MUS AN

Ensuring Child Friendly Services in Public Health Facilities

MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA
Ensuring Child Friendly Services in Public Health Facilities

2021

MINISTRY OF HEALTH & FAMILY WELFARE

GOVERNMENT OF INDIA
© 2021, National Health Mission, Ministry of Health & Family Welfare,
Government of India

Reproduction of any excerpts from this document does not require permission from
the publisher so long as it is verbatim, is meant for free distribution and the source is
acknowledged.

ISBN : 978-93-82655-27-5

Ministry of Health & Family Welfare

Government of India
Nirman Bhavan, New Delhi, India

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 List of Contributors
1. Ms. Vandana Gurnani Former AS&MD, MoHFW

2. Shri. Vikas Sheel AS&MD, MoHFW

3. Shri. Vishal Chauhan JS, Policy, MoHFW

4. Dr. P Ashok Babu JS, RCH, MoHFW

5. Dr. Sumita Ghosh Addl Commissioner (Child Health),

MoHFW

6. Maj Gen (Prof) Atul Kotwal ED, NHSRC

7. Shri. Sachin Mittal Director, NHM II

8. Dr. J N Srivastava Advisor, QI, NHSRC

9. Dr. Ashoke Roy Director, RRC-NE

Consultants from MoHFW and NHSRC

10. Dr. Deepika Sharma Senior Consultant - QI, NHSRC

12. Dr. Kapil Joshi Senior Consultant, Newborn Health,

MoHFW

13. Dr. Rashmi Wadhwa Senior Consultant, Maternal Health,

MoHFW

14. Ms. Vinny Arora Consultant – QI, NHSRC

15. Mr. Mandar Randive Consultant - NHM

16. Mr. Vishal Kataria National Technical Consultant, Child

Health

17 Dr. Vaibhav Rastogi Lead Consultant, Child Health

18. Mr. Sharad Singh Lead Consultant, Child Health

19. Mr. Vinit Mishra Senior Consultant, Child Health

20. Ms. Sumitra Dhal Samanta Senior Consultant, Child Health

 List of Contributors
NHSRC & RRC NE Quality Improvement Team
1. Dr. Arvind Srivastava Consultant, QI
2. Dr. Chinmayee Swain Consultant, QI
3. Dr. Shivali Sisodia Consultant, QI
4. Dr. Arpita Agrawal Consultant, QI
5 Mr Gulam Rafey Consultant, QI
6. Dr. Abhay Kumar Consultant, QI
7. Dr. Alisha Dub Consultant, QI
8. Dr. Neeti Sharma Consultant, QI
9. Dr. Sushant Agrawal Consultant, QI
10. Dr. Vineeta Dhankhar External Consultant, QI

11. Mr. Anupjyoti Basistha Consultant, QI, RRC-NE

Others
1. Dr. Ashfaq A Bhat Director, NIPI
2. Dr. Vivek Singh Health Specialist, UNICEF
3. Dr. Deepti Agarwal NPO, WHO
4. Dr. Renu Srivastava IHAT, UP TSU
 Table of Contents Page no.
Introduction 2
Rationale 3
Purpose of the document 4
Target Audience 4
Chapter 1: MusQan Initiative 5
1.1 Goal 5
1.2 Objectives 5
1.3 Key Strategies 6
1.3.1 Strategy 1: Strengthen Clinical Protocols and Management Processes 6
1.3.2 Strategy 2: Ensuring Child Friendly Services 8
1.3.3 Strategy 3: Strengthening Referral and Follow-up Services 8
1.3.4 Strategy 4: Ensuring Provision of Respectful and Dignified Care 8
Chapter 2: Institutional Framework 10
2.1 National Level 11
2.2 State Level 11
2.3 District Level 12
2.4 Facility Level 13
Chapter 3: Operationalisation of MusQan 15
3.1 Scope 16
3.2 MusQan: Rapid Improvement Events 16
3.3 Steps for Implementation of MusQan at Facility 18
3.4 MusQan Certification Process 20
3.5 Certification Protocol 22
3.6 Norms for Certification and Incentivisation under MusQan 23
Chapter 4: Measuring, Improving and Learning 25
Annexures 27
Annexure A: List of Key Performance Indicators (KPI) and their targets 27
Annexure B: MusQan Assessment tool for DH/SDH and CHC 31
Abbreviations 32
Bibliography 34

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 Introduction
India has made considerable progress in improving the survival of newborn and
children. A major reason for this achievement is the massive scale-up of community
and facility-based care that is being provided for newborn and children. A series
of national level initiatives launched by the Government of India (GoI) under its
flagship programmes, such as the National Rural Health Mission (2005), National
Urban Health Mission (2013) and Ayushman Bharat (2018) have contributed to these
improved indicators.

Undoubtedly, these initiatives have had significant impact on newborn and child
mortality and morbidity. The neonatal mortality rate (NMR) which was 44 per 1000
live births in the year 2000 went down to 23 per 1000 live births (SRS 2018).
Similarly, the Under Five Mortality Rate (U5-MR) reduced from 96 to 36 per 1000
during the same period.

Various maternal, newborn and child health initiatives and programmes, such as Janani
Suraksha Yojana (JSY), Janani Shishu Suraksha Karyakram (JSSK), Facility Based
Newborn Care (SNCU), Maternal and Newborn Care Unit (MNCU), strengthening
of Maternal and Child Health (MCH) Wings, First Referral Units (FRU), Dakshata
(for strengthening intrapartum and post-partum care), Surakshit Matritva Aashwasan
(SUMAN) for assured delivery of Maternal and Newborn health-care services),
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) which focuses on quality
antenatal checkup for pregnant women for early identification, preparedness and
management of complications), Infant and Young Child Feeding (IYCF) promotion,
Mothers’ Absolute Affection (MAA Programme) for infant and young child feeding,
Anaemia Mukt Bharat (AMB), Rashtriya Bal Swasthya Karyakram (RBSK) (moving
from child survival to development and protection of children and adolescents of age
group 0-18 years from disease, delay, defect and deficiency) and the Social Awareness
& Action Plan to neutralise Pneumonia Successfully (SAANS) Campaign have been
initiated for having better outcomes for Newborns and Children in the country.

