Consultancy - Revision of the “Rehabilitation Management System”
The overall purpose of the Rehabilitation Management System (RMS) is to assist physical rehabilitation service providers in effective and strategic management of their services and provide the highest quality care in the most sustainable manner. To achieve this, the RMS summarizes the literature concerning good practices, legal requirements and agreed standards and guidelines, compiled in a set of standards. A scoring and planning system in excel sheets helps measure the compliance with those standards, identify gaps and priorities and take actions for continuous improvement in a systematic way. The core areas of the service evaluated are: Service Users, Service Outputs, Staff, Equipment & Supplies, Finances and Management Processes.
The RMS has been developed in 2011 by Humanity&Inclusion (HI) –also known as Handicap International- and has been implemented in 12 countries so far and in more than 20 rehabilitation centers. Several revisions of the set of standards were made since the first pilot, based on users’ feedback and efforts to align to global frameworks of quality in health. The reliability of the RMS as a quality assessment tool has been shown in a study done in 2016-2017, where a good internal consistency between the standards was found. In 2017, a new version of the RMS was made available based on the inputs and propositions issued from a participatory review in 2016 by several RMS implementers (international workshop). Following this last revision, the overall number of standards has been reduced to eliminate redundant items; others were slightly re-formulated to enhance understanding of more complex concepts. Since 2017, the new version has replaced the old one in countries where the RMS was already in use (Nepal, Cambodia, Bolivia, others) and it has been introduced for the first time in new programmes ( Iraq, Rwanda, Vietnam, others). The current package includes 1) 6 scorecards and a planning document in excel sheets 2) A practical guide that explains the evaluation and planning process, standards and core concepts related to rehabilitation services
Positive feedback from RMS implementers and HI programmes’ staff on its utilization include an appreciation of the guidance provided by the system, that allows a very comprehensive analysis of processes and helps identify priorities of interventions; the participatory approach, with the involvement of the entire rehabilitation service staff in the problem analyses, planning and implementation is also appreciated. Lessons learned from the implementation of the RMS have been identified in details only for the partners in one country (Cambodia, 2017). However, an overall understanding of how are new frameworks and standards on rehabilitation implemented in practice and what are the challenges for the implementation is needed. The effectiveness of the RMS in improving manager’s skills and consequently the actual performance of services has not been evaluated either.
The RMS is a center-based governance system and has been largely used as an auto-evaluation tool by each service, to support managers in their routine work. When the RMS is used by several services under the same authority ( Bolivia, Cambodia, Vietnam, Laos, Bangladesh), it can contribute to support central planning and fund raising strategies as well, by helping define common gaps or priority interventions.
2. Needs of revision
Following the introduction of the latest RMS version and its implementation in several countries, some areas of improvement related to the set of standards and the overall scoring system and methodology have been identified by HI rehabilitation specialists and RMS implementers. In the meantime, international standards have evolved as well . Revised standards for P&O services were released by ISPO (2017 and 2018), as well as guidelines for Rehabilitation services in Health Systems by WHO ( 2017).
2.1 General gaps identified:
2.1.1 RMS guide/glossary: details on the section statements not always useful: many of the complex or specialist terms in the tool don’t translate directly, they are not well understood. This includes concepts such as appropriate technology, holistic approach, code of conduct, continuous professional development, job description, equity, evidence based practice. For some of them, references are often requested.
2.1.2 Standards: some standards should be added, in particular in the scorecard on equipment and supplies; others should be differently organized and better explained (ex: finance). See Annex 1
2.1.3 Standards (2): when scoring is done by government services (in particular in the health system) trainers feel some difficulties in explaining “ not relevant” indicators. Usually they are related to finance and often HR management too- but a sample sub-set of standards has been requested to ease the selection of core set of standards.
2.1.4 Scoring system: descriptions are not always useful to identify and “measure” gaps in compliance with a standard.
2.1.5 Objective/subjective assessment and evidence: even though the need of providing evidence ( documentation of processes, data) is an overall requirement in RMS for demonstrating compliance with a standard, the RMS promotes simple reporting on how a decision was made regarding scoring. This is of course valuable for reflections and participation of the team, but at the same time teams might be uncertain on how to make a decision ( see point 3 and 4 ).
2.2 Rehabilitation standards in accreditation systems
Health systems use broad quality assurance frameworks for their facilities. Those systems usually do not include rehabilitation services. Lately, new demands from HI programmes were identified in relationship with the process of integrating “private” rehabilitation services into health systems. In particular, the development of accreditation mechanisms to evaluate non-government services are requested when private-public partnership models ( PPPs) are implemented.
The RMS is not designed to support audits or formal evaluations for accreditation and incentive-based mechanisms, however it can definitely contribute to such processes by providing standards to be integrated into local quality assurance systems. Following a workshop hold in Kigali ( Rwanda) in August 2019, the Ministry of Health requested HI to support the accreditation agency for health facilities (named RAAQH) to integrate and adapt 5 standards selected from the RMS into their accreditation package.
3.Overall objective and expected results of the consultancy
3.1 Objective: The revised RMS package allows understanding and improvement of quality of rehabilitation services and provides options for its monitoring, including indicators and tracking mechanisms.
3.2 Expected results:
ER 1. The overall effects and current challenges in RMS implementation are identified among implementing partners
ER 2. Rehabilitation standards are up to date; method for developing service-level indicators for center managers is developed and core indicators are available, with priority for core dimensions such as service user, service outputs, equipment and supplies, management processes.
