1. Using the Supervisory Checklist Module 9 Part B

2. How do I monitor? The supervisory checklist gives you a structure you can use … … but it should not limit what you look at There are further steps to take to interpret the data and get a complete picture

3. The Supervisory Checklist Take a look at the supervisory checklist Understand the scoring system We’re going to look at three important parts of the checklist: –Suspect and Sputum Dispatch Register –TB Facility Register –Treatment Card

4. The Supervisory Checklist Scoring System 0 Not Done 1 Poor 2 Satisfactory 3 Good

5. The Supervisory Checklist Scoring System 0 Not Done 1 Poor 2 Satisfactory 3 Good Per Quarter Entry not completed <75% complete >=75% complete >= 90% complete

6. The Suspect and Sputum Dispatch Register 1.Regularly Used: All Registered TB cases found in SSD; additional unconfirmed Suspects also in SSD; SSD used for registering f/up exams. Good= On average, 90% of confirmed cases and f/ups logged in. 2.Columns complete: Good= On average, 90% of columns completed. 3.Suspects have 3 Sputums. Good= On average, 90% suspects have 3 specimens logged in. 4.Results Correctly Recorded. Good= On average, 90% of logged entries have results for all specimens recorded as N or P with a grade 1+ 2+ etc.

7. Three sputum smears examined? Level of knowledge: –Do the HCWs understand the need for three sputum smears? Attitude / Perception –Do they care? Are they interested in complete, quality data? Seeking guidance –Do they have questions?

8. Checklist: The TB Register

9.  Level of knowledge:  Do the HCWs understand what each column is for?  Attitude / Perception  Do they care? Are they interested in complete, quality data?  Seeking guidance  Do they have questions? Is the Register Complete?

10. Checklist: The TB Register 1.Confirmed ases registered (compared to Lab Reg and SSD) Good= On average, 90% of confirmed cases registered. 2.Pt Information complete: Good= On average, 90% of columns completed. 3.Sputum results recorded. Good= On average, 90% suspects have correct number of specimens AND results recorded 4.Compliance correctly recorded. Good= On average, 90% of doses to date recorded and signed

11. Checklist: The TB Register 5.Treatment outcome recorded correctly: Cured or Completed based on presence of bacteriology results. “DISCHARGED” IS not AN OUTCOME! Good= On average, 90% of confirmed cases registered. 6.HIV results recorded: Good= On average, 90% of columns completed as positive OR negative. 7.IPT History recorded. Good= On average, 90% of HIV+ cases have been asked whether they ever received IPT & date started 8.ART status: Good= On average, 90% of HIV+ cases have been asked whether they are on ART & date started.

12.  Level of knowledge:  Are the HCWs familiar with 1+, 2+ etc.?  Attitude / Perception  Do they know that microscopy is essential for diagnosis?  That follow-up is essential for patient monitoring and documenting cure?  Seeking guidance  What do they need to understand to do their job better? All Sputum Results Recorded?

13. The comments column: Why is this important? TaskScor e Comment 1. All suspected cases have three sputum investigation 2. Patient’s compliance is correctly recorded 1 1  What does the score tell you?  both activities are poorly done Dropped from 95% in last supervision to 20% in this supervision. DOT Workers report that they do not understand how to use the form and are too busy to do it.  What do the comments tell you?  Something caused a sudden drop in indicator 1  DOT workers need training This is your chance to be heard.

14. Checklist: Patient Treatment Card

15. Communication with DOT Workers

16. DO’s:  Listen and be prepared to learn  Give the person space and time to answer  Be tactful and discrete  Talk to as many people as possible (at all levels) DONT’s:  Don’t “lead the witness” – ie don’t try to get the answer you want to hear  Don’t overreact to a negative verbal report. First check against the data, then form an opinion. Some communication tips (2)  

17. Planning the supervision visit

18. Logistics 1.Make a list of all the facilities in your district - Include the name and cell phone number of the Matron and TB Focal Person 2. Group them by location/region Facilities in the District capital where you work and reside will be the busiest and the easiest to visit, so 3.Plan your visits to outlying areas first 4.Schedule local facility and lab visits next

19. Scheduling supervisory visits For example, split the district into sections and visit different regions on alternate weeks DateDistrictRegionClinics to be visited 1 st MondayChobeNorthern ChobeKasane PH, Kachikau Clinic, Pandamatenga Clinic, etc 2 nd MondaySouthern ChobeSatau, Kazungula, Plateau, etc.

20. Supervisory Visits  Confirm the dates with the TB Focal Person or Matron before arriving  Provide explicit expectations Are treatment cards organized and complete? Is register up-to-date? Have they made a list of things requiring your follow-up? (e.g., transfers)  Listen and note problems or issues they are experiencing (e.g., test kit shortages)  Offer to bring needed supplies

21. Checklists and Reminders  Checklists and reminders are a good visual aid  Should be clear and concise, strategically placed  Well-designed and visually pleasing

22. Communication about next steps / debriefing

23. DO’s:  Follow any lead you are given  Report back on what steps can / should be taken  Encourage internal discussion and try to “facilitate” a solution  Identify experienced people and draw from their experience DONT’s:  Don’t dismiss anyone’s concerns  Don’t worry if you don’t have an immediate answer. You might need to talk to lots of people.  Don’t take anything at face value. Check against the data! Some communication tips (3)  

24.  Working alone, review the sample suspect register worksheet  Answer questions 2-4 on your handout  Faculty will assist Exercise 9.1

25.  Using the handout, review the register and make note of any possible problems in recording and reporting  Enter a score and your findings into the supervision checklist  Discussion Exercise 9.2

26.  Based on your observations and analysis in the previous exercise develop follow-up checking questions for the following indicators in the supervision checklist:  Patient’s attendance is correctly recorded  Patient’s information is complete  All HIV Status results are correctly recorded Exercise 9.3

27.  Working in groups, and using the patient register, calculate the following indicators:  AFB Diagnosis Rate  Program Default Rate  Sputum Conversion Rate  Proportion of notified cases tested for HIV  Enter your findings and interpretation into the supervision checklist Exercise 9.4

28.  Working in pairs, review the sample treatment cards  Calculate % of patients who received all treatment under DOT  Review quality of recording and reporting  Enter a score into the supervision checklist, along with comments  Faculty will assist Exercise 9.5