For ensuring continuum of care, post-discharge home-based care and regular follow-
up through the Accredited Social Health Activist (ASHA), Home Based Newborn Care
(HBNC) and Home-Based Care for Young Child (HBYC) have also been strengthened.

The growth and development of children depends on various physiological, nutritional,

social and cultural factors. Often children are prone to complications that may

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require prompt life-saving interventions. There is sufficient evidence to show that it is
necessary to go beyond maximising coverage of essential interventions to accelerate
reduction in childhood mortality and severe morbidity.

Quality of Care (QoC) for paediatric services within the health facilities looks through
the prism of the Donabedian model of health quality. This is a conceptual model that
provides a framework for re-organising health services for delivery of quality care. It
includes availability of required infrastructure, equipment, supplies, adequate human
resources with requisite knowledge, skills and capacity to deliver the committed level
of service, adherence to administrative, clinical and service delivery protocols along
with periodic measurement of system performance.

The National Quality Assurance Standards (NQAS) for District Hospitals, Community
Health Centres (CHC), Primary Health Centres (PHC) and Urban Primary Health
Centres (UPHC), accredited by the International Society for Quality in Healthcare
(ISQua) supports the delivery of quality care within the facilities. A systemic approach
under the NQAS implementation has established a well-structured institutional
framework from the facility level to the national level. There is an in-built system of
State and National level certification of health facilities those exhibiting compliance
to the NQAS norms and sustaining also.

Rationale of Launch of ‘MusQan’

Efforts over the past decade to minimise adverse outcomes for newborns and children
have been directed for increasing access to institutional care. This has resulted in
higher footfalls in health facilities in all regions. With increasing utilisation of health
services, poor quality of care (QoC) in many facilities has become a major roadblock
in the quest to end preventable mortality and morbidity.

The quality of newborn and paediatric services delivered in public health facilities
need to achieve standard benchmarks for accomplishing desired goals and improve
the child health scenario in the country. Moreover, every child needs skilled and
evidence-based care, delivered in a humane and supportive environment. While states
and union territories (UT)s are encouraged to undertake improvements at their own
level, there is urgent need to make health facilities more accessible and favourable for
both newborn and children, including families.

For ensuring child-friendly services in public health facilities, the Ministry of Health
& Family Welfare (MoHFW) is introducing a new quality improvement initiative

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 “MusQan” for the paediatric age group (0-12 years), within the existing National
Quality Assurance Standards (NQAS) framework. MusQan aims to ensure timely,
effective, efficient, safe, person- centred, equitable and integrated quality services in
public health-care facilities.

Purpose of the Document

The document elaborates the Key features of the MusQan initiative, its scope,
strategies, targets, institutional arrangement for operationalisation. It contains Quality
Standards, assessment tools to measure & improve the quality of care provided to
newborn, infant & children in secondary care health facilities.

Target Audience

This document provides guidance to all stakeholders including policymakers,

programme managers at district and state level and service providers on the MusQan
initiative.

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 Chapter 1
MusQan Initiative
MusQan is designed to ensure provision of quality child-friendly facility based services
from birth to children upto 12 years of age. The framework of health system QoC
approach depicted below has been adopted to design the strategies for the MusQan
initiative for paediatric care.1
Figure 1: Framework for Improving Quality of Paediatric Care
HEALTH SYSTEM
1. Evidence-based

Individual and facility level outcomes

practices for illness
management
Provision 2. Actionable
information systems
of Care 3. Functional referral
systems Coverage
4. Participatory of key
practices
Quality and effective
communication Health
of Care 5. Respectful and Child and
Outcomes
rightful care
family
6. Emotional and
Experience psychological support centered
outcomes
of Care 7. Competent,
motivated and
empathetic HR
8. Essential child
friendly physical
resources

1.1 Goal
MusQan aims to ensure provision of quality child-friendly services in public health
facilities to reduce preventable newborn and child morbidity and mortality.
1.2 Objectives
1. To reduce preventable mortality and morbidity among children below 12 years of age.
2. To enhance Quality of Care (QoC) as per National Quality Assurance Standards
(NQAS).
3. To promote adherence to evidence-based practices and standard treatment
guidelines & protocols.
4. To provide child-friendly services to newborn and children in humane and supportive
environment.
1. Adopted from Standards for improving Quality of Maternal & Newborn Care in Health Facilities,
WHO-2016.

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 5. To enhance satisfaction of mother and family, seeking healthcare for their child.
1.3 Key Strategies

A framework has been developed to highlight four key strategies for rollout of
‘MusQan’ along with proposed actions for implementation.

Figure 2: Framework of MusQan Quality Initiative and Key Actions

• Strengthening of early screening, • Enabling accessibility, availability

diagnosis, and intervention services and affordability of services
• Ensuring preparedness of facilities • Developing child-friendly ambience
to manage sick children • Managing co-location of
• Competence and skill services
enhancement of the staff Strengthen Children & • Ensuring availability of
• Promotion, Protection and clinical parent-attendant essential paediatric drugs
Supporting breastfeeding protocols and friendly
management ambience and
processes infrastructure

Provision of Strengthen
respectful and referral and
• Culture of respect in dignified care follow up • Establishing
related to child care services continuum of care
• Trainings for mothers / • Timely and
parents appropriate linkages
• Ensuring empathetic staff • Institutional
behaviour mechanism to conduct
• Family participatory care referral audits

1.3.1 Strategy 1: Strengthen Clinical Protocols and Management Processes

Strengthening the clinical protocols and management processes is the cornerstone for
quality improvement. This can be achieved by taking the following steps:

1. Improvements in clinical and non-clinical processes: Apart from various

structural changes, gap identification in clinical and nonclinical processes will
be undertaken and suitable steps for their improvement completed using rapid
improvement events. Adherence to policies, guidelines and treatment protocols
such as FBNC guidelines, Paediatric care guideline and MAA will be used to
achieve the envisaged results.

