Certification

Process
under NQAS
Ms. Vinny Arora
Senior Consultant
Quality & Patient Safety Division
NHSRC
Targets for HWC
 Level of Assessment
The first assessment
score will be baseline
score
Na
ti o
na
l
Internal Assessment DQAU Assessment State Assessment

As
ses
s m
1. Continuous process 1. Quarterly by DQAU

e
1. Every Facility should

n t
2. Find the gaps 2. Share the findings
be assessed atleast
3. Perform with SQAU
once in a year.
3. Support/ Hand hold
2. Once the facility is
facility in closing gaps
state certified and has
been consistently
4. Close gaps
getting high score on
5. Review Score > 70%
assessment the
6. Apply for State
facility would apply
Certification
for National
assessment.
 Mandatory Criteria for Certification
For a facility to apply for the state and national certification it is mandatory to apply atleast for the
following 7 packages:
1. Care in pregnancy and child-birth.
2. Neonatal and infant health care services.
3. Childhood and adolescent health care services.
4. Family planning, Contraceptive services and other reproductive Health Care services.
5. Management of Communicable diseases including national Health Programmes.
6. Management of Common Communicable diseases and outpatient care for acute simple illnesses and
minor ailments.
7. Screening, Prevention, Control and Management of non-Communicable diseases.
 State Certification at Primary level

Certification assessment of Primary Health Care facilities

(HWC-SC/HWC-PHC/ PHC/U-PHC) in a district may be
planned at the district level through a robust system of
peer assessment. Such team will have at least one
experienced NQAS Internal Assessor from another district.
 National level Assessment Process
Fi
be nal d
tak ec
en isio
co n a
mm nd
u n ac t
Appeal Committee ica ion Recommendation for Three Years validity for
ted to Final reports are prepared
& sent to MOHFW Certification to full certification and one
Asses MoHFW
Yes smen year for conditional
t fe edbac
k issue NO

Yearly
Feedback submitted Surveillance
Final Report
to NHSRC Assessment
sent to NHSRC
and
1 week prior to Recertificati
Assessor feedback is Report are compiled and sent Assessment assessment, toolkit on after 3
requested from facility for administrative approval concluded is sent to assessors years

State is requested Document After

to submit the clearance from confirmation
documents the consultant from State

Receiving Review of SOPs and

application from Records and Tentative dates are Assessment Team of Assessors
State feedback provided to State Scheduled is finalized
 Audit Man-days

Physical
Facility Types No. of Departments
No. of Assessors Man Days

PHC / UPHC All 6/12 2 2

HWC All Packages 2 1

 Phase for assessment

1 2 3

Pre During Post

Assessment Assessment Assessment
Phase Phase Phase
 Phase – I Pre Assessment Phase
Avoid possible Conflict of Interest

Finalize the team

Considering the scope of packages applied

Refer Program guidelines

Review the documents

Share the Assessment schedule & plan

 Documents required for Certification
S. No. Name of the Documents
1 No. and Names of service packages to be assessed
2 Latest District level assessment report verified by State*
3 Minutes of last Quality Team meeting (Preferable within Last Quarter)
4 Work Instructions (As per Service Packages)
5 Copy of Facility Wide Policies/ Instructions
a Quality Policy & Objectives
b Policy for Maintaining Patients’ Records [its security, sharing of information and safe
disposal] (Both physical and digital copies)
c Referral Policy
6 Last 3 months Patient Satisfaction Survey Report (Analysis) with subsequent Corrective and
Preventive actions undertaken.
7 Last 3 months data of Key Performance Indicators (KPI).
8 Bio Medical Waste (BMW) Authorization Certificate
9 Letter for Fire compliance from the appropriate authority.
 Checklist
(DH/SDH/CHC/PHC/UPHC/H&WC/MusQan)

Toolkit Word Format Report

shared by Opening & Closing Meeting Format

NHSRC Co-Assessor feedback form

should only
be used Declaration of Impartiality and Confidentiality
form

Role and responsibilities for the Assessors

along with Do’s & Dont’s
Phase – II During Assessment

Compilatio
Opening Departmen Closing
n of
Meeting t Assessed Meeting
Reports
 Certification Criteria
Criteria Fully Certified Conditionality Deferred/ Declined

Aggregate score of the health facility - >70% √ √ Not met

Score of each service package of the health √ Met 3 out of 5

facility (minimum 7 packages) - >70% criteria
Segregated score in each Area of concern - √
>60%
Score of Standard - >60% √

Individual Standard wise score- >50% √

Patient/client Satisfaction Score - 60% or Score √

of 3.0 on Likert Scale

For State level Certification score of above criteria may be reduced by 5%

DO letter no – NHSRC/ 13-14/ QI/01/ QAP dated 10th August’ 2017
 Core Standards under NQAS
Core-Standards For H&WCs

Standard A1 - The facility provide comprehensive primary healthcare services.

Standard D3 - The facility has defined and established procedure for clinical record and data
management with progressive use of digital technology.

Standard D4 - The facility has defined and established procedure for hospital transparency and
accountability.

Standard D5 - The facility ensures health promotion and disease prevention activities through community

mobilization.

Standard G2 - The facility has established system for patient and employee satisfaction.
 Phase – III Post Assessment
1. Report submission
2. Honorarium is provided by the State.
3. Share your major findings including best practices and recommendations
during closing meeting.
4. The final status of the assessment not to be shared with facility.

“The Quality of the report reflects the Quality of Assessment”

Score Cards
Score Cards
Score Cards
 Score Card
Area of Reference Score Maximum
Standard Percentage
Concern No Obtained Scores
The facility provides Comprehensive
Service Provision Standard A1 Primary Healthcare Services 50 100 50%
The facility provides drugs and diagnostic
Service Provision Standard A2 services as mandated 4 8 50%
The facility provides information to care
seeker, attendants & community about
Patient Rights Standard B1 available services & their modalities 14 28 50%
Facility ensures services are accessible to care
seekers and visitors including those required
Patient Rights Standard B2 some affirmative action 9 18 50%
Services are delivered in a manner that are
sensitive to gender, religious & cultural needs
and there is no discrimination on account of
Patient Rights Standard B3 economic or social reasons 8 16 50%
The facility maintains privacy, confidentiality &
Patient Rights Standard B4 dignity of patient 6 12 50%
The facility ensures all services are provided
Patient Rights Standard B5 free of cost to its users 5 10 50%
The facility has adequate and safe
infrastructure for delivery of assured services
Standard C1 as per prevalent norms and it provides
Inputs optimal care and comfort to users 17 34 50%
 Surveillance and Re-certification
Certification / recertification would be valid for a period of three years,
subject to validation of compliance to the QA Standards by the SQAC team
every year for subsequent two years.

In the third year, the facility would undergo re-certification assessment by
the National Assessors after successful completion of two surveillance audits
by the SQAC.

Surprise Audit
A total of 10 % facilities are selected for surprise visits who have attained
certificate on/or before current financial year.
IT Solution For management of
Certification Process and Quality
Dashboard
GUNAK APP. : NQAS, KK &
LaQshya Assessments

IT Solution for
certification Process

SaQsham :
Complete IT solution for
Assessment, certification &
Reporting
 HWC(SC) Certification Status
18 17
16

14
Number of health facilities

12 Gujarat
10

8
Assam
6
4
4 Chhattisgarh
2
2 1
0
Andhra Assam Chhattisgarh Gujarat
Pradesh
Lets see which is the next state
States
Thank You!