1. MESH Mentoring and Enhanced Supervision as a QI strategy at Health Centers
Manzi Anatole, MPH
MESH-QI Program Director

2. Challenges in Health Center Nurse Training and Supervision
Misalignment of nurse training and their clinical responsibilities
Limited supervision:
Infrequent health center visits: hospital supervisors have competing clinical, administrative and M&E responsibilities
Supervisors focus on data collection: little emphasis on quality of care

3. Health Center Staffing
Trained, but not seeing patients in the appropriate discipline
Responsibility
Training
Maternity
Family Planning
ART
IMCI CH
Nutrition
TB med distribution
SONU
General consultation
Pharmacy distribution
Vaccination
Prenatal Care
Prenatal care
Titulaire
Administration
IMCI, vaccine
SONU, FP
ART, PMTCT
No specific training
IMCI “clinic” 3-4x/mo

4. MESH Program Aims 1
Decentralized initial training of health centre nurses
Improved nurse practices
Improved quality of care at health centers
Improved patient outcomes 2
Additional MOH Supervisors
Ongoing, on-site mentoring of HC nurses 3
Routine mentoring ,supervision & data for
quality improvement

5. MESH Supports the District Hospital
Supervision System
MESH supervisors are MoH employees added to the hospital supervision team
Bigger team = more frequent HC visits
Complements current data collection activities with focus on clinical mentoring
PIH provides technical, financial, and logistical support

6. MESH Mentoring/Supervision Visits
Intensive
Approx 2 consecutive days per health center
Regular
Each health center visited every 4-6 weeks
Responsive
Dedicate more time to high-need health centers, as identified through M&E and supervision data

7. Associated Pre-Service Training and Protocols
Mentoring Domains
Clinical Service
Associated Pre-Service Training and Protocols
Under-5 out-patient acute care
IMCI
Adult acute care
IMAI (S.Kayonza only)
Women’s Health
SONU
Infectious Disease
(HIV & TB)
TRAC HIV training & protocols
PIH HIV Curriculum (in future)

8. Mentoring Visit Structure
Presentation in morning staff meeting
Direct observation of clinical care and side-by-side mentoring
Feedback to nurse mentees
Assess facility issues
Afternoon teaching
Meet with titulaire to discuss findings and recommendations; develop joint action plans

9. Direct Case Observation
Assess nursing skills, knowledge, decision-making in practice
Model best practices
Promote adherence to national protocols
Provide specific, real-time feedback to mentees
Guides subsequent teaching
IMCI mentor providing feedback to nurse mentee at Ndego health center

10. Observation Checklists: Nurse Practices

11. Observation Checklist: Nurse Decision-Making

12. Mentoring/Teaching Activities
Teaching sessions may include review of clinical cases and protocols, discussions on clinical topics, role plays, demonstrations, review of documentation, practice of clinical skills
Kirehe ID mentor teaching ID nurses and titulaire about new PMTCT protocol at Kabuye Health Center.

13. In-depth insight into health center operations
Systems Improvement
In-depth insight into health center operations
Identify operational/systems issues
Problem-solving with nurses and titulaire
Feedback to district hospital and PIH
Promote a culture of systems improvement and advocacy

14. Gahara ID clinic HIV charts
BEFORE MENTORING AFTER MENTORING

15. Mentoring Tools Clinical observation checklists
Facility/operations checklists
Knowledge questionnaire
Case scenarios
Patient case recording forms (for nurses)
Supervisor activity log
Issue tracking log
Nurse problem resolution form

16. Available in the Following Spheres
Name of Tool
Purpose
Who Fills it Out?
Frequency
Information Flow
Available in the Following Spheres
IMCI
IMAI ID WH
Observation checklist
Assessment of nurse practices/adherence to protocols (evaluation, diagnosis, management) through direct observation of clinical care
Mentor
Every HC visit
1) Mentor reviews strengths and weaknesses with nurse mentee during HC visit
2) Mentor submits checklists to MESH Mgt every Monday
3) MESH Mgt tallies checklists and enters into “HC Visit Record”
4) If possible, Tech Advisor reviews subset of checklists for data quality & clinical issues/patterns and provides feedback to mentor to guide mentoring
5) MESH Mgt submits to M&E dept for data entry (subset of indicators entered on ongoing basis)
6) M&E/Tech Advisors generate brief quarterly/biannual report on key indicators to share with IMB, mentors, DH, titulaires/HCs (guides subsequent mentoring) X
Knowledge questionnaire & case scenarios
Assessment of nurse knowledge (pre/post-test format); administered on-site at HC
HC nurse
Baseline; 6-12 month follow-up
1) Mentor submits to MESH Mgt/Training Dept for review & data entry
2) Technical advisors review data to identify key areas for intervention
3) Technical advisors generate brief report to compare baseline and 6/12 month data KQ
Facility checklist
Assessment of facility issues, such as availability of equipment
1) Mentor submits to MESH Mgt/Training Dept for data entry
2) Technical advisors review to identify key gaps liaise with MESH, clinical programs, DPM to address issues

