Transforming Hospital Housekeeping: The Kayakalp Journey

Abstract

Introduction

The Kayakalp guidelines for public healthcare facilities under the Swachh Bharat Abhiyan (Clean India Mission) focus on improving sanitation, cleanliness, and infection control at public hospitals in India. This study was conducted in a 960-bed tertiary-level teaching hospital in eastern India. Housekeeping has been a challenge in public institutions, with factors like overcrowding and resource constraints. Tobacco and betel nut chewing, spitting, poor sanitation practices, and open urination are major challenges in ensuring sanitation at the hospital. The research objective was to study the implementation of the Kayakalp guidelines for quality improvement in housekeeping services at the institution.

Methods

A pre- and post-interventional study was conducted using the Plan-Do-Check-Act (PDCA) quality tool. Plan phases included the gap assessment using the Kayakalp checklist with numerical scoring. Necessary interventions were done under three headings: structure, processes, and outcomes in the “Do” phase. The “Check” phase included monitoring of the activities followed by the “Act” phase, which included a review of the action plan. External experts nominated by the government conducted the final assessments and recommended it as one of the cleanest hospitals.

Results

A 360-degree improvement was observed in hospital services, with assessment score improvement from 73.68% to 95.0%. The institution received the first prize in 2020 and 2021 and runners-up Kayakalp National Award under category “B” (Institute of National Importance) Hospitals in 2019.

Conclusion

The implementation of Kayakalp guidelines of the Government of India proved to be efficient in the improvement of housekeeping and infection control practices in the institution.

INTRODUCTION

Kayakalp is a word in Hindi (an Indian Language) that means rejuvenation. The Swachh Bharat Abhiyan (Clean India Mission) was launched in 2014 by the Government of India to generate awareness among the general public to keep homes, cities, villages, and public places clean, resulting in improvement of sanitation across the nation for a healthier disease-free environment. Under this mission, the Ministry of Health and Family Welfare released the Kayakalp guidelines[1] for public healthcare facilities in the year 2015. These guidelines focus on improving sanitation, cleanliness, and infection control in public hospitals through infrastructure development, process standardization, staff training, and policy changes. Kayakalp has six components: hospital upkeep, sanitation and hygiene, support services, hygiene promotion, waste management, and infection control. The Ministry incentivizes public health facilities that demonstrate a high level of compliance with the Kayakalp guidelines.

Kayakalp is an ongoing assessment of healthcare facilities to ensure sanitation activities throughout the year. A checklist-based[2] assessment is conducted in three stages: self-assessment, peer review, and a final evaluation by external experts. The institution conducts the self-assessment. Full compliance to the standards in the guidelines is scored 2 points, partial compliance is scored 1, and zero for noncompliance. The Ministry reviews self-assessment and assigns peer groups consisting of faculty members of hospital administration, community medicine, and microbiology to assess the institutions. Based on the observations of the peer assessment team, the healthcare institution takes measures to close the gaps and prepare for the final assessment. The scoring in the self-assessment, peer assessment, and final assessment carries a weightage of 5%, 20%, and 75%, respectively, to calculate the final score. The final score is also based on bed occupancy rates, feedback assessment from Mera Aspataal, hospital statistics in outpatient and inpatient services, and best practices adopted by the institution. Healthcare institutions that achieve the maximum scores are awarded as per the rules. The monetary incentive for the first prize in category B medical institution is INR 2 Crores (∼USD 240,000). Twenty-five percent of the award money gets distributed among the institution’s staff as an incentive, and the rest of the amount is used for developmental activities.

Housekeeping has been a challenge in the institution, given the hospital’s massive load of patients and attendants (∼15,000 footfall per day). Two-thirds of the patients visiting the institution are from various parts of the state of Odisha and the neighboring states. They have a predominant practice of tobacco and betel nut chewing and spitting. Open urination by the general public is a major behavioral challenge.

Considering the preceding, the study was undertaken to evaluate the outcome of the implementation of the Kayakalp guidelines as a quality improvement strategy at the institution and recommend a sustainable model for improving cleanliness at public hospitals.