2. Strengthening of early screening, diagnosis, and intervention

services: Facilities are encouraged to establish paediatric outpatient department

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 (OPD), inpatient department (IPD) services, emergency triage services, Newborn
Care Units (SNCUs, NBSUs for small and sick newborns) and dedicated District
Early Intervention Centres (DEIC). The facility must ensure the screening of
newborns, and children requiring interventions in term of further investigation
and treatment will be referred to next higher facility. Simultaneously, it will be
important for the facility to strengthen its capability to provide the standard level
of mandated care.

3. Ensuring competency and skill enhancement: The competency of

the clinical and paramedical staff will be evaluated at regular intervals. Based
on the identified gaps, refresher trainings and skill stations will be provided
for continuous skill enhancement. Onsite mentoring support, measurement,
learning and sharing for compliance will contribute towards continued quality
improvement.

4. Promotion, protection and supporting breastfeeding and nutritional

counselling: These facilities are encouraged to ensure promotion, protection
and support to breastfeeding and availability of nutritional counselling.
Figure 3: Strategies for Transforming the Facility to a Child-Friendly Facility

IEC corner with Separate Child Zone: Safe

all relevant pharmacy or Strengthening toys and swings
information dedicated drug the Follow up in clean and
dedicated to dispensing services healthy
child care counter environment

Separate Co-located
counter for departments
registration and services

MusQan Certified Facility

Promotion of
Strengthening
immunization
the referral
and IYCF Calm ambience Food and shelter facilities
practices of departments ; facility for
cartoon, animals mothers
and flowers
engaged in care
displayed on
walls, linen etc. of sick baby

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 1.3.2 Strategy 2: Ensuring Child Friendly Services

Under MusQan, the focus for ensuring child-friendly services will be on the following:

1. Ensuring dedicated services for newborns and children: Dedicated child-

care services such as an OPD including growth, development, and immunization
clinic, IYCF counselling room, District Early Intervention Centre (DEIC),
breastfeeding corner, separate collection facility for laboratory investigations,
registration/admission counters, pharmacy counters, SNCU/NBSU/MNCU,
NRC, CLMC, and KMC room, etc will need to be planned together. While
planning, care would be taken to co-locate these facilities in proximity to maternal
health departments (labour, deliver and recovery room (LDR) complex, maternal
OT/HDU, labour room, postnatal ward, etc.).

2. Developing a child-friendly ambience: Efforts would be undertaken to

ensure that all paediatric departments (outpatient and inpatient) are visually
appealing for children. This can be done by using soothing colours, painting the
walls with familiar cartoon characters and themes that depict animals, flowers,
water bodies, etc. Bright coloured linen (bed sheets/ patient clothes) will brighten
the areas and a special child zone with age-appropriate toys, swings and visually
appealing ambience must be created.

3. Ensuring availability of paediatric drugs and formulations: Availability

and accessibility to all paediatric formulations and dosage of essential medicines
as per the norms of the Indian Public Health Standards (IPHS) Guidelines for
district hospitals (DH)/ sub-district hospital (SDH)/community health centres
(CHC) need to be ensured.

1.3.3 Strategy 3: Strengthening of Referral and Follow-up Services

For ensuring continuum of care, it is important to establish referral criteria and

functional linkages for two-way referrals. MusQan emphasises development of a
referral cum follow-up mechanism that conducts a referral audit to identify gaps and
thereafter take-up further improvement actions.

1.3.4 Strategy 4: Ensuring Provision of Respectful and Dignified Care

It is essential to involve the mother and family in the care of a sick newborn/child.
Family engagement in the care has been proven to be beneficial for both child and
mother. Facilities that ensure implementation of family-centric care must include the
following components:

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1. Ensure food and shelter for mothers: Facilities must plan to provide clean
and safe accommodation with basic amenities like drinking water, toilet and
bathing facilities, comfortable seating, sleeping arrangements, regular diet, etc.
for mothers and accompanying family members.

2. Regular trainings: Mother and family members engaged in the care need to
be trained on infection prevention, feeding (breastfeeding or assisted feeding),
KMC, family -participatory care, etc. A designated room/area for training with
proper seating arrangement should be ensured as part of the initiative.

3. Basic amenities: A dedicated waiting area for parent and attendant should
be made available while the sick newborn receives the care in a department.
The outpatient department should have an electronic calling system to facilitate
orderliness in the OPD. Also, availability of child-friendly toilets, provision of
drinking water and having a safe and calm breastfeeding corner for mothers in
the departments must be part of the infrastructure and amenities that go into
making child-safety a priority at the facility.

4. Empathetic staff behaviour: The facility must ensure that the staff in
paediatric care departments and service stations is empathetic and courteous.
This will go a long way in giving confidence to the family and community to seek
care at the facility, and enhancing their experience and satisfaction.

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 Chapter 2
Institutional Framework
Under the NHM, States have been supported in creating an institutional framework
for quality initiatives. Under the ambit of National Quality Assurance Programme,
implementation of all quality initiatives are spearheaded by the Central Quality
Supervisory Committee (CQSC) at the National level. There are State Quality
Assurance Committees (SQAC) which have their execution arm, namely the State
Quality Assurance Units (SQAU) at the state level. At the District level, there are
District Quality Assurance Committees (DQAC) along with its execution arm, namely
the District Quality Assurance Units (DQAU). At the facilities’ level, there are Quality
Teams and at the department level, Quality circles are constituted. These committees,
teams/circles support the implementation of various quality initiative viz. NQAS,
Kayakalp, LaQshya, etc.

