MESH Mentoring and Enhanced Supervision as a QI strategy at Health Centers

1. MESHMentoring and Enhanced Supervision as a QI strategy at Health Centers

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 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. Mentoring Domains

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 Kirehe ID mentor teaching ID nurses and titulaire about new PMTCT protocol at Kabuye Health Center.

13. 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

19. Example of Issue Tracking Log

20. Mentor Training and Support

21. Mentoring  Monitoring Plus real-time feedback

22. FORMAL FEEDBACK LOOPS Participants Objectives • Develop action plan based on mentoring & supervision data • Mentor support/training • Mentors • PIH clinical program reps • Technical advisors • MESH management team • 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 MENTORING

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