On-Site Mentoring for Improved Quality of Delivery and Postpartum Care at 24/7 Primary Health Centres
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On-Site Mentoring for Improved Quality
of Delivery and Postpartum Care at
24/7 Primary Health Centres
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On-Site Mentoring for Improved Quality
of Delivery and Postpartum Care at
24/7 Primary Health Centres
The Story of a Maternal, Newborn and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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RTW f*RH
)*( KHPT
Karnataka Health Promotion Trust
On-Site Mentoring
for Improved
Quality of Delivery
and Postpartum Care
at 24/7 Primary Health Centres
The Story of a Maternal,
Newborn and Child Health (MNCH)
Mentoring Programme
in Northern Karnataka
Sukshema
Maternal, Neonatal and Child Health Project
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern I
An overview of the On-Site mentoring intervention to institutionalize quality improvement
strategy within 24/7 Primary Health Care centers in Karnataka state. The philosophy, design,
The philosophy, design, implementation process and results are detailed herein.
Copyrights
: Karnataka Health Promotion Trust
On-Site Mentoring for Improved Quality of Delivery and Postpartum Care at
Primary Health Centres
The Story of a Maternal, Newborn and Child Health (MNCH) Mentoring Programme in
Northern Karnataka
Year of Printing : May 2014
Publisher
: Karnataka Health Promotion Trust
IT/ BT Park, 5th Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone:91-80-40400200
Fax:91-80-40400300
www.khpt.org
This process document is published with the support from the Bill & Melinda Gates Foundation under
Project Sukshema. The views expressed herein do not necessarily reflect those ofthe Foundation.
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Mentoring Intervention Report
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Government of Karnataka
Department of Health and Family Welfare
National Health Mission
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PREFACE
Institutional deliveries in Karnataka have risen over recent years due to the efforts by the state health
directorate which were strongly complemented by various innovations and schemes implemented under
the National Rural Health Mission (NRHM) such as Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha
Karyakram (JSSK), ASHA support, 108 ambulance services, etc. There has been a reduction in maternal and
newborn mortality rates (MMR, NMR), but not enough to achieve the proposed state targets. With over
80% of pregnant women now delivering in facilities, it is critical that these deliveries are conducted as per
the highest standards for quality of care. To accommodate this rising demand, government had prioritized
upgradation of Primary Health Centres into 24/7 facilities to provide delivery services in rural areas and
reduce the burden on district and larger hospitals enabling them to function more appropriately as first
referral units (FRU) to provide emergency care. To achieve good quality of services provided in public
health facilities it is important that the service providers working at these facilities are proficient in skills
and practices that are appropriate particulariy with reference to pregnant women, mothers and new
borns. To facilitate this, the need for dedicated teams to improve and monitor quality is crucial.
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As a part of technical assistance to NRHM, Karnataka Health Promotion Trust and its consortium of
partners developed an innovative nurse mentor led quality improvement program after detailed situation
assessment and consultations with government. It was pilot tested in Bellary and Gulbarga during 20122013 where trained Nurse Mentors worked with 24/7 primary health centres (PHCs) staff to improve the
quality of delivery and postpartum care. The mentoring programme integrated elements of clinical
mentoring with facility-based quality improvement processes. Another critical component of the
intervention was the use of revised case sheetsby the staff that helped them in multiple ways, i.e. as job aid
to adhere to standard practices, as a simple case documentation tool and as a tool to monitor and audit
quality of care. The intervention results showed marked improvements in facility readiness and provider
preparedness to deal with institutional deliveries and associated complications. Subsequently the
program was scaled up in the remaining high priority districts of northern Karnataka and further taken up
both within and outside the country.
.
I
As a part of this intervention, several technical products and training material were developed; they consist
of 1) process documentation of the intervention that details the process of planning, implementing and
monitoring the mentoring program, 2) Facilitator/ Trainer and Participant manuals. These materials have
as annexures within them, various tools including the case sheets that were implemented under this
initiative. We sincerely hope that these resources will be found useful by program managers in terms of
gaining an in-depth understanding of the intervention and replicating it in their respective contexts.
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Smt. Sowj any a, iajs
Mission Director
National Health mission
Sri.