METHODS

This was a pre- and post-intervention study using the plan-do-check-act (PDCA) tool for quality improvement. It was conducted in a 960-bed hospital that is a tertiary-level teaching institution of national importance in eastern India. It has 36 outpatient units, 37 wards, 15 intensive care units (ICUs), 25 modular operating theaters, and other facilities. In a month, approximately one lakh patient attends outpatient services, 1700 avail inpatient services, and approximately 900 major surgeries are performed. More than three lakh laboratory investigations and about one lakh radio imaging diagnosis are conducted in the institute per month. The institutional ethics committee approved the study and waived the requirement for informed consent. The first external assessment by the Kayakalp team was conducted in 2017 in this study setting, which provided preliminary information about the program.

The details of activities and interventions during the implementation of the PDCA (Fig. 1) quality tool are listed in the following sections.

Figure 1.

Plan-Do-Check-Act (PDCA) quality tool.

Plan Phase

The Kayakalp Facilitation Committee was composed of faculty members from various departments, such as hospital administration, microbiology, community and family medicine, and other departments, infection control nurses, engineers, and other senior officials. The residents, nurses, sanitary inspectors and housekeeping staff, security personnel, and junior engineers constituted the ground workforce. A schedule for periodic committee meetings and supervision of the work by the hospital leadership was also put in place and adhered to. An action plan was developed and responsibilities were assigned to individual members of the team. This included gap assessment, in the housekeeping services, waste management services, and infection control using the Kayakalp checklist for direct observations, staff interviews, review of records, and patient interviews. Preparation of standard operating procedures (SOPs) for housekeeping services, biomedical waste management, and hospital infection control practices were planned. The staff training calendar was prepared to include all staff in a phased manner. Strengthening of the housekeeping team was planned. Expansion of the hospital infection control surveillance to all areas of the hospital was planned, including outpatient units. The development of pictographic Information Education and Communication (IECs) content signage and multilingual signage for wayfinding was included in the action plan. Infrastructure plans included modular nursing stations, adequate housekeeping staff, fire safety, waste management facilities, and adequate handwashing facilities. Procurements of housekeeping items, disinfection agents, and transportation trolleys were planned. A mechanism for the collection of patient feedback and measurement of patient satisfaction through surveys was planned. Hygiene promotion events in the institution and community were planned in collaboration with non-government organizations.

Do Phase

The findings of the gap assessment were listed. Process mapping and cause-and-effect diagrams were used to identify all possible issues and list them as per priority. The gaps were categorized into structural changes, process changes, and others. The action plan along with roles and responsibilities was explained to the concerned staff for its execution.

Interventions (Table 1) included preparing the SOPs, initiating policy changes with office orders for the prohibition of tobacco products, hospital upkeep, energy conservation initiatives, improvement of housekeeping and other support services, supplies and procurements, waste management, infection prevention, and control practices, hygiene promotion, institute quality council for implementation of the quality programs, formation of a human resource development (HRD) cell for conducting the induction and in-service training, and internal audits using Kayakalp checklists.

Table 1.

