemination of QA policy and guidelines :
  • Ensuring Standards for Quality of Care :
  • Reviews, report and process compensation claims for onward submission to the SQAC under the National Family Planning Indemnity Scheme for cases of deaths, complications and failures following male and female sterilization procedures. (for detailed procedures to be followed please refer to the manual on “Family Planning Indemnity Scheme 2013, Ministry of Health & Family Welfare, Government of India”).
  • In case a facility reports a sterilization related death, the convenor of the DQAC should inform the convenor of the SQAC within 24 hours.Death audit needs to be undertaken by the DQAC and report sent to the state with a copy to the Ministry of Health & Family Welfare, Govt. of India, within one month of the death being reported.
  • Capacity building of DQAU and DQT :
  • Monitoring QA efforts in the district :
  • Periodic Review of the progress of QA activities :
  • Supporting quality improvement process:
  • Coordination with the state for :
  • Reporting :

  • The district QAC will be responsible for disseminating the QA guidelines to all the stakeholders.
  • The committee will ensure that QA standards have been achieved at designated health facilities.
  • Ensuring that district level orientation and trainings are accomplished intime for DQAU and also DQT.
  • The committee needs to ensure that facility assessments and subsequent quality improvement efforts are executed as per plan.
  • Will conduct quarterly review meetings and more if needed.
  • Take decisions for corrective actions.
  • Define targets and road maps
  • During the district level program review meetings the Key performance indicators (KPI) of quality can be reviewed.
  • RMNCH score can be used for assessing the performance of the facilities.
  • Sanction and release of funds for implementation and improvement of quality.
  • Reflect fund requirement in the annual DHAP along with justification.
  • Taking all required actions for incentivisation of the facilities on attaining the certified status.
  • Dissemination and implementation of guidelines.
  • Facilitators support for the visits of SQAC/SQAU to the districts.
  • Sharing minutes of DQAC meeting and monthly reports.
  • Corrective action & preventive actions.
The committee’ review report to be put on the state NRHM website.
  • Share with all district committee members and other stakeholders.
  • Share the QA reports with the concerned facility.

Process :

  • The district quality assurance committee will meet at least once in a quarter.
  • The convener will issue meeting notice at least seven working days before the

scheduled date of the meeting with the approval of the chairperson.

  • While every attempt should be made to ensure that the chairperson is able to

attend the meeting, however, in the absence of the chair, the Convenor shall have the right to convene the meeting.Under such circumstances, the minutes of the meeting should be sent to the chairperson for information and ratification.

  • Member Secretary will ensure the preparation of agenda notes, and action taken reports, which will be circulated in advance to all committee members preceding the DQAC meetings.
  • An attendance by at least one third of the Committee members will constitute the quorum required for a valid meeting.
  • Member Secretary will ensure follow-up actions with responsibilities and timelines for the same.
  • The “District Family Planning Indemnity Subcommittee” would meet as often as warranted.
  • At least three members would constitute the quorum of this subcommittee.

(_ FANAI)

Secretary to the Govt. of Mizoram

Health & Family Welfare Department