17. Supervision Activity Log
Paper report of mentor activities (case observation, teaching sessions, etc) and general observations (clinical & operational issues)
** Requirement of MoH/DH supervision system
Mentor
Every HC visit
1) Mentor completes form during HC visit, reviews it with titulaire and nurse mentee at conclusion of visit
2) Mentor photocopies form; submit original to DH and copy to MESH Mgt weekly
3) MESH Mgt reviews and enters key activities/issues into “HC Visit Record” (e.g. “group teaching on malaria”)
4) MESH Mgt provides feedback to mentors and/or HCs
Problem Resolution Form
Brief written action plan for nurse mentee
**Remains at HC for titulaire and nurse reference
Mentor, HC nurse, titulaire
1) Mentor, nurse, and titulaire write action plan together during HC visit (e.g. nurse can fill out Problem Resolution form while mentor fills out Supervision Activity Log)
Issue Tracking Tool (spreadsheet)
Ongoing log of clinical & systems issues and action plans/interventions at each health center
**Functions as a working “to do” list for the mentor (they review prior to each HC visit to follow up on previously identified issues and action plans) and as a longitudinal record of specific HC issues & interventions
Weekly
1) Prior to visit, mentor reviews previously identified issues and action plans; records new issues and status of old issues after visit
2) Mentor submits tool to MESH Mgt and Tech Advisors weekly (via )
3) MESH Mgt/Tech Advisors provide mentor with weekly/biweekly feedback
4) MESH Mgt/Tech Advisors notify appropriate IMB or DH department regarding urgent issues (e.g. med stock-out)
5) MESH Mgt/Tech Advisors review issues and action plans with mentor during Monthly Mentor Debriefing Meeting
6) MESH Mgt reviews summary of issues/action plans with DPMs, DCDs, relevant depts monthly/every 2 months

18. HC Visit Record
(spreadsheet)
Basic calendar record of HCs visited and primary activities carried out by each mentor
** Useful for tallying # visits/HC/sphere or # cases observed/HC/sphere, etc
Manzi
Weekly
1) MESH Mgt develops monthly schedule for each mentor during 3rd week of month according to HC needs; distribute schedule to DHs and HCs
2) MESH Mgt updates record weekly with actual visits completed, # checklists, primary activities, etc
3) MESH Mgt can generate periodic tallies of visits/HC, cases/HC for each sphere and periodic summaries of key mentor activities (e.g. list of teaching topics covered over past 2 months)
Mentoring of Mentor Tool
Evaluation of mentor’s communication, mentoring, and problem-solving skills; basis for formal performance review and informal mentor development
Manzi, Tech Advisors
Biannually (min; can be used more frequently)
1) Manzi/Tech Advisor provide immediate feedback to mentor
2) MESH Mgt incorporate eval into the formal performance review of mentor, which is conducted in collaboration with District Hospital
3) Individual mentor scores by category (e.g. relationship building, identifying problems, etc) can be compared at different time points to evaluate mentor development as part of overall program evaluation
Descrip data logs- General and HC specific
(spreadsheets)
**Not yet in use
Brief month-by-month summary of MESH interventions, HC issues, and other external variables
- Distilled summary of other tools for general program monitoring, internal feedback loops, external reporting (including DDCF research)
Monthly
1) MESH Mgt/Tech Advisors complete log based on Issue Tracking Tool, mentor debriefing, site visits, etc
2) MESH Mgt circulates log prior to monthly MESH call
3) MESH Mgt reviews issues with DCDs, DPMs, DH during monthly meetings

19. Example of Issue Tracking Log
OBSERVATION/ISSUE
ACTIONS TAKEN DURING VISIT
RECOMMENDATIONS/ACTIONS PLANNED
RESPONSIBLE
TIMELINE
Some HIV+ delivered mothers not followed up in Combined clinic
Called accompagnateurs' leader to track and tell them to come to Combined Clinic ASAP for follow up
Track HIV+ delivered mothers and tell them come to combined clinic for follow up
Combined Clinic nurse
Immediate
Delayed CD4 count control
Told Combined Clinic nurse to identify those with delayed CD4 count control so that next visit it can be done
Check CD4 count for the mothers with more than 6 months CD4 results
Apr-11
Delayed DBS control for 1 HIV exposed baby
Told Combined clinic nurse to track the baby's mother to come for DBS control
Do DBS test for the HIV exposed baby whose HIV status is unknown
FOLLOW-UP DATE
FOLLOW-UP COMMENTS
FOLLOW-UP ISSUE STATUS

20. Mentor Training and Support
Clinical/Technical
Mentoring
Pre-service training and work experience in respective clinical domain
Initial training in clinical mentoring techniques (based on I-TECH and MOH supervision training)
Monthly clinical work in hospital
Ongoing support from MESH management team and PIH training department
Ongoing support from technical advisors (PIH staff)
Monthly mentor debriefing meetings
Monthly accompaniment by technical advisors and hospital doctors (when possible)

21. Mentoring  Monitoring
Care delivery
Data collected by supervisors
Data analysed by M&E dept
Feedback to hospital, health centers, supervisors
Mentoring
Plus real-time feedback
Care Delivery
Feedback & Mentoring

22. FORMAL FEEDBACK LOOPS Participants Objectives
Monthly Mentor Debriefing Meeting
Monthly Hospital Supervision Meeting
DH supervision and M&E teams
DH medical director & admin
Mentors
MESH management team
Monthly Hospital Coordination Meeting
Titulaires
Mentors
PIH clinical program reps
Technical advisors
MESH management team
Develop action plan based on mentoring & supervision data
Mentor support/training
Share health center findings
Refine health center action plans with hospital team
Share health center findings
Share and revise health center action plans with titulaires

23. Measuring the Intervention
Training coverage
Nurses trained per sphere per health center
Knowledge acquisition and retention
Pre- and post-tests
Change in clinical practices
Assessed through observation checklists
Facility improvements
Clinical outcomes
E.g. CD4, weight gain
Baseline Assessment
Intermediate Assessment
MENTORING

24. Murakoze cyane!