Summary of the Kayakalp implementation program in the hospital

Category or Domain	Pre-intervention Status	Interventions	Post-intervention Results
Policy implementation	Public spitting, spit marks on walls, open urination in hospital premises.	Prohibition of spitting, tobacco usage, and open urination on hospital premises and penalty imposed.	The incidence of spitting and open urination was reduced, and patient satisfaction improved with better ambiance.
Hospital upkeep	High usage of plastics. The gardens and pavement were not maintained. Patient inconvenience due to lack of signage and roofing of pavement near OPD, pharmacy, and emergency.	Policy implemented for single-use plastic–free campus. Vermicomposting, herbal garden, and indoor plantation improved. Installation of multilingual signage, TV networks, and roofing barricades of the footpaths.	Cloth bags were provided to patients and staff for usage. Landscaping and interior improved. Improved wayfinding through signage and safe patient passage provided comfort to the public.
Energy conservation	High consumption of electricity and water in the hospital. Use of motor vehicles inside the campus.	Installation of solar panels, a rainwater harvesting system, wastewater recycling, and provision of bicycles and e-vehicles on the campus.	Financial benefit of USD 6000 per month from solar electricity generation. Rainwater harvesting added to the groundwater reserve. Recycled wastewater was used for gardening. Use of cycles on campus added to staff convenience.
Housekeeping services	Lack of standardized cleaning methods, untrained staff, and ineffective cleaning and disinfection practices. Poor communication among sanitation with low motivation.	Housekeeping manual prepared. Staff training. Availability of cleaning materials. Live communication (WhatsApp group). Award and cash incentives for best sanitation staff.	Effective cleaning and disinfection with trained staff and improved communication. Motivated staff.
Procurement	Use of single bucket for cleaning. Irregular supplies of cleaning materials prevented regular cleaning activities. Wheelchairs used for transportation of items.	Procurement of three-bucket system. Cleaning materials. Mobile tablets. Transport trolleys.	Improved cleaning and disinfection. Ensured uninterrupted services. Improved communication and internal transportation of items.
Support services	Irregularities in linen management. Inadequate supervision of kitchen services. Pharmacy stockouts. Missing (laboratory) samples incidents.	Linen and laundry, kitchen, and security services streamlined with SOPs. Pharmacy – regular purchases to avoid stockout. Closed safe containers for transportation of laboratory samples.	Improved linen services added to patient satisfaction. Smooth and timely diet services with regular staff health checks ensured service improvement. Stockout of essential medicines prevented. Reduced incidences of mission samples.
Waste management services	Mixing of general waste and biomedical waste. Incidents of needle stick injuries. Missing BMW bags as the waste yard was not secured.	Monitoring of waste collection with regular staff training. IEC installed in all areas. Disinfection of recyclable waste. Barcoding of waste bags barcoded. BMW yard secured with boundary wall.	Regularization of BMW services by the authorized agencies. Reduced incidence of NSIs. IEC helped as quick aid. BMW transportation improved and prevention of unauthorized access.
Hospital infection control activities	Limited infection control surveillance. Irregular committee meetings. Low compliance to hand hygiene among staff.	The team was strengthened. Hospital infection control manual was developed. Hand hygiene audits and HAI surveillance was expanded to all areas. Antimicrobial stewardship program implemented. Recognition for best hand hygiene compliance on World Hand Hygiene Day.	Standardization of infection control activities with regular meetings and improved HAI surveillance. Sharing of audit reports ensured improved compliance in infection control practices. Recognition of departments for strict infection control practices motivated the staff.
Hygiene promotion	Limited activity of community education and public awareness.	Special events like marathons, cycle rallies, painting competitions for children, soap distribution, and campaigns in schools and communities, conducted.	Faculty members, officials, students, nurses, and other staff in the events. Children's involvement in such activities helps to create a better future.
Quality control	Infrequent quality audits and low incident reporting by the staff.	Committees in the Institution Quality Council conducted awareness sessions for incident reporting with RCAs and CAPAs, periodic audits, and research studies.	Research projects in quality improvement. Sharing of audit reports among the stakeholders improved compliance and prevention of errors.
HRD cell	Lack of orientation of staff about hospital and policies and incidents due to inadequate staff training.	Induction training for orientation and skill development of staff.	Improved patient outcomes through improved patient care services.

OPD: outpatient departments; SOP: standard operating procedure; BMW: Biomedical waste; IEC: information education and communication; NSI: needle stick injuries; HAI: healthcare-associated infection; RCA: root cause analysis; CAPA: corrective and preventive actions; HRD: human resource development.

SOPs for housekeeping services, biomedical waste management, and hospital infection control practices were prepared and circulated. Single-use plastic items, spitting inside the hospital premises, the consumption of tobacco items, pan (betel), or any other illegal items were banned, and a penalty was imposed for the violation. Senior management brought the policy changes and ensured strict compliance.

