Impact on Kayakalp scores after undertaking of a primary health center by community medicine dept. of a medical college of J and K

ABSTRACT

Introduction:

To complement the Swachhata Abhiyaan effort, the Ministry of Health and Family Welfare, initiated “KAYAKALP.” Kayakalp is an initiative to improve the cleanliness, hygiene, and sanitation of public health facilities by recognizing and giving awards to those who exhibit a high level of cleanliness, hygiene, and infection control. Our study aimed to assess the level of cleanliness, hygiene, and infection control practices in the health care facility after undertaking by the department of Community Medicine of a medical college.

Methodology:

A retrospective comparative observational study was conducted at RHTC in the Kathua district of UT J and K. We compare the level of cleanliness, hygiene, and infection control practices using the Kayakalp scoring tool before and after taking over by the department of Community Medicine of a medical college. The scoring for various areas of concern is based on a checklist for quality assessment which includes facility upkeep, sanitation and hygiene, waste management, and infection control.

Results:

The total scores vary before and after undertaking of a Primary Health Center (PHC) by the Community Medicine Department of new medical college of J and K. Overall scores vary from the baseline score of 56% before to 84% now after 2 years of the undertaking.

Conclusion:

Resource management and capacity building under the guidance of public health professionals can result in a significant increase in hygiene, cleanliness, and infection control. So integrated approach involves public health specialists and other medical professionals like medical officers, field workers, sanitary inspectors. etc., can be helpful in recognizing the challenges and barriers.

Introduction

The mainstay objective of all health care facilities is to treat the patients. In addition to cure disease and infection, health care personnel are meant to “do no harm” to all those visiting the health care facilities. For the prevention of hospital-based infections, the most vital factor is the maintenance of cleanliness and hygiene of the health care facility environment. This can lay the foundation for a positive experience for patients and visitors.[1,2]

“Swachh Bharat Abhiyaan” was launched by the government of India in 2014 to promote cleanliness in public.[3] To complement this effort, the Ministry of Health and Family Welfare, initiated “KAYAKALP.” Kayakalp is an initiative to improve the cleanliness, hygiene, and sanitation of public health facilities by recognizing and giving awards to those who exhibit a high level of cleanliness, hygiene, and infection control.[4] Each year under Kayakalp, tertiary care hospitals, district/zonal hospitals, community health centers, and primary health centers are assessed as per formulated guidelines under the program. This process is completed in three steps, at first an internal assessment is made by the health facility and later on peer assessment is done for the same facility to validate internal scores. Final nomination for the award is made only after a score of an aggregate of more than 70% in peer assessment. In the final step, an external assessment is done followed by the result of the winners.[5]

Many times health care facilities especially in the peripheral area do not even reach the level of qualification for external assessment under Kayakalp.[1] But of the total public health facilities in Tamil Nadu, only 23% of the facilities got the Commendation Award/Commendation Certificate/Runner/Winner, and the remaining 77% of the public health facilities are either non-performing in Kayakalp or not qualified for external assessment or not selected in external assessment, respectively, for the year 2018–19.[6]

Various factors can lead to low scores. One of the factors includes a lack of proper sensitization and training in health care and proper resource allocation. Many studies have also highlighted that regular periodic monitoring and training increase the knowledge, awareness, and practices among the health care providers which can improve biomedical waste management (BMWM) in the health care facilities.[7,8] Proper resource management and training of the staff done under a specialist like public health specialist can improve the scoring of Kayakalp checklist and eventually can lead to improvement in insanitation and hygiene at peripheral level health care facilities. This can be overcome if public health expert is present at the peripheral level.

There is a dearth of literature to determine the role of public health experts in improving the quality of sanitation of public health facilities. So this study was conducted to assess the change in the overall sanitation and hygiene of public health facilities under the guidance of people with expertise in public health. Our study aims to determine the change in the level of cleanliness, hygiene, and infection control practices in the health care facility after undertaking by the department of Community Medicine of a medical college.

Methodology

Study design: A retrospective comparative observational study was conducted at RHTC in Kathua district of J and K state. Study setting: RHTC Budhi is the field practice area of the Department of Community Medicine, GMC Kathua in J and K. RHTC Budhi caters to a population of around 18,000 and provides promotive, curative, and preventive services. Administrative control of RHTC Budhi was taken by GMC Kathua in 2019. Before that, it was under the direct control of the health department. Study duration: Duration of the study was for 1 month—March 2022. The study was conducted after getting the approval from Institutional Ethical Committee. We compare the level of cleanliness, hygiene, and infection control practices using the Kayakalp scoring tool before and after taking over by the department of Community Medicine of a government medical college. Eligibility criteria: Out of 27 total primary health centers (PHCs) in the Kathua district, only RHTC Budhi, GMC Kathua was qualified for Kayakalp.