Commissioner
Dept, of Health & Family welfare
Sri. Ahii Kumar Tiwari, (AS
Principal Secretary,
Dept, of Health & Family welfare
I
Mentoring Intervention Report--------------------------------------------------------------------------------------------------------------------------------------
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Mentoring Intervention Report
HHHI
Report at a Glance
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Noi
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Table of Contents
List of Acronyms
7
Acknowledgements
8
Executive Summary
10
Introduction
23
Organization of Report
23
Methodology and Data Sources
25
1. Context, Evidence and Programme Overview
26
Findings from Situation Analysis in Project Districts
26
Overview of On-Site Mentoring Intervention
28
Collaboration with the National Rural Health Mission
29
Mentoring and Quality Improvement Interventions
29
2. Project Tools and Approaches
31
AMMA Approach
31
Assessment Tools
33
Case Sheets
33
3. Hiring and Training Mentors
37
Determining Mentor Cadre
37
Recruitment Process
38
Hiring Mentors
39
Training Nurse Mentors
41
Lessons Learned: Induction Training
44
Ongoing Training
46
Summary
48
4. Mentor Visits in Pilot Districts
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Mentoring Intervention Report
49
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Mentoring Intervention Report
Schedule of Mentor Visits
49
First Mentor Visit
50
Second Mentor Visit
54
Third Mentor Visit
57
Fourth Mentor Visit
61
Fifth Mentor Visit
65
Sixth Mentor Visit
70
Mentor Visits Summary and Conclusions
72
5. Scaling Up the Mentoring Programme
73
Mentor Recruitment and Training
73
Mentor Visits in Scale-Up Districts
74
Lessons Learned: Programme Scale-Up
76
Scale-Up Summary and Conclusions
81
6. Managing the Mentoring Programme
82
Management Structure
82
Management Tools
83
Monitoring Processes
84
Review Meetings
85
Lessons Learned: Managing the Mentoring Programme
87
7. Voices of PHC and District Staff
88
Purpose of Mentoring Programme
88
Value of Mentoring Programme
88
Improvements Attributable to Mentoring Programme
91
Support for Mentoring Programme
91
8. Coordination with Community Intervention
93
Early Stages of Coordination
94
District Coordination Evolution
95
Examples of Coordination
97
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Lessons Learned: Community Intervention Linkages
9. Intervention Results and Costs
98
100
Monitoring Data
100
Pilot District Endline Evaluation
104
Cost Analysis of Mentoring Programme
106
Summary
106
10. Summary of Mentoring Programme Achievements and Challenges
107
Mentoring Programme Achievements
107
Lessons Learned: Mentoring Programme
107
System and Community-Level Recommendations
109
Conclusion
111
References
113
Appendix A. Cost Analysis of Mentoring Programme
114
Mentoring Intervention Report
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Mentoring Intervention Report
List of Acronyms
AMMA : Assess and diagnose, manage,
measure, advocate(quality
improvement approach)
AMTSL : Active management of third stage
of labour
ANC
: Antenatal care
ARS
: Arogya Raksha Samithi meetings
ASHA
: Accredited social health activist
AWW
: Anganwadi worker
AYUSH : Ayurveda, Yoga & Naturopathy,
Unani, Siddha and Homoeopathy
MIS
: Management information system
MMR
: Maternal mortality rate
MNCH : Maternal, newborn, and child health
MO
: Medical officer
MOIC
: Medical officer in charge
NGO
: Nongovernmental organization
NRHM : National Rural Health Mission
NSSK
: Navjaat Shishu Suraksha Karyakram
ORD
: Outpatient department
OSCE
: Objective structured clinical
examination
RAC
: Post-abortion care
ROSA
: Plan Do Study Act (quality
improvement approach)
PHC
: Primary health centre
PI
: Performance improvement
RIH
: Pregnancy-induced hypertension
PPH
: Postpartum haemmorhage
PQI
: Performance and quality
improvement
PROM
: Premature rupture of membranes
QI
: Quality improvement
RP
: Resource person
SBA
: Skilled birth attendant
SJMC
: St John's Medical College
THO
: Taluka health officer
TT
: Tetanus toxoid
BEmOC
Basic emergency obstetric care
CC
Community coordinator
Cl
Community intervention
CPG
Clinical practice guidelines
DCM
District coordination manager
DCS
District community specialist
DHO
District health officer
DPMO
District program management officer
DPS
District programme specialist
DRHO
District reproductive health officer
EDD
Estimated date of delivery
FRU
First referral unit
GoK
Government of Karnataka
GP
Gram Panchayat (village council)
IFA
Iron and folic acid
IMR
Infant mortality rate
IUD
Intrauterine device
JHA
Junior health assistant
VHSNC : Village Health, Sanitation and
Nutrition Committee
JSSK
Janani Shishu Suraksha Karyakram
VIMS
JSY
Janani Suraksha Yojana
: Vijayanagar Institute of Medical
Sciences, Bellary
M&E
Monitoring and evaluation
WISN
: Workload Indicators of Staffing Need
MCTS
Mother and Child Tracking System
WHO
: World Health Organization
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme ir
Acknowledgements
Authors: Elizabeth Fischer, LTroy Cunningham, Janet Bradley and Krishnamurthy Jayanna.
The authors appreciate the support provided by numerous individuals over an extended period
of time to allow documentation of this important innovation. Special thanks to Dr B.M. Ramesh,
former Project Director of Sukshema Project, for recognizing the importance of documenting
the mentoring programme so others can learn from this activity and for the guidance provided
throughout. Thanks to Anna Schurmann for helping to structure the projects knowledge
management strategy and to Baneen Karachiwala who provided independent observation and
interviews of thefirst mentor training.The dedication of project staff—including several Bangalore
based technical leaders, support staff, and district programme specialists who coordinated
numerous field visits to several districts—ensured high-quality observations at primary health
centres and insightful interviews with those implementing the intervention. These staff include
Dr Swaroop, Dr Mahantesh, Dr Seema, Dr B. Pavan, Dr Nazia Shekhaji, and Laxshmi C. We thank
the team from St John's Research Institute that included Dr Prem Mony, Maryann Washington, Dr
Annamma Thomas, Dr Swarnarekha Bhat, Dr Suman Rao and other consultants for their support
in the trainings and handholding visits and for sharing their experiences that have informed the
process document. We appreciate the support of clinical consultants from University of Manitoba,
Lisa Avery and Maryanne Crockett for their support during the design of the program. We also
acknowledge the efforts of Dr Sudarshan and Dr Nagaraj from Karuna Trust for their support to
the implementation of the program. Appreciation is extended to Arin Kar, Deputy Director of
Monitoring and Evaluation, for providing data support and to H.L. Mohan, Director of Community
Interventions and Somshekar Hawaldhar, Deputy Director of the community intervention
component for contributing to the discussion on program coordination. Special appreciation is
also due to the nurse mentors for their enthusiastic participation in interviews and focus groups,
and for facilitating the ability to observe their work in action. We thank the many primary health
centre staff and district government officials who met with us to share their candid views about
the mentoring programme. Finally, we thank Stephen Moses, Professor and Head of Community
Health Sciences of Dr James Blanchard, Director, Centre for Global Public Health, University of
Manitoba for their valuable reviews and inputs.