Hospital upkeep initiatives included the improvement of lighting; indoor plants; maintenance of lawns and fountains; development of an herbal garden and vermicomposting system that provided manure for gardening; building maintenance with periodic painting of walls; repair of soakage in walls, broken tiles, and replacement of broken toilet accessories; installation of fire safety and wayfinding signage; and extension of pest control activities for the campus. The light-emitting diode (LED) televisions installed in the waiting rooms of the hospital block were integrated into a shared network to display hospital information and IECs (Supplemental Tables S1 and S2).

Energy conservation initiatives included water conservation and solar power generation. Energy-efficient LED lights were installed. Awareness signage on water conservation and auto-switch water faucets were installed. Rainwater harvesting systems were enabled. Solar panels were installed on the rooftop of the hospital and other buildings. Collaboration with “Mo-cycles,” a government agency that provides bicycles was done to provide bicycles for transportation on campus. Battery-operated vehicles were used for the transportation of waste from the hospital to the waste yard. Wastepaper packaging materials were converted into reusable waste bins. Scrap wood was used for making flower pots and fences. Wastewater treated at sewage and effluent treatment plants was used for gardening. The food waste was collected from the kitchen for vermicomposting.

The housekeeping team was strengthened by recruiting an additional workforce. Staff allocation was streamlined using duty rosters and each patient care area was provided with housekeeping or sanitation staff on each shift. Staff was trained through a structured training program on cleaning methods, dilution of cleaning solutions, cleaning frequency, biomedical waste, and liquid waste management, and use of personal protective equipment. The cleaning activities were divided into daily, weekly, and special activities.

Floors, cots, and other types of furniture were cleaned daily. Weekly and special cleaning included cleaning of equipment, operation theatre (OT) complexes, terraces and rooftops, cobwebs, windows grills, and window shades. A special team was deployed to collect waste directly from patients and visitors. An appreciation system was developed to recognize the best sanitation employees with monetary rewards on important days such as the institute’s Annual and Foundation Day.

A fast-track system was initiated for the procurement of housekeeping items like mops, three-bucket trolleys, cleaning and disinfection agents, cleaning equipment, foot-operated color-coded dustbins, and others. Linen hampers for dirty linen collection from the wards and ICUs, foot-operated bio-medical waste collection (BMW) waste bins of appropriate sizes, color-coded bags for BMW collection in patient care areas, and twin dust bins for general waste collection were purchased. Mobile tablets were procured and used for general communication, telemedicine, and feedback collection. Container trolleys were procured for the transportation of hospital waste. Hand-held, temperature-proof, closed containers were procured to transport laboratory samples from the patient care areas to the respective laboratories.

The linen distribution system was centralized and the damaged linens were recycled to make hand towels. The kitchen staff was vaccinated and trained in self-hygiene, safe food handling practices, pest control, and food waste management. Security staff were trained in behavioral skills, prohibition of tobacco usage, single-use plastics, spitting, and crowd management. Statutory and other legal contracts were updated as per requirement.

A dedicated waste management team timely collected the solid and biomedical waste from all the areas as per the schedule. Biomedical waste was segregated at the point of generation. Signage was installed in all units and SOPs were provided. Adequate foot-operated color-coded dustbins and sharp containers were made available in each unit. Training sessions were conducted for resident doctors, nurses, and other paramedics for safe practices while handling biomedical waste. A barcoding system for waste bag tracking and measurement of waste volume was implemented, and hazardous and infectious waste was disinfected by microwaving at the waste collection center before handing it over to the authorized agency for further disposal. E-vehicles are used to transport the waste from the hospital to the waste collection yard.

The hospital infection control manual was revised and made available to each unit. The infection control team was strengthened. Hand hygiene compliance and microbiological surveillance for catheter-associated urinary tract infections, central line-associated bloodstream infections, ventilator-associated events, and surgical site infections were extended to all areas. Faculty members, residents, nurses, students, and other staff were trained in standard precautions and other infection control measures. Compliance reports were circulated across all departments. The availability of handwashing facilities and sanitation items was ensured. IEC for occupational exposure, spill management, 5-S (Sort, Set in Order, Shine, Standardize, and Sustain) implementation, hand hygiene, no spitting, no tobacco, good toilet practices, and waste management (Supplemental Table S1 and Supplemental Figures S1–S4) were fixed. Closed containers for the safe transportation of samples, steel trolleys for the transportation of items, and registers for documentation were made available.

