CLINICAL CARE MANUAL FOR MIDWIVES

QUALITY ASSURANCE PACKAGE FOR MIDWIVES

Rev. Primitivo N. Fostanes, D.DDeputy Program Manager, CMSUQAP Orientation & QMT Planning Session

QUALITY ASSURANCE PACKAGE FOR MIDWIVESa collaboration betweenPrivate Sector Mobilization for Family Health Phase 2(PRISM2)BACKGROUND: 2007 DOH-HHRDB and PRISM1: recognized need for quality standards of care for midwives (DOH: midwives to the barrios/PRISM1 QMT for PPMs) 2010 DOH-NCDPC and PRISM2*: worked on revisions to align with BEmONC for midwives, EINC, AMTSL and other updates2012 DOH Secretarys Message/Foreword

Value: standardizes professional midwifery practice

General ObjectivesTo ensure that midwives, in both public and private practice, adhere to quality standards in the provision of MNCHN (Maternal, Neonatal and Child Health and Nutrition) services, either in government birthing facilities or in private clinics, throughout the country.To provide continuing quality improvement by setting standards of quality care and by providing an opportunity for midwives to conduct their own technical self-assessment, followed by technical monitoring and assistance by their supervisors.

Quality Assurance Package for Midwives (A Toolkit for Practicing Professional Midwives)5 Booklets : 1 Introduction to the Manuals and 4 main sections:Clinical Care for MidwivesManagementSpecial ProceduresClinical Operation StandardsStandard Operating ProceduresStandard Clinic FormsMonitoring Tool for Practicing MidwivesMidwives PortionSupervisors PortionGuide to Organizing and Managing the Conduct of Clinical Case Conference for MidwivesSection 1

CLINICAL CARE MANUAL FOR MIDWIVES

6Section 1: Clinical Care Manual for Midwives Part 1 : Management guidelines in the management of the different phases of pregnancy, labor and delivery (prenatal, intrapartum, postpartum and newborn care)

Part 2 : Special Procedures a review of the correct steps in performing some basic and special procedures Special procedures that ONLY previously trained midwives are expected to performPart 1: Standard Operating Proceduresguidelines for the professional midwife as she performs various clinic tasks such as outpatient consultations, admissions, infection prevention practices, referral systems, waste management

Part 2: Standard Clinic Forms different forms for recording patients data

Section 2: The Clinic Operation Standards Manual Part 1: Midwife Portion

the self-assessment portion which determines the midwifes perspective of the level of quality of MCH/FP services she provides, and

the action plan that addresses the things that need to be improved as identified in the self-assessment portion

Section 3: Monitoring Tool for Practicing MidwivesMidwife Self-Assessment Tool/ Supervisors Monitoring ToolSix (6) components that can be assessed:

Facility Technical CompetenceContinuity of CareManagementCommunity InvolvementBusiness Practices (for private MWs)

Six (6) ComponentsComponent 1: Physical Environment This refers to the facilitys ability to provide a safe environment for health care and examines equipment, supplies, and medicines in facilities and the condition of the clinics infrastructure.Component 2 Technical Competence: Examines providers performance and determine if it meets acceptable standards. These include performance in counseling, infection prevention (IP), antenatal care, immediate newborn care, postpartum care, family planning, and immunization.Component 3 - Continuity of Care: Examines functional referral systems when care is needed outside of what you can do in your clinic. It includes knowing when and where to refer, procedures for referral, use of referral forms and client follow-up.