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Improved Maternal, Newborn & Child Health
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in I
Executive Summary
his report tells the story of an innovative nurse mentoring programme to improve maternal
and newborn care in northern Karnataka. It documents the process and experience of
implementing the mentoring intervention, shares intervention results, and concludes with
lessons learned and recommendations. Information is derived from qualitative and quantitative
sources including extensive interviews, site visits and observations over a 2-year period. We hope
it helps others who are interested in learning from the experience to develop similar approaches
in India or elsewhere to improve maternal and newborn care.
Context, Evidence and Intervention Overview
In India, too many women and infants die from causes that are both preventable and easily
treatable. Evidence points to the critical importance of ensuring high-quality care during labour,
delivery, and the immediate postpartum and newborn period for saving maternal and newborn
lives. This is the window in which more than half of maternal and newborn deaths take place.
The ability of providers to manage normal deliveries according to best practice guidelines and to
identify, manage and refer those patients with maternal and newborn complications can have a
direct impact on maternal and newborn health outcomes.
The Sukshema project developed a mentoring intervention designed specifically to improve the
quality of facility-based maternal and newborn care in 24/7 primary health care centres (PHCs) in
Northern Karnataka. By providing on-site mentoring for improved clinical care and service delivery,
the project hypothesised that the quality of services and continuity of care would improve and
that women and newborns would have better health outcomes.
Findings from situation analysis in project districts and evidence review
A situation analysis in eight project districts in 2011 revealed the need to both improve provider
competence in managing maternal and newborn care and to address facility-level factors such
as drug stock-outs and lack of infrastructure. The analysis showed that providers did not follow
best practices such as active management of third stage of labour (AMTSL), use of partograph,
or essential newborn care. Labour augmentation (not a recommended practice) was found to
be very common. PHCs in particular often lacked the drugs and equipment to provide delivery
services.The situation analysis also revealed a weak referral and follow-up system.
In designing the mentoring intervention, the Sukshema project reviewed findings from similar
interventions across a variety of settings and clinical areas. The evidence suggested that a
mentoring intervention should include components focused on on-the-job provider training and
support, user-friendly clinical job aids, and team-based approaches to quality improvement.
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Overview of intervention design
The Sukshema Project's maternal, newborn, and child health (MNCH) mentoring intervention
integrates elements of on-site clinical mentoring with facility-based quality improvement
processes to support PHCs'abilities to deliver critical maternal and newborn care services. The
project employed a new cadre of full-time nurse mentors who were each responsible for mentoring
staff in six to eight 24/7 PHCs. Since staff nurses are responsible for labour and delivery services
in PHCs, Sukshema opted for a peer mentoring model and thus hired and trained qualified staff
nurses to be mentors.
Project Approaches and Tools
The Sukshema project introduced a quality improvement approach backed by tools to assess and
track quality improvements.
AMMA quality improvement approach
Sukshema developed and promoted a quality improvement framework called AMMA that means
"mother" in Kannada. PHC teams were encouraged to use this quality improvement approach
with individual patients and at the facility level.
Is
IH
ASSESS:Assess and
diagnose quality gaps
or problems
MEASURE:Measure
progress in resolving
problems and quality gaps
MANAGE:Manage
solutions to address
problems
clients'and providers'
rights to quality services
ADVOCATErAdvocate for
_ ________________ _ _______ ®
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
At the same time, the project introduced several tools such as case sheets, self-assessment tools,
and action planning tools to operationalise quality improvement.
Case sheet A key innovation of the mentoring intervention was the introduction of a newly
developed case sheet for PNC providers that incorporated the AMMA approach. The case sheet
served as a clinical record, a job aid and a teaching tool. The case sheet guided providers through
the critical steps of patient assessment, labour monitoring and postnatal care and included a
simplified partograph to monitor labour (Assess and diagnose).The case sheet directed providers
to complication case sheets that provided details on how to manage and refer maternal and
newborn complications (Manage). Providers used the case sheet to make clinical decisions aligned
with SBA guidelines for PHCs. Mentors also used the case sheet to conduct case audits and monitor
changes in compliance with SBA guidelines and as a teaching tool (Measure). Discussions about
the case sheet led to wider discussions of how to improve quality of care for patients (Advocate).
Case Sheet Components for 24/7 PHCs
HHI
.
Supplemental compfication case sheets
Section 1 : Initial assessment
A: Prolonged/obstructed labour
Section 2 : Labour monitoring (including
simplified partograph)
B : Preeclampsia/eclampsia
Sections : Delivery notes
Section 4 : Postpartum period
Outcome sheet
C : Antepartum haemorrhage
D: Infection/sepsis
E : Premature rupture of membranes
F : Postpartum haemorrhage
G : Newborn complications
1 H : Other complications
Self-assessment tools and action planning. The Sukshema project developed self-assessment
tools that mentors used with PNC teams to assess quality of care, identify gaps and examine causes
of those gaps (Assess and diagnose). The self-assessment checklist included questions for PHC
teams to discuss and to decide whether the quality standard is met or whether there might be
an opportunity for improvement. The checklists focused on patient and provider rights as critical
aspects of quality. PHC teams prepared an action plan based on these assessments (Manage).
Follow-up meetings with staff allowed for assessment of progress towards goals (Measure) and
provided a forum for discussions about how to improve quality along the continuum of care
(Advocate).