The same institutional framework will be used to support the implementation of

the MusQan initiative. The SQAU, DQAU, Quality teams/ circles will work in close
coordination with the Child Health division or equivalent at all levels

Figure 4: MusQan Institutional Framework

Central Quality Supervisory Committee

State Quality Assurance Committee & Units

District Quality Assurance Committee & Units

Quality-Teams

Quality Circles

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2.1 National level

The primary role of the Central Quality Supervisory Committee (CQSC) is to provide
overall guidance, monitoring and mentoring of quality assurance efforts under various
programmes/initiatives. The Child Health Division at the MoHFW and QI Division
NHSRC have been jointly mandated to provide overall guidance and implement the
roll-out of MusQan. Oversight function of the ‘MusQan’ implementation and its
monitoring and review will be performed by the CQSC.

Roles & Responsibilities of CQSC

™ Dissemination of guidelines, standards and assessment tools to the states.

™ Ensure orientation, capacity building and continuous support for MusQan’s
implementation.
™ Conduct periodic visits to the states and provide mentoring support to a
sample of the health facilities.
™ Recommend mid-course correction whenever required.
™ Ensure a system for reporting and sharing States’ achievements in terms of
indicator/target improvement of services.
™ Handhold Quality Assurance committees & units at the State level.
™ Develop monitoring & evaluation protocols and ensure their implementation

2.2 State Level

State Quality Assurance Committees (SQACs) are functional in all states/UTs. The
SQAC comprises of ACS/ Principal Secretary, NHM Mission Director, Director
of Family Welfare/Directorate of Health Services (DHS)/Director of Public Health
or Additional/Joint Director of Family Welfare or equivalent and several other
representatives as elaborated in the ‘Operational Guidelines for Quality Assurance
in Public Health-care Facilities’. The committee’s main responsibility is to oversee
quality assurance activities in the state in accordance with National & State
guidelines. To ensure seamless implementation of MusQan, the State Child Health
Division will support the SQAU under the guidance of SQAC.

Moreover, the SQAU and State child health team will be jointly responsible for
undertaking assessments, extending implementation support under the initiative
including capacity building, resource allocation and state level certification of
targeted facilities.

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 Roles & Responsibilities at the State Level
™ Ensure availability of required technical resources, such as programme
guidelines, standard treatment protocols, Standard Operating Procedures
(SOPs), etc and its effective dissemination.
™ Capacity Building of Quality team and Department Quality circles in
implementation of guidelines, SOPs and protocols
™ Ensure conduct of baseline assessment of targeted health facilities within
stipulated timelines, and measurement of the key performance indicators
(Please refer relevant NQAS Assessors’ Guidebook for the assessment tool
and Annexure ‘B’ of ‘MusQan’ Guidelines).
™ Mobilise state support, including provision of human resources, drugs,
equipment, finance and other inputs through the State programme
implementation plan (PIP).
™ Develop resource materials/tools for competency evaluation, and organise
trainings for skill enhancement of both clinical and non-clinical staff
™ Provide onsite support to continuously underperforming facilities
™ Provide inputs for improvement in guidelines and ensure implementation of
recommended mid-course corrections.
™ Organise and undertake state-level assessments and provide support for the
national certification.
™ Ensure regular monitoring and validation of indicators at the state level. Also
support reporting of indicators at the national level.

2.3 District Level

District Quality Assurance Units (DQAUs) are the functional arm of District
Quality Assurance Committees in the States/UTs. The District Collector/Deputy
Commissioner, Chief Medical Officer (CMO)/Deputy Director/ Chief District
Medical Officer (CDMO)/ Civil Surgeon/Chief Medical Health Officer (CMHO) or
equivalent, District Family Welfare Officer (DFWO)/ Reproductive Child Health
Officer (RCHO)/Additional Chief Medical Officer (ACMO) or equivalent and various
other representatives as given in the ‘Operational Guidelines for Quality Assurance
in Public Health-care Facilities’ are the members of the DQAU. The DQAU’s main
responsibility is to oversee quality assurance activities across the district in accordance
with National & State guidelines.

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To ensure seamless implementation of MusQan, the district level child health team
and DQAU will be jointly responsible for assessments and validation of indicators.

Roles & Responsibilities at the District Level

™ Mentoring and handholding of the facilities or department level quality circles
for implementing MusQan.
™ Capacity building of facility staff for undertaking assessments (internal/peer),
generating scores, measuring target indicators, progression on quality and
clinical care practices, gaps using improvement cycles and reporting scores
and targets.
™ Ensure conduct of baseline assessment of targeted health facilities within
stipulated timelines, and measurement of the key performance indicators
(Please refer relevant NQAS Assessors’ Guidebook for the assessment tool
and Annexure ‘B’ of ‘MusQan’ Guidelines).
™ Competence assessment of the staff deputed for newborn and childcare in
various departments such as the SNCU, NBSU, OPD, Paediatric ward and
NRC.
™ Conduct assessment and prepare facilities for state and national assessments
and certification.
™ Ensure regular reporting of indicators to the state and validate reported data
at regular intervals or as and when required.
™ Provide onsite support to the regularly low/ underperforming facilities.

2.4 Facility Level

Facility level Quality teams are functional in all public health-care facilities. The
team comprises of Medical Superintendent or facility in-charge, Hospital Manager
(wherever available), nursing in-charge and representative from other functional and
related departments. The primary responsibility of the quality team is to oversee
quality assurance activities across the facility.

Department level Quality Circles: To ensure implementation of the MusQan

initiative at the facility/department level, Quality Circles need to be constituted in
each of the targeted departments. These Quality Circles can serve as an informal
group of staff designated to improve services dedicated for newborn and child health.
Each Quality Circle comprises of Medical officer/Paediatrician Incharge of relevant

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 department such Paediatric ward, SNCU, NBSU, Paediatric OPD, Immunisation
clinic. Nursing professionals of such departments would also be a part of department’s
quality circle, which will also co-opt other staff such as lactation counsellor, lab tech.,
pharmacist, housekeeping supervisor, etc.

