LaQshya Labour room

To achieve this
Strategies will be

1.Reorganise labour room and OT as per Labour room standardisation guidelines
2.Follow Maternal and Newborn Health toolkit issued by MOHFW GOI
3.Establishment of dedicated HDUs as per MOHFW guidelines
4.Strict adherence to clinical protocols

OBJECTIVES OF LaQshya

1.To decrease MMR
2.To decrease IMR
3.To improve quality of care
4.Respectful maternity care (RMC)

For this, at the facility level you have already formed Quality circle and Quality team
You must have already started working towards closure of gaps as per Labour room standardisation guidelines and Material and Newborn Health toolkit of MOHFW GOI

The Dakshata skills lab applies to OR staff also .e.g.. they should know to conduct delivery, AMSTL, pph management, standard precautions etc.   Apart from this they should also know about the procedures pertaining to the OT. These are given in the OT  checklist- PREPARE A LIST Of wherever staff competency is required. These should be available in the sop. These form the basic questionnaires.

Questions:
1) Have you formed the Quality Circles required for L 2)How many QC s have been formed 3) when were they formed 4)who should be the members of these QCs 5)what are the agenda for discussion 6) what is the difference between Quality Team and Quality Circle 7) In L which is the important working group. 8) what is the frequency of meeting of the QCs. 9) Documentation - in register- i)page 1-  Index ii) page 2- Members of the QCs with sign of members and date . L Nodal officer  should be included in both QCs.

Questions continued:-
9) Documentation-  iii) page 3 - scope of services
iv) Meeting - minutes.
10) The problems identified in the QC meetings should be represented in the Quality Committee meeting by the Department in charge who ought to be a member of the Quality Committee.
11) Who is responsible for the documentations  in  L. - i) Department in charge or nodal officer ( Internal assessment, Gap analysis  and Action planning,  sop, case records, forms , QC register, checklists , mock  drills
,  Quality tools, OSCE and  Staff competency testing , clinical risk management, all Audits, analysis of audits and KPI, training needs assessment , training  etc. , --- work allotment at be  given to specific persons) ii) Key performance indicators - designated  staff nurse iii) PSS - OP and IP - NQAS  nodal officer ( see that the patient samples are  included from all maternity related wards) iv)HIC related-  HIC staff nurse and MO - including  Annual medical check up , NSI register maintenance , HIC audits including Hand hygiene compliance , autoclave registers , BMW management registers , Linen register,stock registers for Hand wash and ppe,   HAI, House keeping registers  and checklists etc.v)Adverse events register and Incident forms and analysis regarding this - either Quality Team or Safety officer.

Questions continued:-
11) vi) Registers related to Labour Ward ( og in charge) - OBSTETRIC casualty register, complicated cases  register, nominal register, referral in , referral out, duty report, AN corticosteroid, PPIUCD, Parturition, Birth companion , IUD register, Blood transfusion register , Abortion register.
vii) Handing over Taking over register ( by staff nurse)
viii) Verbal order register ( SN) ix) Data Source register for the KPI
12) Committees to be functional  for Laqshya- i) Quality Improvement committee or Core Committee ii) HIC  Committee. U
13) How to maintain a Committee register - page 1-  Index : page 2 - Scope of services : page 3 - frequency of meeting : page 4 - office order for formation of committee : page 5 - names of committee members with their sign
Page 6 onwards - convening meetings should include circular from cmo  ( Date and time ,venue, chairman , convener, agenda for the meeting , action taken for previous discussions, minutes of the meeting , sign of all members)
14)How to maintain Training records - i) Training calendar  with sign of co Ordinator and cmo to be put up on notice board ii) Training register - a) circular b) pre test c) documentation of training - Date and time , venue, topic , name of trainer and sign , training materials used ,sign of all trainees,  post test, feed back

Questions continued :
15) i)what is meant by Laqshya - latchiyam - it is a targeted approach to maternal care
ii) which part of maternal care is targeted- Intra natal and Immediate postpartum care ( because this is the period when maximum maternal deaths occur) - so the aim of L is to reduce the maternal mortality.