In addition to these tools, mentors brought mannequins, flip charts and other teaching aids to the
sites to provide skills practice.
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Hiring and Training Mentors
Recruitment and hiring
The Sukshema project team crafted a 3-tiered hiring strategy to identify the best candidates to
be mentors. Because of the varied skills that mentors needed to possess, it was thought that a
conventional hiring process of screening curricula vitae and interviewing candidates might not be
sufficient to fully assess a candidate's capacities for the position. The projects need to hire many
candidates at once also offered opportunities for more creative group-based assessment processes.
The process followed for identifying and recruiting mentors worked well. The candidates that
were ultimately selected were the best performers on various assessments and evaluations.
Training
The Sukshema project developed a 5-week induction training programme to equip mentors
with the knowledge and skills needed to carry out their responsibilities. A combination of KHPT
staff and faculty from St Johns Medical College (SJMC) trained mentors at SJMC in these skills.
The training covered the following topics:
Introduction and practice applying self-assessment and quality improvement approaches
Skilled birth attendance (SBA) clinical content and hands-on training focused on skills to
provide routine care, identify and manage complications, and make timely referrals
Exposure to PHC-level systems such as drug supply, referral, infection control, record-keeping
and use of tools to help improve PHC systems
Field visits to PHCs to practically apply the skills and tools.
The project also provided ongoing capacity-building of mentors using a combination of on-thejob support, refresher trainings and clinical postings.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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Mentor Visits in Pilot Districts
The project piloted and evaluated the mentoring programme in Bellary and Gulbarga districts
with 11 mentors and 54 intervention PHCs in August 2012.
Structure of mentor visits
In the pilot districts, mentors were assigned six PHCs for mentoring and visited their assigned
PHCs once a month initially and at longer intervals thereafter for a total of six visits a year. Each
visit was expected to last two days, but later visits lasted 3-4 days. The time was extended to enable
mentors to complete planned tasks, which was not always possible in a two-day visit given high
outpatient loads and provider availability.
Flow of a typical mentor's visit
Initial meeting with PHC teams for introductions,
briefing the purpose of the visits
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IS
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Mentor audits case sheets |
observe practices
I
Self assessment exercise
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PHC teams develop action |
plans to solve gaps
I
Provide on the job coaching 1
using case sheets, models, I
demonstrations,etc I
Debriefing meeting
The structure for the first mentor visit focused on establishing rapport and initiating the
team-based quality improvement approaches through use of some of the self-assessment tools
and development of an initial action plan. In subsequent visits, mentors continued to support PHC
teams in using the self-assessment tools and developing and revisiting action plans, and provided
individualised support to staff nurses on maternal and newborn topics. Mentors facilitated
team-based problem-solving to address specific quality gaps such as equipment and supply
logistics, infection prevention practices, referral practices, record-keeping, teamwork and staff
attention to patient rights. Mentors also strengthened staff nurse SBA skills through teaching,
case reviews, case studies, demonstrationsand modeling bedside patient care. All mentor visits
included a review of the action plan, a case sheet audit and teaching.
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Pilot district successes
Mentors in the pilot districts were able to work effectively with PHC teams to enact quality
improvement processes and strengthen provider skills. Highlights include:
Rapport with PHC teams. Mentors expressed and demonstrated confidence in building
rapport with PHC teams and carrying out the mentoring visits.
Support for team-based quality improvement process. The PHC staff were willing to
engage with the mentors in quality improvement sessions. PHC teams remarked that they
had rarely come together as a team before mentoring and welcomed the opportunity to
do so. In some PHCs, teams initiated their own reviews and resolved their own problems in
between mentor visits.
Value of self-assessment tools and action plans. Mentors found that PHC teams were
able to use the self-assessment tools and that these tools helped teams identify where they
had problems.
Action plans addressed system strengthening. Mentors noted that the process of
reviewing and developing action plans was well entrenched as part of the mentoring visits.
Use of teaching models. The training models provided to the mentors were used effectively
to carry out demonstrations. Staff nurses appreciated the opportunity to practice with
newborn and pelvic models.
Case sheet acceptance and use. Mentors indicated that with continued encouragement
staff became more accustomed to the case sheet and appreciated its value as a job aid. Some
staff initially resisted using the case sheet, perceiving it as a time-consuming documentation
burden. Promoting consistent and correct use of the case sheet was a major undertaking for
the mentors in all visits.
Opportunities for patient-focused teaching. Mentors and project staff reported that they
encountered pregnant women and recently delivered women in the PHCs so they had the
opportunity to provide bedside teaching and demonstration.
Customised support. Mentors had a keen understanding of their PHCs and individual staff
nurses and were able to objectively assess their strengths and shortcomings and develop
individualised plans to support nurses.
Sustaining relationships with PHC teams. Mentors became sources of support even
between visits. Staff calledmentors between mentoring visits to tell them about complications
or ask for information.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnatal
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Pilot district challenges
Mentors encountered some circumstances that made it more difficult for the mentoring
programme to achieve its objective of improving maternal and newborn care. Some of these
challenges include:
PHC leadership engagement. Mentors found it more difficult to facilitate change in
PHCs that did not have a full-time medical officer or a medical officer who was engaged in
providing strong leadership and support of the PHC teams. In these facilities, it was harder
for the mentors to inspire a sense of team work and mutual accountability.
High-volume PHCs. At some PHCs with high delivery and outpatient department volumes,
it was hard for mentors to get time with staff. In busy PHCs, mentors found it difficult to retain
the attention and focus of staff to provide teaching. Busy nurses sometimes had to deal with
many patients and were less likely to fill out case sheets or follow expected protocols.