Cleanliness campaigns were organized for hygiene promotion among the public and the community. The “Swachhata Pakhwada” campaign in the month of April and the “Swachhata Hi Sewa” campaign in October were the major hygiene promotion activities in the institute. They included the Swachhata pledge by the staff and the students, tree sapling planting, mass cleaning drives on campus and outside campus, walkathon and cyclathon rallies (cycle rallies), essay writing competitions among school children, painting competitions, short movies by staff, street plays, and soap distribution among visitors and patients. The IECs like posters, banners, and leaflets on personal hygiene, hand hygiene, and waste management were used for patient education. Various national and international health days were observed. Patients and visitors were provided with a cloth bag in exchange for plastic carry bags on a free-of-cost basis to make a single-use plastic–free campus a reality. An online patient feedback system was implemented in addition to the paper-based system.

The Institute Quality Council took initiatives in areas of hospital infection control, medical audit, medication safety, surgical safety, fire safety, and sentinel event monitoring. An online medication error reporting system was developed. A mechanism was developed to assess the implementation of Kayakalp guidelines in various patient care areas. A modified Safe Surgical Checklist, covering the preoperative preparedness for surgical cases was implemented. The antimicrobial stewardship program was implemented in departments. The Quality Council conducted national-level seminars and workshops on patient safety, healthcare quality, and nursing excellence. Fire safety infrastructure was improved with fire signage, escape maps, staff training sessions, and mock drills. Research projects on quality and patient safety were initiated.

The HRD cell was formed to conduct induction training programs for all categories of staff to orient them to Kayakalp guidelines and their implementation at the institute. Topics for the training are provided in Supplemental Table S2. The structural modifications as per requirement were completed by the engineering team.

Check Phase

The nodal officer of the Kayakalp committee supervised the activities to identify the bottlenecks during the daily leadership rounds. Staff awareness about SOPs was assessed. Findings of gap assessment and observation by various members and staff were discussed in review meetings.

The housekeeping activities were supervised by sanitary inspectors using area checklists. Staff feedback was collected on cleaning frequency, methods of cleaning, usage of cleaning equipment, and chemicals for cleaning and disinfection activities. Social media app chat groups were created to monitor all activities before cleaning and after cleaning an area. The outsourced services were monitored and evaluated for contract validity and deliverables. Noncompliance or breach of the terms and conditions by the outsourced agencies was highlighted to the authorities.

The handling of biomedical and solid waste was monitored physically and also on the website. The barcoding system helped to track the waste bags and the measurement of volumes of waste generated.

Departments with poor hand hygiene compliance were identified by the hospital infection control team and were informed about the findings. Staff members were interviewed to demonstrate the steps of hand hygiene, cleaning methods, spill management, steps in the management of needle stick injuries, and waste management practices. Culture reports of surface, water, and air samples from ICUs, labor rooms, and modular operation theaters were assessed for environmental monitoring. The centralized air conditioning system was also assessed as per the hospital infection control (HIC) protocols. Monthly trends of the healthcare-associated infection (HAI) surveillance were analyzed and reports were shared with all state holders.

Patient feedback was collected from the suggestion boxes, patient feedback forms from wards, online feedback, and patient grievances through the administrative control room. Reports from the Mera Aspataal (Government of India initiative to collect feedback on hospital services) feedback system were also collected.

Hazard identification and risk assessment of the hospital block was conducted by the hospital administration. The internal audits included nursing audits, medication errors, adverse events and sentinel event monitoring, pharmacy inventory, fire safety, hospital infection control surveillance, and patient satisfaction. Reports of peer assessments, internal audits, and the hospital infection control team were analyzed.