Roles & Responsibilities at the Facility Level

™ Ensuring adherence to protocols and key clinical practices for newborn and
childcare, IYCF, guidelines etc.
™ Conduct regular assessments using NQAS checklists for MusQan. Collect
and analyse indicators/targets.
™ Prioritisation and action planning for traversing the gaps as per current
recommendations and best practices.
™ Ensure achievement of indicators using rapid improvement events
approaches.
™ The quality circles shall undertake various rapid improvement events for
improving outcome indicators leading to the achievement of defined targets.

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 Chapter 3
Operationalisation of MusQan
The operational framework for MusQan encompasses a systematic approach where
the facilities are supported by state and district level teams. Figure 5 depicts the key
activities to be undertaken by the facility. These activities are supported and validated
by the district and state Quality and Child Health teams those include identification of
training needs of clinical and para-clinical staff, capacity building, technical support for
process improvements, availability of resources, data collection and regular validation of
QoC indicators. The roles of the state and district level teams are outlined in ‘Chapter
2: Organizational Framework’.

Figure 5: MusQan - Operational Framework

MusQan Initiative : Operational Framework defining the role of state, district & facilities

Regular Mentoring & Monitoring

1. Establish Quality Circle at each department

2. Conduct Assessment — using NOAS Standards &

measure Performance indicators

3. Identify Gaps & perform Root Cause Analysis

4. Plan interventions & RIE

Ensure availability of Resources

Plan
Capacity Building

5.
Undertake
Act Do
improvement
Activities

Check

6. Traverse the gaps in Timebound manner

7. Achieve MusQan Certification & Targets

8. Sustenance

Continuous Measurement of Quality Indicators

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 3.1 Scope

Public health facilities and departments mentioned in Table 1 below are to be included
under the ‘MusQan’ initiative.

Table 1: Departments to be Included Under MusQan

District Hospitals Sub-District All functional All other facilities

Hospitals (SDH) FRU CHCs (LaQshya certified,
Medical Colleges)
4 Departments 3 Departments 2 Departments 4 Departments
‰ Paediatric OPD ‰ Paediatric OPD ‰ Paediatric OPD ‰ Paediatric OPD
‰ Paediatric Ward ‰ Paediatric Ward ‰ NBSU/ SNCU ‰ Paediatric Ward
‰ SNCU ‰ SNCU/ NBSU (if available) ‰ SNCU
‰ Nutrition Rehabilita- ‰ Nutrition Rehabil-
tion Centre itation Centre

Note:

District hospital and equivalent facilities may take exemption for the NRC
assessment, if NRC is not established in the State.

At the CHC level, it is mandatory to include both OPD & NBSU for MusQan
external assessments.2

See annexure for #NQAS checklists for paediatric OPD (DH& CHC),
paediatric ward, SNCU, NBSU and NRC.

3.2 MusQan: Rapid Improvement Events

Through MusQan, a conscious effort is being made to make newborn and childcare
services more easily accessible and friendly. To do so, the targeted facilities will
undertake following rapid improvement events. Each event will be of two months
and its progress will be rigorously mentored by the state and district-level teams.

Suggested list of Rapid Improvement (RI) Events:

1. Ensuring timely initiation of emergency treatment of sick newborns and children

and making timely referrals.
2. In the states, if NRCs are established at CHCs, same would be included in MusQan initiative
of such CHCs.

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2. Improving breastfeeding, hypothermia (temperature maintenance), KMC
practices in eligible neonates and developmental supportive care.

3. Ensuring improvement in infection prevention practices and reduction in Hospital

Acquired Infections (HAIs)

4. Improving documentation and record management practices. This RI event must

include timely recording and updation of records and data.

5. Ensuring implementation of clinical protocols such as rational use of antibiotics,

oxygen, fluids, etc.

6. Providing respectful care and improving engagement of mothers and families in

newborn care and enhancing parents’ and families’ satisfaction with the care,
given in the facilities.

These RI events will support the quality circles to reach the target population. Apart
from these suggested RI events, facilities are encouraged to consider and include in
RI events any other critical issue pertaining to their facilities. For implementation of
the suggested RI events, the facilities will undertake the following steps which will aid
them to achieve MusQan certification.

Figure 6: MusQan – Rapid Improvement events

1
ETAT &
Referral
Mechanism

6 KMC & 2
Respectful Development
and Support
Participatory Care
Care
Rapid
Improvement
Events of
MusQan
Clinical Infection
Protocols prevention
5 3
Record
Keeping

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 3.3 Steps for Implementation of MusQan at Facility-level

1. Constituting Quality Teams and Quality Circles at facility and

department level, respectively: A team consisting of motivated and
committed staff of all cadre can contribute immensely to the efficient running of
a facility. By constituting departmental quality circles, as an extension of facility
quality teams , the level of operational efficiency and monitoring of progress at
regular intervals will be enhanced considerably.

2. Assessing Quality of Care: The Quality team, will undertake the assessment
of the departments utilising MusQan checklists. Simultaneously departmental
quality circles will capture the indicators (departmental as well target indicators
under the ‘MusQan’) and parent/family satisfaction (manually or through Mera
Aspataal3). The team will also conduct and analyse information accumulated
through audits vis-à-vis prescriptions, clinical and death audits. Quality tools will
be utilised to detect bottlenecks/trends in existing parameters.

3. Identifying critical gaps: The MusQan quality tools (checklists) along with results
of target indicators, audits (medical, death, prescription), competency evaluation,
etc. will help the facility to identify gaps at the structural and process level. Each of
these will be classified as critical and non-critical after due analysis.