Staff turnover, motivation, and abilities. Mentors also reported that there was a degree of
staff turnover and they often had to bring new nurses up to speed. Another issue was that it
was harder to consistently engage and have time with staff nurses who lived some distance
from the PHC. Other challenges included staff with poor attitudes or those who were slow
learners.
PHC quality improvements
The use of team-based quality improvement processes combined with ongoing mentor support
generated improvements in the quality of care in PHCs. Observations and mentor and PHC team
interviews highlightednotable improvements:
Increased availability of drugs and supplies. Mentors and PHC teams remarked that most
pilot PHCs now had essential medicines and medical officers were very supportive about
getting needed drugs and supplies, usually using untied funds. Vitamin K, which was not
available at all when the intervention began, was present in most PHCs. PHCs had acquired
autoclaves, delivery sets and other equipment as needed.
Improved organisation of labour room. Mentors observed marked improvements in
the organisation of the labour room and its equipment, including separation of waste and
increased cleanliness. Many PHCs now had kits readily available for emergencies. Many had
posted guidelines on the walls and a list of essential drugs.
Decreased labouraugmentation. Mentors reported that nurses were no longer performing
labour augmentation in most cases. Mentors observed that some senior nurses were reluctant
to change practices.
Improved adherence to SBA guidelines for normal deliveries. Mentors had been able to
assist and observe deliveries and were thus able to assess how well nurses were handling
normal deliveries and complications.They reported that increasingly nurses were following
the SBA guidelines, including using the partograph, practising AMTSL and providing
improved general clinical care.
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Increased capacity and confidence to manage maternal and newborn complications.
Nurses reported that they were now more comfortable and confident in handling maternal
complications and were using the case sheets for guidance. Some mentors noted that nurses
still needed some support in pre-referral patient management.
Improved referral processes. Mentors and PHC teams reported that their referral processes
were more systematic since the mentoring programme started. PHCs were now more likely
to have referral directories and to call referral facilities in advance and follow up on patient
outcomes.
Areas that were slower to improve include:
Infection prevention. While labour rooms were cleaner and sterilization had improved,
there was still scope for improvement. PHC teams and mentors remarked that Group-D staff
(who are responsible for general hygiene and cleanliness) were resistant to change.
Inadequate postpartum care. Mentors reported that nurses did not properly monitor
patients after delivery at the recommended intervals of every 15 minutes for two hours.
Often this proved difficult for the nurses attending to other outpatient department functions.
Mentors noted that the postpartum care section of the case sheet was often incomplete or
incorrectly filled out.
Understaffing. The blanket policy of three nurses for every 24/7 PHC results in staff in PHCs
with high patient loads being overstretched and often unable to give sufficient time and
attention to women in labour or during the postnatal period.
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The Story of a Maternal Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programm
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Scaling Up Mentoring Programme
The mentoring programme was extended to the other six Sukshema districts starting in October
2012, and in September 2013 it was expanded further to include all PHCs in the pilot districts.
As of July 2013, the mentoring programme covered 385 24/7 PHCs with a total of 53 mentors.
Programme refinements
The project made some changes to the mentoring programme design in the scale-up districts
based on learning from the pilot districts. In the scale-up districts, each mentor was expected
to cover 7-8 PHCs with three days set aside for each PHC visit from the start. Additionally, the
project decided to intensify the mentoring support
in high-volume PHCs and lessen the frequency and
duration of mentor visits to PHCs that consistently
reported low delivery loads. Data indicated that 20
high-volume PHCs accounted for 19% of all PHC
deliveries in the eight districts. For these high-volume
PHCs, two experienced mentors together visited the
PHC for three days every month.
Mentors in scale-up districts followed the established
process for planning and carrying out PHC visits,
which included preparatory work, periodic reviews
after each mentor had conducted 1-2 PHC visits
and a final review once each round of PHC visits was
complete.
Lessons learned
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Lessons learned in the scale-up districts emphasised
the importance of creating an enabling environment,
orienting providers to case sheets in advance of the
intervention and the need to further strengthen
referral processes. The high-volume PHC strategy worked well for PHCs in all districts. The pace
and nature of quality improvements also followed a consistent pattern among PHCs, with
improvements in the labour room and drug supplies being some of the first signs of quality
improvement. Practices that were more resistant to change included infection prevention and
postnatal care.
The scale-up experience demonstrated that the intervention could be replicated and applied
in other districts. Systematically using the approaches and tools developed to implement the
intervention resulted in a smooth and efficient implementation process and in just a five-month
period the mentoring programme was extended to all eight project districts. Overall, mentors in
these districts observed similar levels of staff engagement and improvement in their PHCs.
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Managing the Mentoring Programme
The Sukshema project developed a management structure and management processes to
oversee implementation of the mentoring intervention. Overall guidance and support came from
a core technical team based in Bangalore, consisting of the technical lead, quality improvement
specialist and clinical specialist. These individuals routinely visited the project districts, advised
on management processes and anticipated and provided troubleshooting as issues arose. At
the district level, a district programme specialist (DPS) based in each district was responsible for
managing and monitoring the mentoring intervention in that district. These individuals had a
Master's in Public Health degree with a medical background (e.g., ayurvedic). As the principal
liaison with district health officials, the DPS routinely informed them about the intervention and
system-level issues that needed district-level attention. The Sukshema team also developed a set
of tools to assist mentors in planning their mentoring visits and to assist DPSs in carrying out their
supervisory and reporting responsibilities. A monitoring information system was also established
to track intervention indicators.