Act Phase

The action plan was revised based on the review of all three phases of the plan, do, and check. Necessary email communications and official circulars were sent to all concerned. The SOPs and manuals were revised wherever found to be necessary based on the user feedback after validation of the same. Violations of hospital policy on tobacco usage, spitting, and open urination were reviewed and the security team was assigned the task of public awareness on the same. The challenges in procurement and engineering-related issues were addressed with the involvement of senior management officials. A penalty was imposed on vendors for unsatisfactory performance and delays in supplies or services. Several pieces of equipment and furniture were identified to be condemned. The timeline of the collection of waste by the authorized vendors was ensured. The departments with poor compliance with hand hygiene and infection control practices were guided by the team to take necessary steps for improvement. The institution observed World Hand Hygiene Day in which the departments with the highest hand hygiene compliance were appreciated.

The best housekeeping staff members were appreciated with a monetary award each month on the institution’s annual day.

Actions were taken on the suggestions and feedback received and were communicated to the complainant or the patient. The low-scoring points in the Mera Aspataal feedback system were included in the action plan.

RESULTS

The assessment score based on the Kayakalp checklist improved from 73.68% to 95.0%. A 360-degree improvement was observed in all six domains of the Kayakalp initiative within a period of 6 months.

Feedback analysis showed an improvement in overall patient satisfaction from 63% to 81% (Fig. 2). The patient satisfaction score related to staff behavior (Fig. 3) also improved. The patients’ grievances about the housekeeping services were reduced and this was evident in the feedback. The patient satisfaction score for housekeeping services increased from 71% to a level of 93%. Hand hygiene compliance by the staff improved from 46% to 95% in all the patient care areas. The incidents of occupation exposures like needle stick injuries were reduced by 53% over the study period. The biomedical waste segregation practices showed gradual improvement and were appreciated by the Central Pollution Control Board, Government of India. The compliance with the safe surgery checklist improved to 100%.

Figure 2.

Overall patient satisfaction trend.

Figure 3.

Patient satisfaction level with staff behavior.

The well-maintained hospital building through engineering interventions helped in safe and smooth patient and staff movement in the hospital and added to their satisfaction.

Solar energy systems generated approximately 4500 MW of electricity per month. Surplus power was transmitted to the grid for public use. This activity had a financial advantage of approximately INR 5 lakh (∼6000 USD) per month for the institute. Approximately 5 lakh liters of wastewater was recycled daily and used for gardening purposes.

Rational distribution of sanitation staff with the addition of manpower as per the gap assessment helped to improve the housekeeping services. The regular supply of disinfectants and cleaning agents along with the cleaning equipment like the three-bucket systems ensured higher compliance with cleaning and enhanced patient as well as staff satisfaction with the cleaning activities. Adequate illumination and maintenance of furniture, equipment, and electrical, civil, air conditioning, and fire installations contributed to patient safety. The modular nursing stations ensured the use of the Five-S method at the wards, ICUs, and other areas for continuous quality improvement. Standardized templates for records and registers made the documentation easier for the staff.

The institution was assessed twice a year (peer assessment and final assessment) by experts assigned by the health ministry. The institution received the prestigious Kayakalp first prize under category B in 2019–2020 and 2020–2021 and as a runner-up in 2018–2019.

DISCUSSION

The PDCA quality tool implemented by the institution for improving housekeeping services helped the institution to get the National Award of Kayakalp. Strategies like internal audits, the institution’s Quality Council, HRD, and teamwork with committed leadership of hospital administration ensured sustainable improvement in the quality of healthcare services.

Housekeeping practices, infection control practices, hand hygiene, patient satisfaction, signage, training, and development of SOPs were possible with an organized action plan, efficient execution, and teamwork. The study highlighted the impact of education, training, incentivization, and work culture on the sustainability of quality programs.

The best practices of cloth bag distribution in exchange for plastic bags given the prohibition of single-use plastics in the institution, the best housekeeping employee award, the best hand hygiene compliance award for departments, trilingual signage, and Swachhata campaigns were acknowledged and appreciated by the Ministry of Health and Family Welfare, Government of India.