Component 4 - Management: Refers to the provider capacity to plan, organize, implement, and maintain effective health delivery services. It includes utilizing data for decision-making and proper tracking of finances and supplies.Component 5 Marketing: Refers to providers knowledge of the people in their communities and how effectively they market their services to maintain their clients and attract new ones.Component 6 Business Practices: Examines providers goals, financial-management practices (including record keeping), resources for adequate financing, and allocation of resources.Midwife Self-Assessment ToolCOMPONENT I: FACILITYASSESSMENTYNINONAIndicator A. Conditions/Amenities (12 items)Does the clinic have:1. A sign that bears the name of the facility?2. A big sign inside and outside the facility that lists the services offered?3. Sufficient seats for patients in a well-ventilated waiting area?Indicator B. Facility/Infrastructure (12 items)Does the clinic have:1. A generally clean environment?2. Adequate potable water?Indicator C. Educational Materials for Clients (3 items)Indicator D. Professional Appearance of Provider (1 item)Midwife Self-Assessment ToolCOMPONENT II: TECHNICAL COMPETENCEASSESSMENTYNINONAIndicator A. Attitude, Behavior of Midwife (10 items)As a midwife, are you: 1. Punctual?2. Cordial in greeting clients?Indicator B. Standards of Care (3 items)1. Do you have a copy of the most recent midwifery service delivery guidelines?2. Do you use the guidelines during your work?Indicator C. Basic Counseling Guidelines (6 items)Indicator D. Infection Prevention (10 items)Indicator E. Prenatal Care (21 items)Midwife Self-Assessment ToolCOMPONENT II: TECHNICAL COMPETENCEASSESSMENTYNINONAIndicator F. Obstetrical (Physical) Exam (11 items)Initial VisitSucceeding VisitsIndicator G. Labor and Delivery (29 items)During LaborDuring DeliveryIndicator H. Postpartum Care (11 items)Indicator I. FP : Info-giving and Counselling (16 items)Indicator J. STI: Patient Counselling and Education (1 item)Midwife Self-Assessment ToolCOMPONENT III: CONTINUITY OF CARE 3 IndicatorsASSESSMENTYNINONACOMPONENT IV: MANAGEMENTIndicator A. Review of Practice, incl Review of Action Plan (5 items)Indicator B. Client Records (5 items) Indicator C. Supplies, Consumable Drugs, incl Vaccines (8 items) Indicator D. Medical Equipment, instruments, furniture (2 items)Indicator E. Information on Clinic Hours (3 items)COMPONENT V: COMMUNITY INVOLVEMENTIndicator A. Client Feedback (3 items)Indicator B. Advertising (2 items)Midwife Self-Assessment ToolCOMPONENT VI: BUSINESS PRACTICES (for private-practice MWs)ASSESSMENTYNINONAIndicator A. SMART Goals (2 items)Indicator B. Financial Practices (6 items) Indicator C. Pricing and Collection System (3 items) Indicator D. Profitable Facility/Practice (1 item)Indicator E. Adequate Financing (3 items)

Action PlanComponentIndicatorIssuesRoot causes (WHY)SolutionsAction/ Next StepsBy WhomBy WhenSTATUS (After some time)I. FacilityA.7No contamination solnNot aware of the needPrepare & always make availableBuy Zonrox, container; prepareMWTomorrow(1 week after) DONE18Part 2: Supervisors Portion

to validate the midwifes assessment of her own quality of services and her facility; and

determines the midwifes progress in improving the quality of FP/MCH services based on her validated numerical scores and the action plans developed during the midwifes self-assessment portion.

Section 3: Monitoring Tool for Practicing MidwivesMonitoring Tool for Practicing Midwives:SUPERVISOR PORTION Two parts:

Supervisors Assessment ToolThe same checklist as that of the midwife portionWith helpful tips, reviewers, instructions, comments, etc.Supervisors Scoring SheetNumerical score summary (2 points for YES/Satisfactorily done; 1 point for Needs Improvement; 0 point for NO/Not satisfactorily done; NA for Not Applicable)Objective measurement of quality of service provisionSupervisors Assessment Tool