Voices of PHC and District Staff
Interviews were conducted with four PHC teams and one District Health Officer (DHO) in May
2013 in pilot districts and with three PHC teams in scale-up districts and another DHO in October
2013 and April 2014 to assess their understanding of the mentoring programme and their own
assessments of improvements since the programme began.
Nurses pointed out how mentors were helping them be more systematic and thorough in
providing care. As one nurse stated, "We didn't know much before and now the mentor tells us
how to do each thing and explains why we do these things. The mentor reminds us about things
we forget." Nurses and other PHC staff praised the professionalism and interpersonal skills of the
mentors. "Mentors are very helpful and relaxed. Even if we are rude or stressed because we are
busy they don't react and are always at ease with us which helps ease the tension. A MO stated,
Mentors are very good and cooperative.
Some PHCs had fully embraced the approaches the mentors used to strengthen systems. Several
nurses interviewed appreciated the case sheet. Nurses and medical officers nevertheless pointed
out the challenges in filling out the case sheet, especially when staff were busy.
PHC teams also appreciated the mentoring programme for contributing to facility-level
improvements. They commented on how the mentoring programme had helped them with
managing stocks and coordinating with each other to ensure they had the drugs and supplies
they needed. PHC teams described many improvements in their operations and their quality of
care since the start of the mentoring programme.
Nurses and medical officers felt the mentoring programme should continue. A MO noted, "There is
so much workload here that things sometimes fall behind so it is good to have the mentors to remind
us and to keep coming often." A nurse valued the intervention "because mentors come with new
information and they provide access to experts" A DHO commented that nurses in PHCs rarely have
someone available who can monitor their skills and support them and he felt that the mentoring
programme was filling this important gap.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring
Coordination with Community Intervention
Sukshema project's community intervention is designed to work on community-level issues
through building the capacity of accredited social health activists (ASHAs), Anganwadi workers
(AWWs) and junior health assistants (JHAs) to improve birth preparedness and maternal and
newborn practices at the community level. The community intervention and mentoring
programme coordinated together in each district to see how they complement each other in
ensuring MNCH care continuum across levels of care. Each district held coordination meetings
including thefull community and mentoring teams and developed joint action plans. Infrastructure
issues were a common concern that mentors and community coordinators tried to join forces to
resolve. Other issues they discussed included preventing home births, encouraging women to
come to the facility earlier in labour, follow up in the community after mothers and babies are
discharged from the facilities.
The linkages between the two programme components evolved somewhat organically as the
two teams got to know one another and found ways to work together. As the project moves into
its final year, it will be important to develop clear guidance on what role mentors can play in
extending AMMA to the community level and how this relates to the community intervention.
Intervention Results and Costs
A more quantitative assessment of the mentoring programme's achievements was based on
monitoring indicators and the pilot district evaluation findings.
Management information system (MIS) findings
According to MIS data, the use of case sheets increased overtime. As of March 2014, nurses had
completely filled out a case sheet for more than 65% of all PHC arrivals compared tol 2% in January
2013.The mostfrequently occurring complications related to prolonged labour, premature rupture
of membranes or pregnancy-induced hypertension/preeclampsia.The use of complication case
sheets was also improving: the proportion of complication case sheets filled out as a proportion
of total referrals reported (derived from the referral registers) was 42% in March 2014 up from 5%
in January 2013.
Endline evaluation findings
The project corroborated its qualitative findings with an endline evaluation of the mentoring
programme and its impact on knowledge, skills and facility readiness to provide maternal and
newborn services. PHCs in Bellary and Gulbarga were randomly assigned to either intervention or
control groups. The endline study involved facility audits, provider interviews and interviews with
postpartum women in the month after delivery in 2012 and again in 2013.
In terms of knowledge of management of labour and delivery, intervention and control sites both
improved over the one-year period. There were improvements overall in knowledge of how to
identify prematurity, AMTSL, eclampsia, sepsis, postpartum haemorrhage, obstructed labour,
and foetal distress and how to manage neonatal resuscitation. On almost every indicator, the
intervention sites performed statistically significantly better than the control sites. Post-delivery
issues improved overall but there was little actual difference between intervention and control
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sites, especially when the practices reported by staff were compared with postpartum client
interviews.
PHCs were much better equipped in 2013 than in 2012. Again, there were improvements overall
in both types of sites; however, the intervention sites outdid the control sites and in many cases
the differences were highly statistically significant. The biggest differences were observed with
respect to drug availability and adherence to referral protocols; here, intervention sites were far
better equipped to manage all emergencies than were control sites in 2013.
Mentoring was not able to affect more systemic problems such as staff shortages, the physical state
of PHCs,or services such as food, water, and linens for postpartum women within the year's time.
Cost
The total start-up and annual cost of the intervention was 2,71,03,453 INR (467,301 USD) for all
eight districts. This translates to 3,387,932 INR (58,413 USD) per district and 511,386 INR (8,817
USD) per mentor per year.
Summary of Achievements and Challenges
Qualitative and quantitative information were all consistent in suggesting that the mentoring
programme has been successful in improving many aspects of clinical care and helping PHCs
be better equipped and supplied to provide MNCH services. Key improvements are summarised
below:
Clinical improvements
Knowledge and skills
Diagnosis and management
of complications
Improved referral processes
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Use of case sheet
Management
improvements
Physical improvements
Availability of drugs and
supplies
Labour room
organisation
Infection prevention In
labour room
Greater teamwork
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Action plans
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Major lessons learned are listed below and are elaborated on in the full report:
1. The best mentors combine strong clinical and communication skills.
2. A focused training programme combined with a strong system for ongoing training and
support can prepare a capable and effective mentoring workforce.
