DEPARTMENT OF HEALTH & FAMILY WELFARE GOVERNMENT OF … of FRU... · DEPARTMENT OF HEALTH & FAMILY...

DEPARTMENT OF HEALTH & FAMILY WELFARE

GOVERNMENT OF ORISSA

First Referral Unit (FRU/ MCH level 3 facility)

Delivery Registers Automation Pilot

District Headquarter Hospital, Puri

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District Headquarter Hospital, Puri

ORISSA TECHNICAL AND MANAGEMENT SUPPORT TEAM Orissa TMST

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Table of Contents

ACRONYMS ............................................................................................................................................. 2

EXECUTIVE SUMMARY ............................................................................................................................. 3

ACRONYMS ............................................................................................................................................. 4

1. INTRODUCTION ............................................................................................................................... 5

2. SPECIFIC BACKGROUND ................................................................................................................... 5

2.1. Scenario of O&G Ward at DHH, Puri ......................................................................................... 5

2.2. Record Keeping System at DHH, Puri ........................................................................................ 6

2.3. Current Patient & Service Workflow ......................................................................................... 6

3. THE FRU AUTOMATION SYSTEM ...................................................................................................... 7

3.1. Objective ................................................................................................................................. 7

3.2. Benefits.................................................................................................................................... 7

3.2.1 Improve Record Keeping System ...................................................................................... 7

3.2.2 Strengthening Monitoring and Supervision for Improved Facility Performance ................. 7

3.2.3 Support Death Auditing Process ....................................................................................... 7

3.2.4 Enhance Work Efficiency of Staff ...................................................................................... 7

3.3. Automated System Design & Process Flow ............................................................................... 8

3.3.1 Flow Diagram of Automated Solution ............................................................................... 8

3.3.2 Off- Line Record Entry ...................................................................................................... 9

4. INTRODUCTION OF STANDARDISED DELIVERY REGISTERS ................................................................ 9

4.1. Review of Existing Delivery Registers ...................................................................................... 10

4.2. Piloting of New Standardised Delivery Registers ..................................................................... 10

5. SELECTION OF AGENCY FOR SOFTWARE APPLICATION DEVELOPMENT .......................................... 11

5.1. Roles & Responsibilities of the Agency ................................................................................... 11

6. REPORTING AND DELIVERABLES..................................................................................................... 11

7. ISSUES AND LESSONS LEARNT ........................................................................................................ 12

8. COSTS AND SCALE-UP .................................................................................................................... 12

9. CONCLUSION ................................................................................................................................. 13

ANNEXURE 1: Approval of Terms of Reference for Piloting FRU Automation .......................................... 14

ANNEXURE 2: Letter from DoH&FW, Government of Orissa for FRU Automation Start up Meeting ....... 15

ANNEXURE 3: Letter from DoH&FW, Government of Orissa for Demonstration of FRU Automation

Application ............................................................................................................................................ 16

ANNEXURE 4: SNAP SHOTS OF THE SOFTWARE APPLICATION SCREENS ................................................. 17

ANNEXURE 5: REPORTS OF HARDWARE AND NETWORK INSTALLATION AT DISTRICT HEADQUARTER

HOSPITAL, PURI ..................................................................................................................................... 20


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ACRONYMS

ADMO Assistant District Medical Officer

DHH District Headquarter Hospital

DoH&FW Department of Health & Family Welfare

ICDS Integrated Child Development Services

IMR Infant Mortality Rate

IPD In-Patient Department

ISO International Organisation for Standardization

IT Information Technology

FRU First Referral Unit

GIS Geographical Information System

GOI Government of India

GOO Government of Orissa

HMIS Hospital Management Information System

JSY Janani Surakhya Yojana

MCH Maternal & Child Health

MCP Mother Child Protection

MCTS Mother and Child Tracking System

MIS Management Information System

MMR Maternal Mortality Rate

MTP Medically Termination of Pregnancy

NIC National Informatics Center

NRHM National Rural Health Mission

O&G Obstetrics & Gynaecology

OHSP Orissa Health Sector Plan

OPD Out Patient Department

OT Operation Theatre

PHC Primary Health Center

PIP Project Implementation Plan

PPC Post Partum Center

TMST Technical & Management Support Team

TOR Terms of Reference

UNFPA United Nations Population Fund


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EXECUTIVE SUMMARY

The Department of Health and Family Welfare has successfully increased the percentage of

deliveries taking place in institutions (to about 60%, HMIS 2009-10) through implementation of

strategies under NRHM such as FRU operationalisation, JSY, ASHA and training of health

providers to manage normal and complicated deliveries. More deliveries in institutions, with

good quality care, are expected to reduce maternal and infant deaths in the state.