I. FACILITYIndicator A. Conditions/Amenities (12 items) Indicator B. Facility/ Infrastructure (12 items) Indicator C. Educational Materials for Clients (3 items) Indicator D. Professional Appearance of Provider (1 item) Total Score (28 items)Comments12821282101221922192203210230102304211141112521215212260627172Score: _18_/_24_Score: _20_/_24_Score: __0_/_6_Score: _2 / 2___Score: _40_/_56__Supervisors (Numerical) Scoring SheetMonitoring Tool for Practicing Midwives:SUPERVISOR PORTION: Suggested StepsThere are several advantages to conducting the monitoring this way: the supervisors assessment will not be influenced by the midwifes answers;time will be saved;the midwifes business need not be interrupted; the presence of the midwife will be required only during the exit feedback;Using the Supervisors Assessment Tool, rate the clinic or the midwifes performance by doing the following:actual client-service provider interactionPresence or absence of the item in the clinicConduct of regular business in the clinicOr by interviewing the midwife, assistants, patients or clients (least priority)Record your own assessment rating under the column heading SUPERVISOR RATING as follows:put number 2 in the box under SUPERVISOR RATING if you assess the item as Yes/satisfactorily done, put number 0 in the box if you assess the item as No/not done, put NA in the box if the question is not applicable to her clinic,put number 1in the box if your assessment is Yes, but needs improvement. After answering the questions in each of the six components in the assessment tool, proceed to computing for the scores for each of the component and accomplish the Supervisors Scoring Sheet Supervisors Scoring Sheet Instructions:Go back to the Supervisors Assessment Tool and review your rating of each of the items in the indicators under the six components. Use the scoring sheet to record the score for each question (copy your ratings on to the appropriate blanks provided for in the scoring sheet). Record the answers in the scoring sheet per component, per indicator, and per question.COMPONENT I. FACILITYMWSUPERVISORRATINGRATINGIndicator A. Conditions/Amenities:Does the clinic have:1. A signage that contains the name of the facility? 22. A big sign inside and outside of the facility that contains the services offered?13. Sufficient seats for patients in a well ventilated waiting area?14. A separate private area/space with a desk, two chairs, examining table for counseling, physical examinations, and procedures that can not be observed or overheard by others? 15. A locked cabinet for storage of medicines?16. A sheet in the examining table to cover client?0I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. .2. 1 .9. .3. 1 .10. .4. 1 . 11. .5. 1 .12. .6. 0 .7. .Score: __/__Supervisors Scoring Sheet Instructions: (cont)Computing the score per indicator. To get the numerator for each indicator, add all the numerical answers (that is, all 2s, 1s, or 0s). To get the denominator, subtract the number of items with NA answers from the total number of items for the indicator, and multiply the answer by 2.I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. 2 .2. 1 .9. 1 .3. 1 .10. NA .4. 1 . 11. 1 .5. 1 .12. 1 .6. 0 .7. 2 .Score: __/__I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. 2 .2. 1 .9. 1 .3. 1 .10. NA .4. 1 . 11. 1 .5. 1 .12. 1 .6. 0 .7. 2 .Score: __/__To get the numerator for each indicator, add all the numerical answers (that is, all 2s, 1s, or 0s). I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. 2 .2. 1 .9. 1 .3. 1 .10. NA .4. 1 . 11. 1 .5. 1 .12. 1 .6. 0 .7. 2 .Score: __/__To get the numerator for each indicator, add all the numerical answers (that is, all 2s, 1s, or 0s). NUMERATOR = _____13I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. 2 .2. 1 .9. 1 .3. 1 .10. NA .4. 1 . 11. 1 .5. 1 .12. 1 .6. 0 .7. 2 .Score: __/__To get the denominator, subtract the number of items with NA answers from the total number of items for the indicator, & multiply the answer by 2. I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. 2 .2. 1 .9. 1 .3. 1 .10. NA .4. 1 . 11. 1 .5. 1 .12. 1 .6. 0 .7. 2 .Score: __/__To get the denominator, subtract the number of items with NA answers from the total number of items for the indicator, & multiply the answer by 2. DENOMINATOR = ____22I. FACILITYIndicator A. Conditions/Amenities (12 items) 1. 2 . 8. 2 .2. 1 .9. 1 .3. 1 .10. NA .4. 1 . 11. 1 .5. 1 .12. 1 .6. 0 .7. 2 .Score: __/__SCORE = _____ / _____1322Supervisors Scoring Sheet Instructions: (cont)Computing the score per component. To get the numerator, add the numerators of all indicators. To get the denominator, add the denominators of all indicators.Each component will then have a total score which is expressed as a fraction, e.g., component 1 score may be recorded as 48/56.