3.
Self-assessment processes and team-based action planning are required to improve quality.
4. The case sheet is a helpful tool but requires time and support to operationalize.
5.
Data use can drive programme improvements on many levels.
6.
PHC leadership is a critical factor in improving quality.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Nortl
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7.
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High-volume PHCs require the most support.
8. The DHO's role is vital to catalyse mentoring programme impact.
9.
Integration with government reporting forms and systems is needed for new formats.
10. Extending mentoring to JHAs could reinforce linkages to community-based services.
Challenges that the mentoring programme cannot address stem from root causes that are at the
community or system levels. The solutions will need to be addressed at these levels. For example,
the issue of inadequate staffing or strengthening referral facilities requires district or state-level
action. Behaviours such as untimely care-seeking and short postnatal stays will require dialogue
at the community level through ASHAs and local village leaders.
Overall, however, the mentoring programme is proving to be an effective intervention to improve
the maternal and newborn services in PHCs. Mentors have been able to support PHC teams to
identify and address quality gaps and to increase the capacity and confidence of staff nurses. In
many PHCs, nurses say they are now providing care according to SBA guidelines and are better
able to handle maternal and newborn complications. Facilities are also better organised, equipped
and supplied to deliver quality services. If scaled up to other PHCs or even higher-level facilities,
the mentoring programme can be an important contributor to reducing maternal and newborn
mortality.
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Introduction
■y n India, too many women and infants die from causes that are preventable or easily treatable.
I For women, preventable and treatable causes of maternal death include haemorrhage,
± hypertensive disorders, sepsis, obstructed labour and unsafe abortion; for newborns, causes
of neonatal death include preterm birth, low birth weight, sepsis and asphyxia. Evidence points
to the critical importance of ensuring high-quality care during labour, delivery and the immediate
postpartum and newborn period for saving maternal and newborn lives. This is the window in
which more than half of maternal and newborn deaths take place. The ability of providers to
manage normal deliveries according to best practice guidelines and to identify, manage and refer
patients with maternal and newborn complications can have a direct impact on maternal and
newborn health outcomes.
The Sukshema project developed a mentoring intervention designed specifically to improve
the quality of facility-based maternal and newborn care in 24/7 primary health centres (PHCs)
in Northern Karnataka. By providing on-site mentoring for improved clinical care and service
delivery, the project hypothesized that the quality of services and continuity of care would
improve and that women and newborns would have better health outcomes. The pilot phase of
the intervention was rolled out and evaluated in two of the project's eight districts (Bellary and
Gulbarga) from August 2012-August 2013. Scale-up to the other six project districts began in
November 2012 and reached full scale by March 2013.
Organization of Report
This report contributes to Objective 4 of the Sukshema project—Facilitate identification and
consistent adoption of best practices and innovations arising from the project at the state and
national levels—by documenting the process and experience of implementing the mentoring
intervention. In essence, this document tells the story of this innovative mentoring approach.
We hope it helps others learn from the experience and stimulates interest in developing similar
approaches in India or elsewhere to improve maternal and newborn care.
The document is structured in ten sections as follows.
Section 1 begins with the context in which the project operated and outlines the rationale for
establishing a mentoring programme. It offers a brief description of the mentoring programme
and reviews the evidence about mentoring and other quality improvement approaches that
informed the intervention design.
Section 2 describes the approaches and tools that were developed specifically for the mentoring
programme. A separately available toolkit includes all the tools and training materials developed.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in N
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_____________________________________________ ____________
Section 3 focuses on the hiring and training of mentors, including a detailed description of the
initial training programme and the ongoing capacity-building support the project provided to
mentors.
Section 4 documents the first year of the mentoring intervention in the two pilot districts by
recounting the experiences derived from each round of mentor visits. In the first year, each PHC in
the intervention districts received six mentor visits.
Section 5 discusses how and when the mentoring programme was scaled up to the remaining
project districts and to all PHCs in the pilot districts. It highlights modifications that were made
in the original programme design as this scale-up took place. This includes more use of data to
drive programme reviews anddevelopment of tailored visit strategies based on PHC volumes.
It highlights mentors' experience in working with PHCs in the scale-up districts, pointing out
where the experiences were similar or differed somewhat from the experiences of mentors in the
pilot districts.
Section 6 describes the management processes and tools the project developed to support
implementation of the mentoring programme and points out some of the challenges encountered
and lessons learned.
Section 7 shares comments from PHC staff and district-level officials about the mentoring
programme and how it has improved services.These comments are based on interviews with PHC
teams during site visits to their PHCs.
Section 8 focuses on the coordination of the mentoring programme with the other major
element of the Sukshema project known as the community intervention (Cl). This aspect of the
project worked at the community level with frontline workers. It should be noted that these two
project componentshad worked synergistically to only a limited extent at the time of the writing
of this report because the Cl had a longer scale-up period than the mentoring programme.
Section 9 introduces quantitative data from project monitoring and evaluation research to
provide a data-driven look at the intervention. It is noteworthy that the data largely corroborate
the qualitative findings derived from observations and interviews.
Section 10 offers a summary of the major findings from the mentoring programme, recapping
the most notable achievements and pointing out persistent challenges, especially those that
require system or community-level solutions.
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Methodology and Data Sources
This report is the culmination of an intentional and intensive effort to document the process
of designing, implementing and managing the mentoring programme. The major sources of
data for describing the process include data
from observations and field visits; focus group
;
documenhton were ;
discussions with participants; interviews with
collected over a 24-month period. The
project staff, consultants and mentors; and
primary sources of information Were: :
interviews with PHC teams and district officials.