Questions continued:
16) i)What is the Laqshya program - It is the National Labour room Quality Improvement initiative ii) what are the goals and objectives of LAKSHYA? - a)to reduce preventable maternal and new born mortality, morbidity and stillbirth, b)improve the quality of care during the delivery and Immediate postpartum care and c) to enhance satisfaction of beneficiaries
iii)what guidelines are to be followed to re-organize LR and OT- "Labour Room Standardization guidelines" and "Maternal and Newborn Health Tool kit" .
Also read the Dakshata  job aids and checklists - for skill development and checking the competency of staff
Also - Sop for Laqshya ( sent by Dr. Sivagami) - read this and write your sops as suits your organization ( do not copy and paste )  iv) what are the new interventions in the L program - a) formation of Quality Circles ( these are the working groups and the main driving force in L) b) Labour room standardization c) Respecful Maternity Care (RMC)- this is our duty and also  paves the way for a good PSS( Patient Satisfaction Score) and training of  para medical should be concentrated on this d) Rapid Improvement Cycles e) Training- Coaching- Mentoring f)Branding- Platinum badge - for more than 90% score ; Gold badge for more than 80% score and Silver badge for more than 70% score
v) what is the frequency of meeting of the Quality Circle - whenever required vi) what activities are to be performed in L - a) Baseline assessment of LR and OT using the checklists b) Baseline competence assessment of Labour Room staff using OSCE( Objective Structural Clinical Examination - it is a modern type of examination to assess clinical competence. It is a performance based testing . How to do this - refer the Dakshata checklists and use this to assess their skills  by observation and by written tests and give them score and  grading at the end of the process )c) Baseline measurement of Facility level indicators ( annexure C) d) Reporting f NQAS ( assessment scores), OSCE and indicators to the State vii) what are the pre- requisites to obtain the NQAS certificate under the L program - a) at least 75% of Facility based indicators are achieved ie. 15 out of 20 indicators should have achieved the target scores b) PSS Score - more than 80%

Questions continued- viii) what are the phases of activities in the Laqshya program and duration of each phase - 4 phases- Preparatory phase ( 2 months) Dissemination, Team formation , Orientation and Quality Circles . ( there should be a coaching team in the district and a District Quality Assurance Committee. At the facility level, there should be Quality Improvement team and Quality Circles for LR and OT).
Next phase is Assessment phase (2monthd) - Baselineline assessment, Gap analysis, Action planning and Resource allocation . Third phase is the Improvement phase- (12 months) Rapid Improvement Cycles, sustaining improvement and coaching team visits. Fourth phase - Evaluation phase(2months)- evaluation of achievements, Quality certification and awards.
ix) Who will perform the following? - 1. Internal assessment - by Quality Circle supported by Quality Team by the 3rd month  . 2. Peer assessment - by the Coaching team 3. OSCE - by trained nursing mentirs/clinicians by 4th month 4. Indicator measurement - by Quality Circle verified by Coaching team from 3rd month onwards (monthly basis) .  (Wherever Quality Circle is  mentioned - it is the responsibility of the L nodal officer) .
x) Responsibilities of District coaching team - ( constituted at district level with members being DD FW, NHM co Ordinator, trained nurses in functional skills ie. Dakshata skill lab trained.  Responsibilities of the team - mentoring of Quality circles, monthly visit and review, hands on training on clinical protocols, OSCE based assessment , verification of indicators, monitoring diagnostics, Blood transfusion and referrals - District coaching team should develop a checklist for these and function accordingly- responsibility JDHS. xi) Members of Quality Improvement team ( already existing in NQAS) - if not suggested the following - cmo,  og department in charge , OT in charge, matron, support services like house keeper, security, pharmacist etc.
xii) what trainings to be provided in the LAKSHYA program - 1. Orientation on the L program 2. Training on clinical skills - Dakshata 3. Training on Quality management ( Assessment, PDCA cycle, Quality tools, Process mapping etc. )4.  Training on Respectful Maternity Care. xiii) what activity follows the assessment? - Gap analysis ( list the gaps identified, write the  standard and ME - measurable element - for each gap , categorize the gaps ( those which can be closed locally at facility level , those at district level and those which require state support) ,Action planning for gap closure, fixing responsibility,  prioritization of actions required for closure of these gaps , tracking of gap closure.