The study findings were similar to those of Gautam et al[3] who assessed the Kayakalp scheme in district hospitals, community health centers, and primary health centers in northern India. Waste management and infection control practices were identified as the major areas for improvement. They opined that hand hygiene, use of personal protective equipment, monitoring HAIs, and taking corrective and preventive measures are vital in hospitals to reduce the rates of HAIs and contribute to patient satisfaction. Agrawal et al[4] retrospectively studied 32 district hospitals certified under National Quality Assurance Standards (NQAS). They found that the impact of Kayakalp is low as compared with that of NQAS, which could be because Kayakalp is one part of the NQAS that focuses on several other domains of quality assurance. In contrast, the Kayakalp program proved to be an effective quality improvement tool in the present study. Chaudhary et al[5] mentioned the usefulness of the Kayakalp guidelines as a standardized approach for the improvement of hospital services. They identified the challenges in housekeeping, security, and other outsourced services. The nonavailability of SOPs in housekeeping, BMW, and infection control were identified as major gaps, which is similar to the findings of the present study. Sungra et al[6] studied the impact of Kayakalp in a primary health center where they compared the level of cleanliness, hygiene, and infection control practices using the Kayakalp scoring tool. They concluded that there is a need for an integrated approach among medical and public health professionals for capacity building and resource management. Sharma and Barwal[7] mentioned behavior change in healthcare staff along with staff incentivization. They highlighted the involvement of community members, non-government organizations, and others to promote hygiene at the grassroots level. Panda and Nanda[8] studied the clean hospital initiative and the quality of health services using the Kayakalp tool in a first referral unit in Odisha, which showed significant improvement in the domains of hospital upkeep, sanitation and hygiene, biomedical waste management, and hospital infection control similar to the present study. Rattan and Sharma[9] assessed the primary health centers (PHCs) using the Kayakalp tool and highlighted the usefulness of a peer assessment for internal validation and gap assessment for further improvement. Tiwari and Tiwari[10] conducted a similar study in district hospitals where the highest improvements were observed in the area of hygiene promotion followed by support services and waste management. Kotwani and Gandra[11] mentioned that the Kayakalp program significantly improved antimicrobial stewardship in public health facilities. A cross-sectional study by Ray et al[12] was conducted in a district hospital and a medical college using the Kayakalp checklist and recommended using it for quality improvement in patient care services.

The present study not only showed improvement in healthcare services but also demonstrated a leap in patient satisfaction levels. It showed a behavioral change among the staff and as well as among the public visiting the hospital. This study can act as a reference for other centers to develop their strategy for the implementation of Kayakalp initiatives.

Challenges

The implementation of quality improvement systems in large public hospitals is a considerable challenge. This is primarily because of a lack of awareness among staff about healthcare quality and safety. Lack of professional behavior and poorly motivated staff hinder all activities. Delay in the procurement process in public sector hospitals needs urgent attention at a higher level. Compliance with hand hygiene by healthcare workers was highly challenging. In public hospitals, teamwork and consistent efforts are extremely vital for change management within the organization for quality improvement.

Limitations

The study was conducted to assess the quality improvement in only one hospital. The challenges and findings may differ in other hospitals considering the size and type of healthcare center. The Hawthorne effect cannot be ignored as the staff was aware of the fact that they were being monitored during the study period.

CONCLUSION

The quality tool (PDCA) implemented by the institution showed that the Kayakalp program is an efficient quality improvement strategy for public institutions. It created a movement among the hospital staff for sustainable and continuous activities, and the institution became a role model for other public hospitals. The Ministry of Health and Family Welfare, Government of India, has bestowed the institution with the Kayakalp award four times in consecutive years at the national level, which is a tremendous achievement for the entire team and motivated the staff who had put in efforts to maintain high standards of sanitation and disinfection at the hospital. Quality is a journey, and we must make sustained efforts to maintain cleanliness and sanitation throughout the hospital.

Supplemental Material

Supplemental materials are available online with the article.