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

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

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

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

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

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

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)

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

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

Observation Checklists: Nurse Practices

Observation Checklist: Nurse Decision-Making

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.

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

Gahara ID clinic HIV charts BEFORE MENTORING AFTER MENTORING

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

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

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 email) 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

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

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  

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)

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

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

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

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