I. FACILITYIndicator A. Conditions/Amenities (12 items) Indicator B. Facility Infrastructure (12) Indicator C. Educational Materials for Clients (3) Indicator D. Professional Appearance of Provider (1) Total Score (28 items)1. 2 . 8. 2 .1. 2 .8. 2 1. __1__1. __1__2. 1 .9. 1 2. 2 .9. 1 .2. _2___3. 1 .10. 1 3. 110. 2 .3. __1__4. 1 . 11. 1 .4. NA .11. NA5. 1 .12. 1 .5. 2 .12. 1 .6. 0 .6. 2 7. 2 .7. 1Score: __/__Score: ___/__Score:__/__Score: __/__Score: __/_142416204612355238Indicator A: 14/24Indicator B: 16/20Indicator C: 4/6Indicator D: 1 / 2Component Score: 35/52Supervisors Scoring Sheet Instructions: (cont)The very first time these component scores are recorded will comprise the clinics baseline component scores. Scores recorded from subsequent monitoring visits will objectively document whether the facility is improving or deteriorating in the quality of its provision of FP/MCH services and supplies.Once the Scoring Sheet is completed, the supervisor can request the midwife to participate in an exit feedback session.The following steps may comprise the exit feedback:Request for the accomplished Midwife Profile sheet (keep this as record for the database on midwives or simply as a baseline record for your office);Review with the midwife her self-assessment answers either by going through each question one by one, or, by.

Look(ing) at the comments table after each component:Agree or disagree and discuss with the midwife her identified good points and areas needing improvement;Be sure to compliment and congratulate the midwife on her good points and encourage her to work on the areas needing improvement.Review and discuss the midwifes Action PlanAgree or disagree with the itemsAs much as applicable and appropriate, confirm or congratulate the midwife on recommendations she herself had made and recorded in the action plan;Ask for updates on each of the recommendations made;The following steps may comprise the exit feedback:Review and discuss the midwifes Action Plan (cont)Add or deduct actions or interventions that are not appropriate;Add recommendations especially if the supervisor has access or ability to mobilize outside resources that will help address the identified gaps in quality care. This will encourage the midwife and convince her of the supervisors commitment to her quality improvement.The supervisor will then provide a recap of the agreed recommendations and next steps, together with the assessment scores.

It would be ideal to leave a copy of the accomplished Supervisors Scoring Sheet with the midwife for her record and reference.

Thank the midwife.Private Sector Mobilization for Family Health - Phase 2 (PRISM2)

Monitoring doneInterviewing the midwife, assistants, patients or clients (least priority)

Conduct of regular business in the clinicPresence or absence of the item in the clinicActual client-service provider interaction MonitoringObservation IS the ideal and recommended method of monitoring. Therefore, the presence of patients in the clinic should NOT be a hindrance rather it is a facilitating factor in monitoring because then the supervisor can simply and quietly observe how the midwife conducts herself during a regular day at the clinic and then record her (the supervisors) findings on the assessment tool.

technical meeting between midwives and medical expertsuser-friendly manual that provides step-by-step guidelines Section 4 - The Guide to Organizing and Managing the Conduct of Clinical Case Conference for Midwives

Five parts:

Organizing guidelinesConference objectivesStructure of the conferenceSteps in organizing AppendicesThe Bohol Experience:Joint Quality Monitoring TeamBackground DOH-CHD7 Office Order No. 0231 series of 2011Establishment of Regional Technical Working Group (RTWG) for Public Private Partnerships (PPP)DOH-CHD7 Regional Circular No. 033 series of 2011Recording and Reporting System for Private FP-MCH Service Providers and HospitalsPHO Special Order No. 001 series of 2011Creation of Public Private Partnership (PPP) for Family Planning and Maternal and Child Health (FP-MCH) Provincial Technical Working Group (PTWG) to improve FP-MCH outcomes in the ProvinceInstitutionalization of CCC cum MDR at the PHO levelInclusion of regular conduct of CCC cum MDRInvolvement of CHD, PHTL, PHO, CHO, POGS, PPS, IMAPUpdating of midwives clinical skills

PPP for FP-MCH Resolution No. 001 series of 2012A Resolution Creating A Public Private Partnership (PPP) Quality Monitoring Team to ensure compliance of DOH and PHIC standards in delivering FP-MCH in the Province of Bohol effective May 7, 2012

PPP for FP-MCH Joint QAP TeamRESOLVED, to constitute a joint public-private quality monitoring team to ensure the compliance of DOH and PHIC-set quality standards for the delivery of family planning and maternal and child health products and services among public and private providers to include compliance with the principle of Informed Choice and Voluntarism (ICV) as stipulated by DOH AO 2011-0005;RESOLVED, that the following shall compose the said quality monitoring team for the province:One representative from the PHO as team leaderOne representative from the DOH-CHD7 Provincial Health TeamOne representative from the local PHIC service officeOne representative from the NGOOne representative from the MHO/RHU of the area being monitoredOne representative from the ILCI/IMAP local chapter

RESOLVED, that the PHO shall allocate funds to cover the expenses related to the conduct of quality monitoring activities of the joint quality monitoring team; RESOLVED, that the team shall initially focus its monitoring activities among public and private FP and birthing facilities in the province; RESOLVED, that the monitoring team shall initially use the USAID PRISM2-developed Quality Measurement Tool (QMT) for use among FP/birthing facilities but which shall be later modified / enhanced / expanded to cover other areas of quality monitoring as may be deemed necessary by the joint quality monitoring team;GroupNAMESOFFICES/AGENCIES1Ruth Cecilia del PradoJosiane T. PepitoAnecita LeopandaoPilar EstafiaDOH-PHTLPHOCHOIMAP

2Machiavilla Loida M. CaliaoGloria CaipangEstrella DumadagCorazon L. Paras PHOCHOIMAPIMAP3Dr. Portia D. ReyesRosalina AmodiaNeneta RelamidaDionisia GacayanDOH-PHTLPHOCHOIMAPThe Provincial Monitoring TeamsClustering of MunicipalityMunicipalityPHIC Accredited MCP/NCPPublicPrivatePPP BHsTagbilaran City IMAP MainIMAP DaoIMAP BoolIMAP UBDauis, PanglaoIMAP TinagoIMAP SongculanLoon, Calape, Tubigon, InabanggaCalape RHUIMAP CatagbacanIMAP CalapeIMAP TubigonIMAP InabangaIMAP St JeraldSandingan BHs