4. Planning interventions & Rapid Improvement Events: Non-critical gaps

are easy to manage and mostly require direct action to close them. However, critical
gaps require further scoping and application of scientific methodology i.e., Plan,
Do, Check, Act (PDCA) to attain the improvement(s). Facilities are encouraged
to plan and undertake rapid improvement events (RI events). A suggestive list of
improvement events is given in ‘MusQan: Rapid Improvement events’ in Section II.
Apart from the suggested list, facilities can undertake other RI events pertaining to
critical issues at local level.

5. Undertaking improvement activities: Once the facility/department identifies

the critical gaps based on their assessments, the facility level quality team or
departmental quality circle is expected to undertake specific steps for improvement/
closure of identified gaps. The improvements steps are outlined below:

3. (My Hospital) is a MoHFW, Government of India (GoI) initiative to capture patient

feedback on services received from both public and empanelled private health facilities. It works
through multiple communication channels, including Short Message Service (SMS), Outbound
Dialling (OBD), a mobile application and a web portal.

18
 a. Setting-up SMART objectives
b. Undertaking Root Cause Analysis: The team/circle will brainstorm
and analyse each gap using tools like Fishbone diagram, why-why analysis,
etc. The in-depth gap analysis will help the team not only to understand the
problem but also develop specific change ideas.
c. Developing change ideas: The team/circle will brainstorm and come
up with specific ‘change’ ideas. These ideas should be implemented after
assessing their effectiveness.
d. Setting up the measuring indicators: To assess whether a change idea
has impacted the main objective or not, the team must measure and analyse
supportive indicators. Run Charts will be useful to analyse the effectiveness
of the change idea over the selected period.
e. Testing ideas through the PDCA cycle: When the team has certain
change ideas, the testing of these ideas becomes important. This is done
using the Plan- Do – Check – Act4 approach. Multiple change ideas are
carried out through the PDCA approach to understand its impact and
capability to achieve objectives. Based on its analyses, the idea will be either
accepted ‘as-it-is’ in the system or require certain tweaking for acceptance.
The same will be discarded, if it has any negative impact or is found to be
unsustainable.
f. Mentoring: The identified clinical/technical gaps should be traversed
with the support of national expert or State expert team involving medical
colleges, Centres of Excellence, State Resource Centres, etc.
6. Traversing gaps in a time-bound manner: Based on the Gap analysis,
facilities will prepare a time-bound action plan (for critical and noncritical
activities) which will be reviewed in Quality circle/ Quality team meetings and by
the district/ state teams providing handholding support to the facility. There will
be resource requirements for organising training, assessment, mobility support,
and other incidental expenses. Therefore, the state may allocate budgets which
may be requested in relevant financial heads through the NHM PIPs.
7. Certification: Once the facility has substantially improved and is able to achieve
at least 70% or more in NQAS assessment tools, it can apply for the State &
National certification. The criteria and process of certification are explained in
Section IV.
4. In certain literature, PDCA has been referred as PDSA, i.e., Plan – Do – Study – Act.

19
 8. Surveillance: MusQan facilities achieving the NQAS certification of selected
departments shall be assessed on yearly basis to ensure sustenance and further
facility improvement.

Figure 7: Quality Circle for Achieving MusQan Certification

Constitute A Quality circle

Capture, analyse and Capture, and analyse Conduct Audits

Conduct regular monitor monthly Patients’ satisfaction through Meet the Legal (Prescription, Prepare policies
assessment using indicators and target Mera Aspataal (if not linked and Statutory Clinical, Death and SOPS
MusQan checklists indicators conduct monthly surveys) requirements etc.)

Gaps Identification

Surveillance

Simple/non critical Critical gaps requiring

gaps requiring action immediate actions

Take action to Use Scientific approach

close the gap/s to analyse the situation Achieve MusQan
and identify the root Certification
cause issues

Undertake improvement
Gaps closed
activities (PDCA)

3.4 MusQan Certification Process

All the health facilities, which exhibit substantial improvement in their scores and
indicators and are State level MusQan certified are eligible for the National MusQan
certification. Such assessments would be undertaken by the NHSRC empanelled
NQAS assessors. Process of empanelment of NQAS assessors is given in the
‘Operation Guidelines of Quality Assurance in Public Health Facilities.’

20
Steps of the Certification Process

a. District Quality Assurance unit/ facility level quality team will inform the State
Quality Assurance unit (SQAU) about its readiness for external assessments. The
SQAU would verify NQAS scores of applicable departments and supporting
documents including analysis of patient satisfaction scores and initiate the
process of state level certification. Details of the state level certification process
have been provided in the ‘Guidelines for Certification of Public Health Facilities
based on National Quality Assurance Standards’.5

b. On meeting all the criteria for state certification, the facility would be declared as
‘State level MusQan Certified’.

c. Subsequently, the SQAC would send the application for the quality certification
along with the requisite documents to Director NHM, MoHFW requesting for the
National assessment. Copies of the application will be shared with the Quality
Division NHSRC. The application and supporting documents would undergo
scrutiny before deputing a team of assessors for the certification, as per NQAS
certification protocol.

d. The Certification Unit shall coordinate the assessment process. After collating
findings of field assessment reports, submitted by the National Assessors, the
unit will make appropriate recommendations to MoHFW regarding certification
status.

e. The facilities with noncompliance in certification criteria would be informed by

the Quality Division about the observed gaps. These facilities will be expected to
undertake concerted efforts for the improvement and gap closure.

f. Quality certification of MusQan facilities will remain valid for a period of three
years. On completion of first year and second year after the national certification,
the state would organise surveillance assessment. Its compliance report will be
submitted to the certification unit and child health division.

g. In the third year, MusQan facilities would be reassessed by a team of National

assessors. In addition, National Health System Resource Centre (NHSRC) and
MoHFW may also undertake surprise assessments for ascertaining the sustenance
of improvement activities.
5. Guidelines for Certification of Public Health Facilities based on NQAS, National Health Systems
Resource Centre, http://qi.nhsrcindia.org/cms-detail/external-assessor-manual/MTEx.