Kayakalp awards are given to those public health facilities that demonstrate the highest standards and levels of cleanliness, hygiene, and infection control. This initiative was launched with the objective to promote cleanliness, hygiene, and infection control practices, incentivize, and recognize such public healthcare facilities that show exemplary performance and inculcate a culture of ongoing assessment and peer review of performance. The scoring under Kayakalp is based on a checklist for quality assessment for PHCs which includes facility upkeep, sanitation and hygiene, waste management, and infection control. Different thematic areas were further divided into different criteria points to reach a consolidated score for that thematic section. Each criterion thereupon was further assessed on the basis of the check point, means of verification, and assessment method as per guidelines.[4] The assessment methods used were direct observation, staff interview, and records and documents. Scores were applied as fully compliant (2), partially compliant (1), and non-compliant (0). A record review of the Kayakalp external assessment checklist was used and results were then compared before and after being taken up by Community Medicine Department. It is a descriptive study so the statistical analysis was done using numbers and percentages.

Results

This study was conducted to assess the level of cleanliness, hygiene, and infection control practices in the health care facility after undertaking by the department of Community Medicine of a medical college.

Table 1 shows the scoring under different themes for the year 2018–19, 2019–20, and 2020–21, that is, before and after the administrative control by the department of Community Medicine of a medical college.

Table 1.

Year wise thematic scores

Kayakalp Themes	Without public health specialist 2018-19	After public health specialist
		2019-20	2020-21
PHC Upkeep (60)	41 (68.3%)	48 (80%)	52 (86.67%)
Sanitation and Hygiene (60)	40 (66.67%)	52 (86.67)	56 (93.33%)
Waste Management (60)	27 (45%)	38 (63.3%)	40 (66.67%)
Infection Control (60)	26 (43.3%)	44 (73.33%)	49 (81.67%)
Support Services (30)	20 (66.67%)	24 (80%)	29 (96.67%)
Hygiene Promotion (30)	20 (66.67%)	26 (86.7%)	26 (86.7%)
Beyond Hospital Boundary (60)	27 (45%)	37 (61.67%)	51 (85%)
Total	201 (55.83%)	269 (74.7%)	303 (84.15%)

There is an upward trend in the Kayakalp Scoring in all the themes for the past 3 years and also increase in the percentage of scores after taken over by community medicine department in 2019 [Figures 1 and 2]. The PHC upkeep of the total scores obtained in 2018–19 was 41, for the year 2019–20 is 48, and 52 for the year 2020–21. There was an increase in the total score in the year 2020–21 because of orientation training by public health experts. Initiatives were taken for gardening, maintenance of open areas, and maintenance of furniture, illumination, etc., As we can see that there is an improvement in the score of the year 2019–20 in the field of landscaping, PHC appearance, and workplace management as compared to the previous year.

Figure 1.

Showing the trends in the Kayakalp scoring under various themes for the year 2018–19, 2019–20, and 2020–21

Figure 2.

Showing the Kayakalp scoring percentage for the year 2018–19, 2019–20, and 2020–21

There was an improvement in the use of standard material and equipment for cleaning, use of standard methods for cleaning, and monitoring of cleanliness activities under sanitation and hygiene measures adopted in the RHTC, where the total score obtained is 56 in the year 2020–21 as compared to the year 2018–19 which was 40.

There was an improvement in sharp management, disposal of biomedical waste, management of hazardous waste, and liquid waste management. On assessment in the year 2018–19, the total score obtained was 27, in the year 2019–20 it was 38, and in the year 2020–21 it was 40.

Scores also showed improvement in spill management and infection control programs. The different parameters included hand hygiene, personal protective equipment to environmental control. Interestingly, on assessment, the score obtained was 26 in the year 2018–2019 and 49 in the year 2020–21.

In the year 2018–19 the total score obtained in regard to support service was 20, in the year 2019–20 it was 24, and it was 29 in the year 2020–21. Improved scores were seen after training and capacity building of the health care workers by public health experts and also due to coordination with local bodies, community participation which leads to increase the alternative source of funding through PRIs (Panchayat Raj Institution) funds. These funds were further used in Swatchta and cleanliness of approach road beyond the boundary.

There was a significant improvement in the scoring of beyond hospital boundary. In the year 2018–19, the score was 27; in the year 2019–20 the score of 37 was obtained, while in the year 2020–21 score of 51 was achieved.

Discussion

There is a lot of concern among the general population about the quality of health care services in public health care facilities. The impression of public health facilities is generally a place with unpleasant and dirty surroundings and poorly maintained buildings, overflowing drains, animals inside the hospital, and dirty or non-functional toilets. Quality healthcare can be provided in government hospitals by improving their hygiene and cleanliness, BMWM, and support services. This study was conducted to assess the change in the quality of sanitation and hygiene and Kayakalp scores of RHTC after taking over by the department of Community Medicine.