However field visits by the Department and its technical partners found a gap in the

completeness and consistency of information about deliveries and births maintained in many

facilities. The earlier practice of using printed registers had lapsed and most are drawing up

their own registers by hand in general note books. Therefore information about birth outcomes

for mothers and newborns is inadequate either to assess performance at the facility level or to

use the information for tracking process and outcome indicators at the state level.

Through a maternal health working group, consultations were held with doctors and nurses

from different facilities, including Medical College Hospitals. Six standardised registers for all

the maternal and neonatal services at an FRU, were agreed upon and printed for piloting in a

few districts. In one district, Puri, it was decided to take the exercise a step further and

automate the registers for easier information retrieval. The main purpose is utilisation of data

by the facility to improve management and practice; and utilisation of data for planning and

monitoring at state level (once more facilities have on-line data).

TMST were given the responsibility to pilot automation of the registers at the District

Headquarter Hospital (DHH), Puri. The IT principle of creating a system which can be integrated

with other systems (eg. comprehensive hospital MIS and Mother and Child Tracking)

underpinned the approach. Between July 2010 to March 2011 the pilot has been conducted

and completed. IT support continues until June 2011. The system is web-based and hosted in

the NRHM server in Bhubaneswar and can be reviewed at any place by approved personnel.

This report documents the steps taken, initial lessons learnt from implementation. The

experience has been positive in terms of the interest and participation of staff at Puri DHH, the

relative ease of automation (contrary to concerns at some levels that this would be a difficult

process) and modest cost (within Rs 6 Lakh).

It is too early to assess change in facility level performance as a result of the system, but

immediate utility has been demonstrated during visits from GoO and GoI when questions on

births and deaths could be quickly and accurately answered. The NRHM PIP 2011-12 proposes

scale up to six more district hospitals. Costs will be considerable less as software and source

code are owned by GoO and only hardware and training costs will be incurred. Once all FRUs

(now level 3 facilities) have on-line MIS, comparing process and outcome performance across

facilities will be possible which should have good returns for improved efficiency and quality of

services provided.


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ACRONYMS

ADMO Assistant District Medical Officer

DHH District Headquarter Hospital

DoH&FW Department of Health & Family Welfare

ICDS Integrated Child Development Services

IMR Infant Mortality Rate

IPD In-Patient Department

ISO International Organisation for Standardization

IT Information Technology

FRU First Referral Unit

GIS Geographical Information System

GOI Government of India

GOO Government of Orissa

HMIS Hospital Management Information System

JSY Janani Surakhya Yojana

MCH Maternal & Child Health

MCP Mother Child Protection

MCTS Mother and Child Tracking System

MIS Management Information System

MMR Maternal Mortality Rate

MTP Medically Termination of Pregnancy

NIC National Informatics Center

NRHM National Rural Health Mission

O&G Obstetrics & Gynaecology

OHSP Orissa Health Sector Plan

OPD Out Patient Department

OT Operation Theatre

PHC Primary Health Center

PIP Project Implementation Plan

PPC Post Partum Center

TMST Technical & Management Support Team

TOR Terms of Reference

UNFPA United Nations Population Fund


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1. INTRODUCTION

The Health & Family Welfare department of Govt. of Orissa is keen to develop and implement

an integrated automation system to improve health care service deliveries in the state. The

Orissa State Health Mission under NRHM is the nodal unit to achieve this goal. The Orissa

Health Sector Plan (OHSP) derives the strategies to achieve these objectives. The output-1

“Improved access to priority Health, Nutrition and Water and Sanitation services” and output-2

“Public Health Management Systems strengthened” of OHSP has key strategies of program

integration and strengthening the Health Sector Management Systems.