21
 Figure 8: National Certification Process

Issue of Certificate & Incentives

Submission of Recommendation
Assessement Report for Certification

Assessement by Processing of Application and Application to Director,

External Assessor Appointment of Assessors NHM, MoHFW, GoI

70%

Internal Assessment and Recommendation for State Level Assessment &

Quality Improvement Certification Certificaton

3.5 Certification Protocol

For ensuring implementation of MusQan, one of the key action point is to achieve
certification as per the NQAS assessment tools.

™ It is mandatory for the District Hospitals and equivalent facilities to include SNCU,
Paediatric ward and Paediatric OPD in MusQan assessment and certification.
Facilities may take exemption for the NRC assessment, wherever NRC has not
been established.

™ For functional FRU-CHCs, assessment of NBSU and Paediatric OPD would be

mandatory.

™ Once a facility meets all the NQAS certification criteria, it can apply for the
state-level certification. After obtaining the state-level certification, it can apply
for national-level certification.

™ External assessors, empanelled with the NHSRC, will conduct the external
assessment for the certification. Procedure for certification shall remain the same
as currently being followed under NQAS.

22
Figure 9: Steps for Assessment and Certification

Undertaking
Meet the Meet the
Assessment
Internal State State National National
using
Assessment Certification Certification Certification Certification
MusQan
Criteria Criteria
Checklist

Table 2: Details of State & National Certification

State Certification National Certification

• Responsibility of State/SQAU • Responsibility of CQSC/NHSRC (Following

SQAU have applied for external assessment)
• Validity is for one year
Facility shall apply for National • Validity is for three years
•
certification within one year • After national certification, the facility will
of attaining State Certification undergo surveillance audit by SQAC during
the 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.

3.6 Norms for Certification and Incentivisation under MusQan

1. Criteria for becoming a MusQan certified facility

For a facility to become eligible for achieving the status of ‘MusQan certified’, it
needs to meet the following criteria:

a) NQAS Certification of SNCU/NBSU, Paediatric Ward, OPD and NRC as

per protocol under the NQAS.

b) Attainment of at least 75% or more facility-level indicators (as given in

Annexure ‘A’) and its verification by National Assessors at the time of
external assessment and by SQAC at the time of surveillance.

c) 80% of the patient families are either satisfied or highly satisfied (or Equivalent
score > 3.5 on the Likert scale). MusQan facilities should endeavour to

23
 introduce the Mera-Aspataal based feedback system. As an interim measure,
feedback may be taken manually from targeted departments. The National
Assessors shall evaluate the component at the time of external assessment.

2. Incentivisation

™ District Hospital and FRU- CHCs could be given incentives of Rs. 3 lakh and
2 lakhs (for each department) respectively on achieving national certification
and compliance to facility-level targets.

™ 25% of this amount may be used for staff incentivisation and 75% for
branding activities like display of logo on signages, and for undertaking
facility improvement activities, for which funds from other sources are not
available.

™ Incentives will be awarded for three consecutive years subject to submission

of surveillance report by the state to QI division NHSRC and Child Health
division of MoHFW. Surveillance will be done to ascertain status of the
NQAS scores, sustenance or further improvement of targets and parent-
attendant group satisfaction scores.

24
 Chapter 4
Measuring, Improving and Learning
One of the key objectives of the MusQan initiative is to inculcate the practice of
continuous monitoring of quality of healthcare and to make proactive efforts to assure
and improve further. The initiative will enable the facility to understand methods
of measurement of services and clinical quality given to patients. Also, the efforts
and change ideas followed in one department will be shared with others in monthly
quality team meetings.

The MusQan initiative is linked with 21 Key Performance Indicators (KPIs), which
need to be measured by the facility every month. Additionally, there are 3 other
indicators, as given in the Table 4 of the Annexure ‘A. After the launch of MusQan, the
state and district teams will make sure that these baseline indicators are appropriately
recorded, validated and shared with the national team. The facility will continue to
work to further improve these indicators while striving to achieve the targets given in
Table 3 (Annexure -A)

Out of 24 KPIs, the progress on 21 indicators will be recorded on monthly basis

while three indicators serve as essential information for which the information can
be collected and updated at least biannually. The list of 24 indicators is given as Table
3 and Table 4 (Annexure -A)

All the indicators are monitored regularly at state, district and facility level, as required.
Further, the change ideas are tested and applied for improvement. Facilities need to
ensure that at least 75% of these indicators meet the target which have been defined
in Annexure ‘A’. NQAS encourages quality circles to identify indicators (apart from
these 21 compulsory indicators), meeting the situational requirements and bring out
the desired change

25
 Figure 10: Diagram Depicting Measuring, Monitoring & Learning Through
KPIs

Measuring

Collect the Baseline

Indicators (as per KPIs)

Identify the Gaps

Learning

Learning
against Targets

Set up Objective & Related Regular Monitoring &

Measuring Indicators Sustenance

Develop the Change Ideas &

Testing the Ideas
Implement the Accepted
Act
A P
Plan
Ideas
C D
Check Do

Monitoring

26
 Annexure A
List of Key Performance Indicators (KPI) and their targets

Table 3: List of KPIs and Targets

S.N. Key Performance Target DH CHC Remarks

Indicator
1 Average waiting More than 90% cases Separately for SNCU/
time for the initial are seen within 10 NBSU
assessment by minutes of arrival in the
physician facility
2 Patient satisfaction 80% of parent-attendants Separately for SNCU/
score (Parent – are either satisfied NBSU, Paediatric OPD,
Attendant) or highly satisfied (or Paediatric Ward and NRC
Equivalent score > 3.5
on Likert scale)
3 Follow-up rate At least 50% discharged Separately for SNCU/
patients report for NBSU, Paediatric OPD,
facility follow-up within Paediatric Ward and NRC
one month
4 Percentage of At least 75% and above NBSU- More than 1800
low-birth-weight success rate gram infants with no
babies successfully complications
discharged after SNCU- Less than 1800
treatment from grams infants
SNCU /NBSU
5 Referral rate 20% reduction from the Separately for SNCU/
baseline NBSU and Paediatric Ward
6 Mortality rate 20% reduction from the Separately for SNCU/
baseline NBSU and Paediatric Ward
7 LAMA rate 20% reduction from the Separately for SNCU/
baseline NBSU and Paediatric Ward
8 Enhanced skills of At least 80% or more Only for cases which are
mothers/families for mothers/families are successfully discharged
providing optimal trained on Family from the facility
care to sick and small Participatory Care (FPC)
newborns