Sikatuna, Catigbian, CarmenSikatuna RHUCatigbian RHUCarmen RHUJagna, Duero, GuindulmanJagna RHUDuero RHUIMAP GuindulmanMabini, AliciaMabini RHUAlicia RHUTalibon, TrinidadTalibon RHUTrinidad RHUIMAP TalibonImplementation Plan (May-Dec 2012)Joint QAP Team to undergo orientation on QAPRequest Clinic Staff to fill up the self-assessment portionConduct actual clinic visitsInterview (3 groups)Feed-backingAction planningSharing of results and experiences (IMAP Office)Scheduling of next clinic visits (IMAP Office)Summary of FindingsName of ClinicAddressStatusDeficiency/iesRecommendationsIMA Bool BranchLigones St., Bool, District, Tgbilaran City, BoholClinic is PHILHEALTH Accredited-Signage is too small-Lacking chairs-Sink out of order-Go to printing shop-Buy more sofa /chairs-Inform plumberIMAP MainNew Calceta St., Tagbiaran City, BoholPHILHEALTH accredited for 6 years already. Botika Outlet soon to open-Placentas are given to watchers for bringing at home-Breast inspection was omitted during prenatal check-up-Alligator forceps was missing-Construct placenta vault-Breast inspection must be included-Buy alligator forcepsSummary of FindingsName of ClinicAddressStatusDeficiency/iesRecommendationsIMAP UB BranchR. Palma St., Tagbilaran City, BoholAccreditable clinic, staff is preparing set-up for PHILHEALTH inspection-Signage too small that contain the services-No eye goggles-Breast inspection during pre-natal not applying-No FP acceptor-Go to printing shop-Buy goggles-Performing breast inspection-Advice client and do counseling for FPIMAP Dao BranchPurok 3, Dao District, Tagbilaran City, BoholAccredited clinic, Botika Outlet soon to open-Medicine cabinet was not lack -sharps container-IEC MCH posted-Boiling and sucking of instruments-method of sterilization-Requested made-Requested to PHO-Request to IPHO-Informed to staff to autoclave instrument to GCGMH at all times.

Gaps and LimitationsPublic Birthing Homes (BHs) were not visitedPrivate Birthing Homes (BHs) were not re-visited after 6monthsCHO staff were not given permission to go outside the CityPHO did not infuse budget for the Joint QMT

Lessons LearnedExpand the membership of the Joint QMT to include Mayors or MHOs (MCP accredited RHUs)Tie up the QAP/QMT to the PHIC accreditation renewalPHO to integrate QMT to AOP (Budget purposes)Strengthen the P-TWG for FP-MCH

SUMMARYThe Quality Assurance Package for Midwives is a Toolkit for the Practicing Professional Midwives. It has been developed as a collaboration between the Department of Health and PRISM2, in support of the Millennium Development Goals (MDG) of the country .

Quality Assurance Package for Midwives

Midwives are at the forefront of community, usually being the first-contact health care provider. Use of the QAP by Midwives as a guide/reference in their daily clinical practice can help improve and sustain the quality of practice of professional midwives and this is expected to lead to better maternal & neonatal outcomes.

QUESTIONS???63Action PlanningKRAsActivitiesTimeframePerson ResponsibleEstablish database on Health Facilities and ProvidersUpdating of Inventory of Facilities and providers in Davao SurJuly 31, 2014Mai2x SuraltaAction PlanningKRAsActivitiesTimeframePerson ResponsibleInformation, Education & CommunicationAudience with the IHLZ technical management committee meetingsJuly - SeptemberMai2x SuraltaIssue and Send Office Order to ILHZ coordinators to schedule committee meeting for the QMT to attend July 14, 2014Mai2x SuraltaSend letter to DMO on the scheduling of ILHZ meetingJuly 14Mai2x SuraltaDr Anthony AranetaAction PlanningKRAsActivitiesTimeframePerson ResponsibleMonitoring Visits and ReportingActual Clinic Monitoring VisitsDATESGROUPs/MEMBERsFACILITIES / PROVIDERSSep 23DOH-RO/PO JoyPHIC AshaPHO EsmeIMAP MillicentAPSOM RaquelMH Tes WoodDigos, Sta CruzSep 24Sulop, PadadaSep 25Magsaysay, BansalanSep 26Malita, Sta Maria, MalalagAM Private PM - PublicNext StepsNext Round by January 2015, focus on the mentoringJoy Dinalo as liaison to the DOH-RO Director for the signing of certificatesMentor-Mentee Midwives capacity Building (EINC, FPCBT1 &2, PPIUD, EBF) July to October 2014