Monitoring of Non-communicable Diseases in a Primary Healthcare Setting in India: A Quality Improvement Initiative

Background The majority of patients with non-communicable diseases (NCDs) seek care in a primary healthcare setting. There is a lack of effective monitoring of patients with NCD, which leads to poor disease control and an increase in morbidity and mortality. We wanted to explore the feasibility of maintaining patient health record and utilising it for disease monitoring in a primary healthcare setting. Therefore, we aimed to increase the availability of patient health records from 0% to 100% using the principles of quality improvement (QI) among patients with hypertension and/or diabetes within six weeks and to use these records for assessing the disease control status of patients through cohort monitoring approach. Methods This QI initiative was conducted at an urban health centre (UHC) located at Dakshinpuri, New Delhi. We specifically focused on two major NCDs: diabetes and hypertension. We formed a QI team and identified the gaps using fishbone analysis and a process flow diagram. We used the model for improvement and the Plan-Do-Study-Act (PDSA) framework. We conducted repeated rapid PDSA cycles for the designed intervention and monitored the change every week using a run chart. The data from the patient health record were entered into Microsoft Excel (Microsoft Corp., Redmond, WA) using Google Forms (Google, Inc., Mountain View, CA) and Epicollect5 (Oxford Big Data Institute, Oxford, England). We used the cohort monitoring approach of the India Hypertension Control Initiative to assess the quarterly control rate for hypertension and diabetes at the UHC. Results The root cause analysis revealed that the lack of a policy for keeping patient records and the lack of perceived need in the past were the primary reasons behind the absence of NCD health records. In brainstorming sessions with the QI team, we designed a paper-based patient health record system involving unique identity (ID) generation, an index register, an NCD record file and an NCD passbook (Dhirghayu card) for each patient. We reorientated the process of patient flow and devised a mechanism for record-keeping at the UHC. This initiative increased the availability of patient health records from 0% to 100% in the initial three weeks. The system of maintaining patient health records was well received by the patients and was better utilised by treating physicians for NCD management. After the intervention, we were able to use the data from the NCD file to assess the quarterly control rates of