27
 S.N. Key Performance Target DH CHC Remarks
Indicator
9 Percentage of sick At least 80% or more Only for cases which are
newborn received medically justified
only breast milk
(either of mother's
own or DHM)
throughout their stay
at facility
10 Percentage of At least 80% or more
babies on exclusive
breastfeeding at the
time of discharge
from SNCU/NBSU
11 Median uninterrupted At least 1 hr or more Only for cases which are
time given for medically justified as per
Kangaroo Mother GoI KMC guideline.
Care (KMC)
12 Number of stock-out No stock out Separately for SNCU/
days for essential NBSU, Paediatric OPD,
paediatric drugs Paediatric ward and NRC
• Formula
– No. of stock
out days for essential
commodities X 100/
Total no. of commodities
X days in a month
13 Hospital acquired Less than 5% or at least
infection rate in reduction of 30% from
SNCU/NBSU the baseline
14 Number of non- 20% reduction from the Separately for SNCU/
functional equipment baseline NBSU and Paediatric
days Ward
15 Rational use of 20% reduction from the Separately for SNCU/
antibiotics baseline NBSU and Paediatric
Ward

28
S.N. Key Performance Target DH CHC Remarks
Indicator
16 Average time lag 20% reduction from the Within 48 hrs
between admission baseline
and ticket uploading
online/filling of
admission ticket
17 Average door-to-drug At least 30% reduction For Paediatric OPD
time in the health from baseline
facility
18 Percentage of mothers At least in 80% cases Only for cases which are
receiving IYCF successfully discharged
counselling availing from the facility
care in the OPD
19 Turnaround time in At least 30% reduction For Paediatric OPD
diagnostic services from baseline SNCU/NBSU and
a. Radiology Paediatric Ward

b. Laboratory
20 Case Fatality Rate
(a) Pneumonia At least 10% reduction For Paediatric OPD SNCU
from baseline and Paediatric Ward
(b) Diarrhoea At least 10% reduction For Paediatric OPD SNCU
from baseline and Paediatric Ward
21 Child Safety Audit * 100% achievement Child Safety Audit includes
of conducting the physical safety & security,
quarterly Child Safety environmental safety,
Audit in last 6 months medication & medical
devices-related safety, HAI
etc.
The audit will be
conducted on a quarterly
basis separately in the
OPD, Paediatric ward,
SNCU / NBSU and NRC
*Child safety Audit includes Physical safety & security, environmental safety, medication &
medical devices-related safety, Healthcare-associated infections, etc.

29
 Table 4: Essential Information

S. Indicator Target DH CHC Status

No
1 Bed: Nurse Ratio Target to reach 4:1(SNCU)
/4:1 (NBSU)
2 Percentage of doctors Target 100%
and staff nurses trained
in FBNC and observer-
ship training
3 Facility conducts Records to be maintained
newborn and child death for root cause analysis and
audit and ‘near-miss’ on actions taken thereafter
monthly basis

30
 Annexure B
MusQan Assessment Tools for DH/SDH and CHC

MusQan National Quality Assurance Standards and Assessment Tools for District
Hospitals include 4 departments i.e. Paediatric OPD, Paediatric Ward, Special Newborn
Care Unit (SNCU) and Nutrition Rehabilitation Centre (NRC).

While MusQan National Quality Assurance Standards and Assessment Tools for
Community Health Centres (First Referral Unit) include 2 departments i.e. Paediatric
OPD and Newborn Stabilization Unit (NBSU).

For further details, please refer Chapter 3 of this guidebook.

The workable excel sheets and print ready version of the checklists for District Hospitals
and Community Health Centres can be downloaded from https://nhsrcindia.org/

31
 Abbreviations
AMB Anaemia Mukt Bharat

CHC Community Health Centre

CQSC Central Quality Supervisory Committee

CLMC Comprehensive Lactation Management Centre

DEIC District Early Intervention Centre

DH District Hospital

DQAC District Quality Assurance Committee

DQT District Quality Team

FRU First Referral Unit

HAI Hospital Acquired Infection

HBNC Home-Based Newborn Care

HBYC Home-Based Care for Young Child

ISQua International Society for Quality in Healthcare

IYCF Infant and Young Child Feeding

JSSK Janani Shishu Suraksha Karyakram

JSY Janani Suraksha Yojana

KMC Kangaroo Mother Care

KPI Key Performance Indicator

LAMA Left Against Medical Advice

MCH Maternal and Child Health

MNCU Mother and Newborn Care Unit

32
NBSU Newborn Stabilisation Unit

NQAS National Quality Assurance Standards

NRC Nutrition Rehabilitation Centre

OPD Outpatient Department

OT Operation Theatre

PDCA Plan-Do-Check-Act

PMSMA Pradhan Mantri Surakshit Matritva Abhiyan

QoC Quality of Care

RBSK Rashtriya Bal Swasthya Karyakram

SDH Sub-Divisional Hospital

SNCU Special Newborn Care Unit

SAANS Social Awareness & Action Plan to Neutralise Pneumonia Successfully Campaign

SOP Standard Operating Procedure

SQAC State Quality Assurance Committee

SQAU State Quality Assurance Unit

SUMAN Surakshit Matritva Aashwasan

SRS Sample Registration System

WHO World Health Organization

33
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36
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA