MESHMentoring 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 StaffingResponsibility Training Responsibility Training
Maternity Family Planning
ARTIMCI
CHNutrition
TB med distribution
IMCISONU
General consultation
Pharmacy distribution ART
IMCIVaccination
IMCISONU Prenatal Care ART
Prenatal careMaternity
TitulaireAdministration
IMCI, vaccineSONU, FPART, PMTCT
IMCI “clinic” 3-4x/mo
Trained, but not seeing patients in the appropriate discipline
No specific training
MESH Program Aims
Additional MOH
Supervisors
Decentralized initial training of health centre nurses
Routine mentoring ,supervision & data for
quality improvement
Ongoing, on-site mentoring of HC nurses
Improved patient
outcomes
Improved nurse
practices
Improved quality of
care at health centers
3
2
1
• 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 Supports the District Hospital Supervision System
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
Mentoring DomainsClinical Service Associated Pre-Service
Training and ProtocolsUnder-5 out-patient acute care
IMCI
Adult acute care IMAI (S.Kayonza only)
Women’s Health SONU
Infectious Disease(HIV & TB)
TRAC HIV training & protocolsPIH 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
Kirehe ID mentor teaching ID nurses and titulaire about new PMTCT protocol at Kabuye Health Center.
Mentoring/Teaching Activities
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
Example of Issue Tracking Log
OBSERVATION/ISSUE ACTIONS TAKEN DURING VISITRECOMMENDATIONS/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
Combined Clinic nurse 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
Combined Clinic nurse Apr-11
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
Plus real-time feedback
FORMAL FEEDBACK LOOPS
• 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
Participants Objectives
•Mentors•PIH clinical program reps•Technical advisors•MESH management team
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
MENTORING
Murakoze cyane!
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