The key objective of NRHM is to reduce IMR and MMR in the state. Over the past decade there

has been a significant decline in the IMR (65 / 1000 live births –SRS’09) of Orissa. However the

neonatal death and maternal mortality is still high in the state. Various strategies are

implemented by the department to reduce the IMR and MMR in the state. One of the key

features is building the capacity at district and state level to ensure improved program

implementation with emphasis on strengthening monitoring & evaluation capabilities, including

facility level with a special emphasis on maternal and neonatal services.

In this regard DoH&FW, Govt. of Orissa has initiated to improve evidence based monitoring

system to monitor the progress on services deliveries and data quality.

2. SPECIFIC BACKGROUND

The record keeping system of O&G ward in all DHH is in manual process. There are no standard

formats to capture the emergency obstetric care and newborn care data on a regular basis. The

registers are designed vertically with minimum data sharing and limited scope of data

integration to generate MIS reports. The Dept. of Family Welfare has initiated a small step

towards this process of integration by standardizing of the labour room registers. This exercise

will help to understand the current practices of maintaining registers and indentifying the gaps.

The DoH&FW has decided to introduce the standard delivery registers in three district head

quarter hospitals at Angul, Mayurbhanj and Puri on pilot basis. UNFPA has assigned to

introduce the manual registers at respective DHH of Angul and Mayurbhanj and TMST has

assigned to pilot the manual registers with facility for automation of registers at DHH, Puri

(Annexure – 1).

2.1. Scenario of O&G Ward at DHH, Puri

The district hospital at Puri is one of the very few Govt. hospitals in the country to achieve

an ISO certification in 2009. This is a model hospital of the state in quality service delivery

to its patients and it acts as a referral institution from the periphery institutions. There is a

fully functional 60 bedded maternity ward (24 beds for normal deliveries and 30 beds for

cesarean deliveries) which provides round the clock services on maternity care. The labor

room has 4 labour tables and on an average 20 to 30 deliveries are conducted daily.

OHSP plan 2009-10 has budgeted provision for standardizing of the labor room records in

all FRUs/24 x 7 PHCs and piloting introduction of electronic records in Puri district hospital,

which is also a recognized FRU.


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2.2. Record Keeping System at DHH, Puri

The maternity ward follows a manual system of keeping and maintaining records of

patients from the date of admission till discharge date. The delivery register keeps the

information on date and time of delivery, type of delivery, weight of the new born,

obstetric history, treating doctor’s name and personal details of the patient with a unique

IPD number. A cumulative serial no (yearly, monthly and daily) is maintained to know the

patient load at any point of time. Separate registers are maintained on utilization of OT,

Indenting of blood and oxygen, Diet, Referral, Death and Discharge etc.

There are at least 18 registers used to keep the data, related to various obstetric services. It

is an uphill task, as most of these registers are recorded and updated daily by a staff nurse.

Besides her clinical duties she has to devote her maximum time to record these data on a

regular basis. During review of registers, it has been observed that data recurrence is very

high (Ex. Patient profile has repeated 10 times in different registers). There is a unique IPD

number provided to each patient during admission, but it is not recorded in each register,

except the admission and delivery register. Hence it is very difficult to track patient details

in different registers (sometime they are referred by patient name). There are absolutely

no reporting procedures regarding deliveries, deaths, immunization details etc. Reports are

prepared as and when needed by the district authorities.

2.3. Current Patient & Service Workflow

The major problem in this system is using of too many registers without any standard links. This

restricts the user to generate accurate timely reports on both patient related as well as on

clinical prospective. It is extremely difficult to reuse the existing manual data in future needs.


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3. THE FRU AUTOMATION SYSTEM

3.1. Objective

Design and develop a road map on standardization & automation of Delivery Registers

with a scope of integration with other Hospital MIS in the future.

3.2. Benefits

3.2.1 Improve Record Keeping System

The systematic storage of delivery data in the standard registers will be helpful to

retrieve the data in need. The information can be used in health planning, research

and evidence based interventions in program planning and implementation.

