mesh mentoring and enhanced supervision as a qi strategy at health centers manzi anatole, mph...

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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