Questions continued- ix) Audits ( LSCS- formats already prepared and  sent  , Referral audit, HIC audit, Maternal death audit, Near Miss audit, Infant death audit).

Quality Circles - i) these are informal groups of staff in each department . These are the main driving force in the quality improvement process of L . They are the actively working members. 2 Quality Circles required- one for LR and another for OT, 3.they should meet regularly but at least once a month , 4.they should get support from the Facility Quality Team in their activities - like Training, Quality tools, indicators , Quality Improvement processes like infection control, record maintenance etc.  They should co ordinate with them. 5. Members- 1) LR- Gynaecologist, Paediatrician, matron, staff nurses, support staff 2) OT- anaesthetist, Gynaecologist, Paediatrician, matron, OT staff, support staff 6. Responsibilities- i)Baseline internal  Assessment using the L checklist ii) Gap analysis and Action planning to close the gaps iii) Collect the data for indicators ( maintain a Data capture register) iv) calculate the indicators. v) Analyse  the indicators vi) Use Quality tools - PDCA cycle  , Route cause analysis, graphic presentations e.g.. trend graph and analyse them vii) write SOP viii) Adherence to protocols and clinical guidelines - discuss all them ix) display of protocols at appropriate places x) display of signage at appropriate places xi) check ofj Quality processes like maintenance of trays, equipment, drugs, BMW , infection control measures, register maintenance, zoning, patient safety measures , postings etc. xii) training of staff - already mentioned ( clinical protocols, Quality, RMC, Quality tools, indicators, L program etc. )xiii) maintenance of Quality Circle meeting register- discuss any of  the activities mentioned above and record them in the minutes.eg. a) training needs of staff - fix a date b) infrastructure related problems c) sop documentation d) indicators and analysis e) process related  problems f) audits and analysis.etc.  ( everything should be like a discussion and debate and record the salient points in the minutes)

List of Registers to be maintained :-
Many if these registers are already maintained in CEmONC centres, some of them as needed for NQAS.
1) CEmONC related - i) Cemonc posting register ii) Duty roster of doctors iii) Duty report of doctors iv) Parturition v) Nominal vi) Sub stock register for medicines and vii) substock register for instruments and equipments viii)Indent book - if electronic system not used ix)  Memo book - to call specialists x) Birth companion register xi) OBSTETRIC casualty AN register xii) Complicated cases register xiii) Referral in register xiv) Referral out xv) AN corticosteroid register- for preterm xvi)IUD register xvii) Abortion register xviii) Anaemia and Blood transfusion register xix) OT schedule.
Registers related to Quality:-
1)HIC related- i) stock register for ppe and hand wash materials and disinfectants. ( use h2o2 based disinfectant for sterilization of LR and Bacillocid for OT-  remember formalin is carcinogenic)ii) Autoclaved- bin and trays register iii) HAI register in on and pop wards - active surveillance iv) wound infection register in wards v) Autoclaving monitoring register ini TSSU and validity testing vi) Swab culture report - active surveillance vii) NSI register viii) Linen R  ix) BMW R  2) Adverse events register 3) Equipment checking register4) Handing over Taking over R 5)Critical values receiving 6) Verbal orders 7) Indicators R 8) Data capture register for indicators 9)Training R .