3.2.2 Strengthening Monitoring and Supervision for Improved Facility

Performance

The automated MIS reporting system provide query based periodic reports on

patient information, institution performance and clinical interventions at institution

level. The central data storage at NRHM server provide access to state and district

managers to review online data and generate reports on specific indicators like

number of deliveries, Infant and maternal deaths, In & Out Referral cases etc. The

dashboard report provides the performance summary of the institution at a glance

on selected indicators.

3.2.3 Support Death Auditing Process

The maternal death register records the details of the mother’s obstetric history

along with under laying causes of death. The evidence based data is useful to

analyse and plan to improve emergency service delivery.

3.2.4 Enhance Work Efficiency of Staff

The new registers reduce the occurrence of data redundancy and improve the data

recording quality. The patient unique identity and their interlinked data set help the

user to retrieve data and generate reports on various indicators.

In future, this application can be integrated with other programs and the expected

benefits could be as follows

� Integration with Mother Child Tracking System (MCTS)

� On line referral

� Integration with ICDS program on Malnutrition and Anemia

� Issue of birth certification


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� Monitoring of Immunization status

� Tracking of JSY beneficiaries

� Compatible with GIS database

3.3. Automated System Design & Process Flow

The application is a web based automated system driven patient monitoring tool which will

keep track of the patients from the date of admission till discharge with a unique ID. The

application is flexible enough to capture the details of patient stay at the institution along

with pre-admission information (JSY card) of the patient. The designing architecture is an

open ended platform, so that it can be up-scaled in both directions with a scope of

integration with other hospital applications like Mother Child Tracking System (MCTS),

Mother Child Protection Card (MCP) and HMIS.

3.3.1 Flow Diagram of Automated Solution


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3.3.2 Off- Line Record Entry

The application has option to facilitate the user to enter patient data during

connectivity failure with the central server. User can enter and generate reports like

Registration slip, Bed Head tickets, Discharge and Referral report etc in off line

mode. The off-line entered data will automatically up-load into the central server as

soon the connectivity is established.

4. INTRODUCTION OF STANDARDISED DELIVERY REGISTERS

Table 1: Key Event Carried Out During the Process

SL.

NO. KEY EVENTS TIME PERIOD

1 Approval of ToR on piloting of Web Based FRU

Monitoring System at DHH, Puri July 2010

2 Review of record keeping process at DHH, Puri

by TMST & UNFPA July 2010

3 Introduction of standard delivery registers at

DHH, Puri August 2010

4 Bid Opening & Agency selection by Technical

Team September 2010

5 FRU Automation Start Up meeting October 2010

6 Installation of computers and setting of Local

Area Network November 2010

7 FRU Automation Application Live Demo at

NRHM January 2011

8

Selection and placing of three data entry

operators by agency at Labour room, OT room

and PPC

January 2011

9 Submission of final deliverables (Source code CD

along with process documents) to NRHM February 2011

10 Start of online data entry at Labour room, OT

Room and PPC March 2011

11 State level FRU Automation dissemination

meeting March 2011


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4.1. Review of Existing Delivery Registers

The joint team of TMST and UNFPA visited DHH, Puri and reviewed the registers (Indoor

Register, Labour Room Register, Discharge Register, Referral Register, Infant and Maternal

Death Register etc.) used in the O&G ward. The team interacted with ADMO (Family

Welfare), In-Charge Medical Officers and Staff Nurses on issues related to data capturing

and register maintaining. The PPC and OT section record keeping systems are also reviewed

by the team.

Review of Registers Discussion with Doctors and Nurses

The six new draft registers in excel format are shared with the concerned users to identify

the missing variables between the old and new draft registers. The user feedbacks are

collected and the registers are revised accordingly.

4.2. Piloting of New Standardised Delivery Registers

The standardised delivery registers are circulated with MCH team for reference and further

developed after bench marking with other state (Rajastan & Tamilnadu) delivery registers.

These six registers are

� Indoor Admission Register

� Labour Room Register

� Operation Theatre Register

� MTP Register

� Abortion Register

� Maternal Death Register

New Registers are reviewed by Medical Officers


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These registers are introduced into practice in three units Labour Room, OT Room and Post

Partum Centre of O&G ward. The concerned Medical Officers and staff nurses are trained

on the use of registers and use of data dictionary available in the registers.

