Implementing a quality improvement initiative for private healthcare facilities to achieve accreditation: experience from India.

BACKGROUND: The Manyata program is a quality improvement initiative for private healthcare facilities in India which provided maternity care services. Under this initiative, technical assistance was provided to selected facilities in the states of Uttar Pradesh, Jharkhand and Maharashtra which were interested in obtaining 'entry level certification' under the National Accreditation Board for Hospitals and Healthcare Providers (NABH) for provision of quality services. This paper describes the change in quality at those Manyata-supported facilities when assessed by the NABH standards of care. METHODS: Twenty-eight private-sector facilities underwent NABH assessments in the three states from August 2017 to February 2019. Baseline assessment (by program staff) and NABH assessment (by NABH assessors) findings were compared to assess the change in quality of care as per NABH standards of care. The reported performance gaps from NABH assessments were then also classified by thematic areas and suggested corrective actions based on program implementation experience. RESULTS: The overall adherence to NABH standards of care improved from 9% in the baseline assessment to 80% in the NABH assessment. A total of 831 performance gaps were identified by the NABH assessments, of which documentation issues accounted for a majority (70%), followed by training (19%). Most performance gaps could be corrected either by revising existing documentation or creating new documentation (62%), or by orienting facility staff on various protocols (35%). CONCLUSION: While the adherence of facilities to the NABH standards of care improved considerably, certain performance gaps remained, which were primarily related to documentation of facility policies and protocols and training of staff, and required corrective actions for the facilities to achieve NABH entry level certification.

Quality of maternity care provided by private sector healthcare facilities in three states of India: a situational analysis.

BACKGROUND: Better quality of care around the time of childbirth can significantly improve maternal and newborn survival. In countries like India, where the private sector contributes to a considerable proportion of institutional deliveries, it is important to assess the quality of maternity care offered by private sector healthcare facilities. This study seeks to fill that information gap by analysing baseline assessments conducted for the Manyata program, which aims to improve the quality of maternity care at private facilities. METHODS: An observation checklist based on 16 clinical standards endorsed by the Federation of Obstetric and Gynaecological Societies of India (FOGSI) was used to assess 201 private sector healthcare facilities in Maharashtra, Jharkhand, and Uttar Pradesh. Data on facility characteristics came from profiles completed when facilities enrolled in Manyata. Differences in the mean number of standards met were analysed by facility characteristics and the availability of essential supplies. RESULTS: Around half (47.1%) of all nursing staff engaged in maternity care services at these private healthcare facilities were under qualified. The mean number of clinical standards met by facilities was 3.2 (SD 2.4). Facilities with a monthly delivery load between 20 and 50 met a significantly higher number of standards, as did facilities that had more than 70% of essential supplies available. Both these factors were also significant in a multiple linear regression analysis. CONCLUSIONS: The overall quality of maternity care in private healthcare facilities is poor in all three states, especially for clinical standards related to management of complications.

Does Quality Certification Work? An Assessment of Manyata, a Childbirth Quality Program in India's Private Sector.

BACKGROUND: In India, more than 60% of hospital beds are in private facilities, yet several studies have observed suboptimal quality of care in private facilities. We aimed to understand the role of Manyata, a quality improvement initiative in private facilities focused on mentorship and clinical standards, to improve the knowledge and skills of health care providers, their adherence to key childbirth-related clinical practices, and health outcomes for women and newborns. METHODS: We conducted a secondary analysis of Manyata program data collected from 466 private facilities across 3 states (Jharkhand, Maharashtra, and Uttar Pradesh) in India from October 2016 to February 2019. We calculated means and 95% confidence intervals for knowledge and skills assessment, adherence to facility standards was analyzed by calculating the proportion of facilities passing a given quality standard at baseline and endline, and changes in pregnancy outcomes were assessed with autoregression modeling. RESULTS: From assessments conducted before and after training among providers in Manyata, we observed a significant increase in average knowledge score (6.3 vs. 13.2 of 20) and skill score (8.0 vs. 34.3 of 40). Overall, a significant increase occurred in adherence to clinical standards between baseline and endline assessments (29% vs. 93%). The standards with the greatest improvements were identification and management of eclampsia/preeclampsia, postpartum hemorrhage, and neonatal resuscitation. There were no significant changes over time in absolute rate of reported complications; however, referral rates from private facilities for preeclampsia and newborn sepsis identification and management declined. CONCLUSION: Our analysis indicates private facilities' adherence to quality standards and nurses' childbirth knowledge and practical skills increased during Manyata. Additional efforts are needed to ensure high-quality care during cesarean deliveries at private facilities. Future studies with rigorous design are required to evaluate the impact of this quality improvement initiative in improving pregnancy outcomes.

Facilitators and barriers to participation of private sector health facilities in government-led schemes for maternity services in India: a qualitative study.

OBJECTIVE: Despite provision of accreditation of private sector health providers in government-led schemes for maternity services in India, their participation has been low. This has led to an underutilisation of their presence, resources and expertise for providing quality maternal and newborn health services. This study explores the perception of various stakeholders on expectations, benefits, barriers and facilitators to private sector participation in government-led schemes-specifically Janani Suraksha Yojana (JSY)-for maternity service delivery. DESIGN: Narrative-based qualitative study. Face-to-face in-depth interviews were conducted with study participants. The interviews were transcribed, translated and analysed using a reflexive and inductive approach to allow codes, categories and themes to emerge from within the data. SETTING: Private obstetricians, government health officials and FOGSI (Federation of Obstetrics and Gynaecological Societies of India) members, Jharkhand and Uttar Pradesh, India. PARTICIPANTS: Eighteen purposefully selected private obstetricians from 9 cities across states of Uttar Pradesh and Jharkhand, 11 government health officials and 2 FOGSI members. RESULTS: The major factors serving as barriers to participation of private practitioners in JSY-which emerged on thematic analysis-were low reimbursement amounts, delayed reimbursements, process of interaction with the government and administrative issues, previous experiences and trust deficit, lack of clarity on the accreditation process and patient-level barriers. On the other hand, factors which were facilitators to participation of private practitioners were ease of process, better communication, branding, motivation of increasing clientele as well as satisfaction of doing social service. CONCLUSION: Factors such as financial processes and administrative delays, mistrust between the stakeholders, ambiguity in processes, lack of transparency and lack of ease in the process of empanelment of private sector are hindering effective public-private partnerships under JSY. Simplifying and strengthening the processes, communication strategies and branding can help revitalise it.