LR is like theatre. Keep the doors closed. There should be no clutter. Do not paste posters and charts on wall tiles- it will be difficult to clean.  Mount removable flex charts ( clinical emergency protocols)which can be removed while cleaning or in Obs casualty.

Green zone - clean area ; Yellow- semi sterile ; Red- sterile. House keeping is different in these various zones . ( Labour room sterilization should be done based on NHM guidelines. Microbiological surveillance in LR should be done every month . This should be displayed outside on a board ( also write the next due date for swab - on the board) .

Questions continued :
17)How to organize a Labour Room - a)Outside the LR complex there ought to be waiting area for  relatives ;  b)after entrance in to the LR complex patient waiting area should be available;  c)patients should be received in OBSTETRIC Casualty ( casualty should have all the features pertaining to it - 2 cots  - one for high risk patients and another for no immediate risk patients, saline stand, emergency tray, 1 delivery tray, table for doctor to write and counsel patients , crash cart if available, eclampsia tray , pph kit , hand wash facility,scan facility in the adjoining area since almost all patients may require imaging; d)pre Labour room for those in I stage and in Latent phase- cots and a copy table  for nurse, hand wash basin; e)Labour room ( clean)- i)Labour boards or cots with foot stool and a stool for birth companion  ,ii) Wash area- sink with elbow tap iii) BMW area , iv)Radiant warmer for NBCC - at least 200 sq. feet moving space , resuscitation tray , autoclaved  bin with sterile towels, supplies required for new born care, there should be free space available on three sides of the radiant warmer for new born care v) area identified  to keep sterile items for delivery- trays, bins vi)area identified to keep materials for  injections vii) place to keep trolley; f) Nursing  station - table to keep registers , a table for Bed side Lab tests , computer; g) Parturition corner in the corridor outside the Labour room ; h)Septic Labour room - this should portray all the features of the clean LR mentioned above;i) Eclampsia room ; j) there should be a stretcher trolley  and wheel chair bay in the corridor ; k) toilets and bathrooms - at least one western toilet. Support hand bars in toilets; l) Preparation room- patient table , bins , BMW bins, trays and bins and items  required for preparation
Zoning in LR complex - the clean and septic labour rooms are in the red zone and ought to be maintained like  a theatre- ppe corner  should be kept outside this place. Patient waiting area  outside the OBSTETRIC casualty  is the green zone. Here there should be 2 chappal stands (one for street chappals and one for clean chappals). The rest of the places are in the yellow zone.

Duty doctor room should be close to LR complex. Nursing station should preferably have an attached Staff toilet.

Though all those mentioned above may not be available in some centres , we should try to find alternatives and arrange to the utmost possible.

Future constructions may be planned as per the LR guidelines of Ministry of Health and Family welfare. The PWD should be informed about this and planned accordingly. For the present , those places which have deficiencies can ask for extensions.

Obstetric HDU , Cemonc OT and NBSU/  SNCU  should be close to the LR.

All our Labour Rooms should have an uplift in  infrastructure. Laqshya - is a good opportunity for this.

Bme visit to Gh- certain instructions given
1) Stock register of all equipments with purchase details  and issue , name of supplier, agency- to be maintained by pharmacist
2) Equipment log book to be maintained for each equipment
3) Breakdown register to be maintained in cmo room and in respective departments
4)preventive maintenance register
5) Work instruction and trouble shooting -  for each equipment - to be displayed. ( bme will give training on this- record the training)
6) procedure to be followed in case of equipment breakdown- to be displayed.
7) Manual for each equipment - to be kept safely and maintained
8) Equipment checklist- to be maintained in each department and checked during each shift.

Fumigation has to be done at least once a month - in LR with H2PO2 based liquid and Bacillocid in OT. If the culture reports are positive, repeat the cleaning and fumigation till the report comes as negative. A Root cause analysis ought to be done for all positive reports.