5. SELECTION OF AGENCY FOR SOFTWARE APPLICATION DEVELOPMENT

A technical team consisting of professionals from NIC, NRHM and TMST was formed to review

the technical bidding documents and select the qualifier bidders to open their financial bid.

CSM Technologies, Bhubaneswar was the prefer bidder to develop and execute the software

application at DHH, Puri.

5.1. Roles & Responsibilities of the Agency

The major responsibilities of the agency was

� Review existing record keeping process to understand the information flow

and identifying the gaps

� System review study especially on Labour Room, OT, PPC, JSY and Billing

process modules.

� Development of open ended application (Database & Front End which can

be up scaled and integrated with HMIS in future

� Installation on prescribed Hardware (Systems, Printers & Furniture) and Local

Area Networking.

� Provide three IT trained personals for six months to perform the regular data

entry tasks at DHH, Puri

� Develop the user training materials and train the concern FRU staff as well as

state level staff on using of the application software.

� Provide technical support to users for six months from the data of go live of

the application.

6. REPORTING AND DELIVERABLES

Final reporting is to the Mission Director, NRHM, Health & Family Welfare Department,

Government of Orissa and process reporting is to the Team Leader, TMST for progress

monitoring and quality assurance.

The following documents have delivered by February 2011:

� System Review Study and Functional Specification documents

� Application software CD

� Source code CD


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� Users training manual

� Hardware procurement & installation report

� Photographs of the process

� Process analysis report (ppt form)

� Project completion report (Installation reports, user’s feedback, core group inputs,

district managers’ certification on functioning hardware and software etc.)

� Handover / Exit Plan document

7. ISSUES AND LESSONS LEARNT

� Provide uninterrupted supply of delivery registers to the institution.

� Assigned dedicated staff to maintain the registers and enter the data into electronic

formats through software.

� The capacity building of nursing staff on use the registers are essential to improve

quality data recording.

� The staffs in O&G and PPC ward are not acquainted to capture the volume of detailed

data mentioned in the registers. The registers are need to be introduced at least a

month before prior to the automated software in place.

� Basic IT skill training is required to Medical Officers and nursing staff to optimise the

use of application software especially MIS reports.

� Regular monitoring and supervision of data at district and state level are necessary to

ensure data quality and timely reporting.

� Working with a local vendor has advantage to supervise and monitor the processes

instantly.

8. COSTS AND SCALE-UP

� The cost of FRU automation at one facility was within Rs 6 Lakhs.. This includes person

time, software, equipment and handholding support for six-months post completion.

� In the state level dissemination meeting the department has shown its willingness to

replicate the software application into other district head quarter hospitals. This year’s

NRHM - PIP has included six institutions to implement the application where standard

delivery registers are already in practice.

� The IT section of NRHM can customise the source code and implement the same

application in other DHHs.


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� The user operational manual and training manual is available on the home page of the

FRU automation website. Online training modules are incorporated for the new users.

9. CONCLUSION

The experience has been positive in terms of the interest and participation of staff at Puri

DHH, the relative ease of automation (contrary to concerns at some levels that this would

be a difficult process) and modest cost. It is too early to assess change in facility level

performance as a result of the system, but immediate utility has been demonstrated during

visits from GoO and GoI when questions on births and deaths could be quickly and

accurately answered. The NRHM PIP 2011-12 proposes scale up to six more district

hospitals. Costs will be considerable less as software and source code are owned by GoO

and only hardware and training costs will be incurred. Once all FRUs (now level 3 facilities)

have on-line MIS, comparing process and outcome performance across facilities will be

possible which should have good returns for improved efficiency and quality of services

provided.


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ANNEXURE 1: Approval of Terms of Reference for Piloting FRU Automation


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ANNEXURE 2: Letter from DoH&FW, Government of Orissa for FRU Automation Start up

Meeting


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ANNEXURE 3: Letter from DoH&FW, Government of Orissa for Demonstration of FRU

Automation Application


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ANNEXURE 4: SNAP SHOTS OF THE SOFTWARE APPLICATION SCREENS


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ANNEXURE 5: REPORTS OF HARDWARE AND NETWORK INSTALLATION AT DISTRICT

HEADQUARTER HOSPITAL, PURI


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