ER 3. A selection of rehabilitation standards are integrated into the national health facilities accreditation system in Rwanda
4.1. Short report on overall effects and challenges in implementation of the RMS
4.2. A methodological guide including a set of rehabilitation standards with description and core indicators in scorecards
4.3. A selection of rehabilitation standards and progress indicators are defined for Rwanda
5. Proposed Methodology
5.1. Rehabilitation standards for Rwanda
- Review of workshop proceedings and reports
- Consultation with RAAQH to finalise technical inputs needed
- Develop standards and progress indicators based on preliminary selection of standards, to be adapted to the Rwanda health facility accreditation system
Consultant with HI Rwanda programme and accreditation agency (RAAQH)-remotely
5.2.Evaluation of the effects and challenges in RMS implementation
- Review of documentation and reports from HI programmes
- Interviews to HI staff
- Analyse findings to support revision
- Consultant to design interview questions or questionnaire for HI rehabilitation specialist and programmes
- HI staff to conduct interviews in the field if required
5.3. Revision of standards
- Revision of standard list based on literature review and feedback from field
- Expand/revise description of standards ( see Annex 1 for some examples)
- Definition of a list of standards (sub-set from all standards ) that are most relevant for government settings
5.4. Progress indicators and method
- Establish progress indicators to determine performance against it: progress ‘not a priority/not relevant’, ‘some progress (describe)’, ‘indicators defined’, ‘indicators progressing (see Annex for examples)
Consultant with feedback from HI rehabilitation programmes
6. Tentative Work Schedule
6.1 Rehabilitation Standards for Rwanda : October/November 2019, to be agreed with RAAQH
6.2 Evaluation of the effects and challenges of RMS : By January 2020
6.3 Revision of Standards : By February 2020
6.4 Progress indicators development : By March 2020
The maximum amount available for this consultancy is 14.000 euro. Transportation costs and field visits costs are not foreseen for this consultancy.
8. Consultant’s profile
The consultancy will be carried out by an individual or group of experts who has the following qualification and specification:
- Relevant professional knowledge on global frameworks and experience in the areas of physical rehabilitation services and assistive products
- Relevant experience in health and rehabilitation services’ development and planning, monitoring and evaluation, in particular in low resource settings
- Proven skills in qualitative research methodologies and participatory approaches. ___
Annex 1: Proposed modifications
A) RMS guide: Glossary
Expand and revise the glossary list: add alternative statement, descriptions and examples to help understand complex topics. This would help translations in different languages too, when terminology is missing, to ensure the correct meaning / message is conveyed.
Adding references for additional reading in the glossary could be helpful ( ex; Appropriate technology: GATE initiative; CPD: WCPT note on CPD..)
The glossary could actually be replaced by a proper section where each standard is fully described, with 2 components:
Standard definition (ex: “follow up”). Appropriate follow-up is planned with clear goals and is available for every client according to their needs. It might be organized in several ways, according to the setting; it can be done through individual sessions at the center, through phone calls, home visits by professionals, or other. Multiple mechanisms and documents need to be present for follow up to operate smoothly. These include individual rehabilitation plans with individual goals and follow up plans, well- defined criteria for follow up procedures (severity of conditions, individual situation, service capacities).
Standard rationale: Follow up is a key component of the rehabilitation process. Follow up should be systematically planned to make sure that rehabilitation interventions are relevant to the individual functional needs of the client as he/she progresses. Limited follow up procedures increase the risk of poor outcomes once the client is at home.
See as an example the “Rwanda Hospital Standards”
B) Scoring ( scorecards)
In order to understand levels of compliance, it would be useful to better describe ( in the form of simple check-lists, with yes/no answer?) levels of compliance, clearly breaking down more complex indicators into their components, if not sufficient in the standard description. This would mean rephrasing scoring definitions in the scorecards ( for 0-1-2-3).
Below an example of “tracking” or monitoring of performance for “follow up”
Progress & Performance Findings Level 0. No procedures
- There is no policy and procedure for follow up of patients in the community or at home
Level 1. Criteria and procedures for follow up defined
A policy and procedure defines conditions requiring follow up in the community or home-based and provides indications for available services
A policy and procedure defines all the steps of follow up and includes goal setting, referral and monitoring mechanisms in regards of drop out or missed appointments
3.The policy and procedure has been approved and has been updated within the past 24 months
Level 2. The follow up process is implemented
Patients who require follow up as per set policies do not receive it as part of treatment plan
Staff shows knowledge of criteria on conditions requiring follow up and provision of community services.
In the majority of patients files reviewed, follow up is appropriately planned as part of treatment plan
In the majority of patient files reviewed, there is evidence of communication with community services providing follow up
Level 3. Monitoring data are used to continually improve the follow up process
0.No data is available on monitoring of follow up
- data on follow up is collected to determine uptake and continuum of care 2.data on follow up is analyzed and made available in service reporting
- minutes of meetings or other evidence show that actions were taken to improve follow up ( drop outs, missed appointment, appropriate referral)
It was proposed to have a set of SMART indicators for each standard-targets. Challenge: how can we identify universal indicators for services? Isn’t this something that needs to be tailored to the capacity of each service?
So it would look reasonable to just provide a set of core indicators of performance as a reference.
Documents requested for the submission:
1) A brief cover letter and CV with references
2) Technical application with detailed methodology
3) Financial application
Evaluation of the expression of interest will be made through a selection committee only if a complete application is received.
The complete application should be sent to : email@example.com
The deadline for the submission of the application is the October 23rd, 2019 at 7pm GMT. Applications submitted after the deadline will not be considered. Only short listed candidates will be contacted. Selected applicants may be invited for an interview.