Having formed the Quality Circles and Identified individuals to shoulder responsibilities, complete the documentations required in Area of Concern G and H
1) Rounds book maintenance by HOD and NS and Department in charge - these are only informal observations made during rounds and what is required for correction. 
2) SOP for i) LR ii)OT
3) Quality policy - frame a statement
4)  Quality Objectives
5) Patient Satisfaction Survey
6) Process Map
7) Gap analysis and Action planning
8) Quality tools- use simple tools like Run chart, Fish Bone diagram, Why Why analysis, Brain storming
9) Calculation of the Quality Indicators
10) Audits- i) Maternal death ii) Near Miss iii) Infant death iv) Referral v) LSCS vi) Infection control

Lakshya model case sheet  has been provided. The safe child birth checklist , pantograph and newborn anomaly screening has been included in this. It is for the Institution to decide on the case sheet format to be used. This model case sheet , that which is convenient and easy for documentation. Medication chart has to be attached. Postpartum assessment and monitoring is already there. The doctors have to discuss about these and choose an appropriate format .

Signages:-
1) Directional signages - leading to Labour Ward, NICU. Directional signage from LR to OT.
2) Patient rights and responsibilities-  in corridor
3) Entitlements-  JSSK, JSY, Family planning incentives, Dr. Muthulakshmi Reddy scheme etc.( at entrance of Labour Ward complex)
4)Any tariff - like x Ray film . (All diagnostics, treatment, investigations- there should be no out of the pocket expenditure for the patients- patients will be interviewed during assessment)- ( at entrance of Labour Ward complex)
5)IEC- Breast feeding, personal hygiene, Family planning methods, Immunization, Hand washing, KMC etc. - in patient waiting areas and in wards.
6) Scope of Services- available and non available services ( at entrance of Labour Ward complex)

7) Layout- of the Labour Ward complex, Fire escape route plan, BMW plan - ( at entrance of Labour Ward complex)
8) Quality policy- at entrance of LR  and in the wards
9)Quality Objectives- at entrance of Labour room
10)Emergency protocols- in OBSTETRIC Casualty and in LR and Nursing stations( display should not be on tiles- these have to be cleaned every day)
11)Dos and Donts, Right drug Management, clean procedures during Delivery, Management of equipment breakdown, RMC, Blood spillage Management, Needle stick injury Management- display in nursing station ( maintain Blood and Mercury spillage kits- if mercury equipments available)
12) Handwash- 6 steps- above washbasin.In Ot- Surgical Hand scrub in addition
13)5 Moments of Hand hygiene- in nursing stations and wards
14)NBCC- Resuscitation, EssentialNB care
15) Restricted entry- LR, NICU, OT
16)Stretcher bay, Wheel chair bay
17) Empty and Full oxygen cylinders
18)Fire Assembly

All signages to be bilingual and pictorial. Labeling- in English.

Cupboards and Refrigerator- label the contents inside rackwise
Equipments- Logbook, work instructions - to be maintained
BMW- segregation display ( above the bins)
General waste- label- biodegradable and recyclable waste

All display should be neat and the walls should not be studded in a haphazard manner

Admission Criteria and Discharge Criteria  to Clean  LR .
Admission Criteria for Septic LR. These should be known.

Admission criteria to LR eg. When patient is in Active Labor.
Discharge criteria from LR eg. After the required period of observation when the vitals are stable, uterus well contracted and no undue vaginal bleeding . This criteria applies to LR

Providing privacy , confidentiality of patient records especially those cases with social stigma like HIV, unmarried pregnancy etc.,  avoiding abusive language and being polite and attentive to her, keeping her informed about her condition and treatment planned, providing all related information like IEC , allowing a companion and making the person relaxed and feel dignified and satisfied. Wherever documentation possible in these including training in RMC , keep records physical or video recordings.

IEC in waiting areas for relatives and patients waiting outside. Include handwash and personal hygiene. BF,KMC,Immunization, FP needs to be displayed near Delivery room also.since everything related to baby starts from here.