In the external assessment for the year 2018–19, RHTC Buddhi had a total score of 201 (55.8%) with thematic scores of hospital upkeep (68.3%), sanitation and hygiene (66.67%), BMWM (45%), infection control (43.3%), support services (66.67%), and hygiene promotion (66.67%). This year RHTC did not qualify for external assessment. The poor scoring can be attributed to inadequate knowledge on the part of the health care workers in providing quality health care as well as maintaining cleanliness in the hospital. This can be compared with a study done on Public Health Facilities in Tamil Nadu which reported that out of the total public health facilities in Tamil Nadu, only 23% of the facilities got the Commendation Award/Commendation Certificate/Runner/Winner, and the remaining 77% of the public health facilities are either non-performing in Kayakalp or not qualified for external assessment or not selected in external assessment, respectively.[6] Various factors leading to low Kayakalp scores can be attributed to non-formation of specific committees to assess the public health facilities, deficiency of proper resource management including manpower, money, material, and lack of regular training and sensitization of staff about the objectives of Kayakalp program at PHC level.

The thematic scores obtained in our study for the year 2018–19 can be compared with the results in a similar study done on Kayakalp peer assessment in Himachal Pradesh in which the best performing PHC had a total score of (66.3%) with thematic scores of hospital upkeep (76%), sanitation and hygiene (81%), BMWM (60%), infection control (62%), support services (43%), and hygiene promotion (60%).[1] Another study was done by Mallappa et al.[9] which had aggregated total scores of (46.4%), hospital upkeep (35%), sanitation and hygiene (53%), BMWM (57%), infection control (50%), support services (48%), and hygiene promotion (26%).

For the year 2019–20 RHTC qualified as well as won the Kayakalp prize by scoring a total score of 269 (74.7%) with thematic scores of hospital upkeep (80%), sanitation and hygiene (86.67%), BMWM (63.3%), infection control (73.33%), support services (80%), and hygiene promotion (86.7%). This was followed by consecutive win next year 2020–21 in which the total score was 303 (84.15%) and thematic scores of hospital upkeep (86.67%), sanitation and hygiene (93.33%), BMWM (66.67%), infection control (81.67%), support services (96.67%), and hygiene promotion (86.7%), respectively. This score can be compared with the similar study done in Mandi Himachal Pradesh where increased scores were reported after staff orientation and training.[10,11] This upward trend in the scoring of Kayakalp scores was noticed only after taking up the PHC by the department of community medicine of a Medical college. Thus, substantial and consistent improvement in the Kayakalp scores can be due to proper orientation, training, and expert supervision of public health professionals who are the part of Community Medicine department.

After the undertaking of the Department of Community Medicine, various deficiencies leading to low scores were addressed. There was the formation of specific committees for infection control, sanitation and hygiene, waste management, hygiene promotion, etc., to assess the public health facilities. A similar study done on the awareness of the Kayakalp has reported that the majority of the participants did not have adequate knowledge of Kayakalp and only one-third of the participants were not trained on Kayakalp.[12]

Keeping all this in consideration, the awareness of the concepts, definitions, and scores was explained in detail to the concerned health personnel through additional training. Emphasis on infection control was improved by staff training and strict adherence to recommended infection control practices. Kayakalp assessment helped the public health facilities to display uniform sign board and proper information, education, and communication (IEC) display in most of the public health facilities. But due to lack of uniform sign board and relevant IEC materials display reduced the scores during the Kayakalp assessment. As the financial commitment was low for IEC display, it was done with the existing funds The other issues faced for the major contribution for getting scores, namely, electricity problem, old lighting system, lack of LED, CFL bulbs, need of mosquito net, registers not maintained, no water connection, lack of inter wall painting, surrounding not clean, vendors outside the campus during AN clinic, lack of municipality drainage, etc., This issue was sorted out by the replacement of LED, CFL bulbs, maintenance of records, purchase of mosquito net, inter wall painting, and cleanliness of the surrounding area with the help of available funds.

Thus under the guidance of public health experts with the existing staff, funds, and infrastructure with proper resource management and training RHTC Buddhi was successful in winning the Kayakalp prize for the next 2 years.

Conclusion

Kayakalp’s assessment of PHCs is the right initiative for hygiene promotion and infection control at the first point of contact at the primary care level. But many times health care facilities do not get enough scores to even qualify. Resource management and capacity building under the guidance of public health professionals can result in a significant increase in hygiene, cleanliness, and infection control. So integrated approach involving public health specialists and other medical professionals like medical officers, field workers, sanitary inspectors. etc., can be helpful in recognizing the challenges and barriers. This can eventually lead to corrective actions for achieving the larger objective of infection control and apt medical care from grass root health care facilities at the peripheral level. The proposal of the establishment of public health cadre has already been made by the government in 2022 to augment the capability of the public health system for quality health service delivery.

Recommendation

The Kayakalp assessment of the public health facilities can lead to improvement in infrastructure, human resource, hospital cleanliness, infection control, etc., Under the guidance of public health specialists, the achievement of high-quality cleanliness, sanitation, and hygiene promotion is possible even with resource limitations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.