—
A senior technical advisor, not directly involved
in the day-to-day' operations
of the mentoring■
24 PHC staff interviews in four districts
programme, carried out most oftheobservations,
.
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interviews and focus group discussions. The
technical advisor developed tools for recording ..
___ ________ :
observations, as well as interview and focus
group guides and prepared notes from each observation, interview and focus group discussion.
This report also includes information gleaned from trip reports from other project consultants
participating in trainings, district-level meetings or visits to PHCs, as appropriate.
8tosgro„pi^5spa^„,s,
Process documentation started with observations and interviews of the mentor training in July
2012. Subsequently, the senior technical advisor visited the pilot districts in September 2012 and
May 2013, meeting both times with all 11 mentors and district-based project staff and visiting six
different PHCs to observe mentors and interview PHC staff. A follow-up visit took place in April
2014 in Bellary and Gulbarga to meet again with mentors in both districts.
Documentation of the intervention in the scale-up districts included two site visits and interviews
with mentors and programme staff in Bidar District in May 2013 and four site visits and mentor
focus group discussions in Koppal and Raichur districts in October 2013. Additional information
was obtained through visits toGulbarga (to new PHCs) and Yadgir districts in April 2014, including
mentor focus groups, provider interviews and three site visits to PHCs.
In addition to the qualitative information obtained through observations and interviews, this report
draws on selected quantitative data from the projects monitoring and management information
system (MIS) data and the endline evaluation carried out in the pilot districts (Section 9).
25
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in h
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Context, Evidence and
Programme Overview
"y n designing the mentoring component of the Sukshema project, the Sukshema team drew on
I the latest evidence on maternal and newborn mortality, findings from an assessment of the
JL maternal, newborn and child health (MNCH) situation in the eight Sukshema districts and a
review of proven capacity building and quality improvement approaches in other contexts.
The mentoring intervention was designed specifically to improve the quality of facility-based
maternal and newborn care. Ensuring high-quality care during labour, delivery and the immediate
postpartum and newborn period can contribute to reduced maternal and newborn mortality
rates (MMR and IMR).
The focus on facility-level maternal and newborn services also recognizes the recent success of
the Janani Suraksha Yojana (JSY) scheme in Northern Karnataka, which has led to an increase in
facility-based deliveries. With over 80% of pregnant women now delivering in facilities, it is critical
that all delivery sites be able to provide quality care. To accommodate this rising demand, the
government is prioritizing upgrading primary health centres into 24/7 facilities to provide delivery
services in rural areas. This will reduce the burden on district and larger hospitals, enabling them
to function more appropriately as first referral units (FRUs). Therefore, the mentoring intervention
specifically targeted the 24/7 PHC level to prioritize support for PHCs as they take on these
expanded functions.
Findings from Situation Analysis in Project Districts
The Sukshema project carried out a situation analysis in eight project districtsin 2011 to assess
the capacity of health facilities to deliver maternal and newborn services. The situation analysis
revealed the need to improve provider competence in managing maternal and new born care
and address facility-level factors such as drug stockouts and lack of infrastructure, which create
barriers to providing quality MNCH services.
Gaps in service provider knowledge and skills
In PHCs in project districts, 63% of staff nurses had participated in the government of Karnataka's
(GoK's) 21-day skilled birth attendance (SBA) training programme and 12% of medical officers
had received 10 days of training in basic emergency obstetric care (BEmOC). Even among these
trained providers, knowledge was inadequate. In an assessment of intranatal care knowledge,
less than 70% of staff nurses knew that active management of the third stage of labour (AMTSL)
was essential for all deliveries, and only 28% knew the proper steps in AMTSL. For postnatal care,
Mentoring Intervention Report
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Mentoring Intervention Report
providers scored only 52% on knowledge questions, and on observation, their practice was correct
in just 31% of provider-client interactions. Over half or more of providers failed to demonstrate
competency in MNCH topics. The situation analysis also found that there were no mechanisms
in place for follow-up of staff after training to ensure good clinical practice and maintenance of
skills or to facilitate solving system-level problems that compromise providers'ability to deliver
high-quality services.
Gaps in drugs and equipment
The situation analysis identified extensive facility-level gaps at all levels but especially at PHCs,
which often lacked the drugs and equipment to provide delivery services. Many facilities did not
have equipment or procedures in place for infection prevention. Supplies of case sheets, referral
forms and partographs were also inadequate. Many essential drugs were unavailable at the time
of the survey, such as magnesium sulphate, essential for the management of eclampsia. Oxytocin
used for AMTSL was not available in many of the facilities.
Gaps in referral processes
The situation analysis found weak referral processes and poor follow-through once referrals were
made, compromising the provision of a continuum of care for mothers and newborns. Providers
did not know how to screen for complications or how to detect complications early. They also
did not know how to manage cases once a complication was identified. Referral protocols were
lacking when a mother or newborn did require referral to a higher-level facility. Only about
one in four PHCs had a referral chart displayed or referral slips available and slightly more than
half maintained a referral register. More importantly, practices to ensure the continuum of
care-including communication with referral facility, stabilization and timely transport and patient
follow-up—were not being followed in most cases.
Areas for improvement
In summary, the assessment identified gaps impeding delivery of quality MNCH services and
highlighted the following areas for improvement:
Adopt a comprehensive focus on "quality," includinga focus on infrastructure and competency
issues
Develop follow-up support systems for MNCH providers (beyond one-time trainings) to
sustain skills and competencies
Promote use of job aids, checklists and protocols related to management of critical services
Address gaps in facility-level systems such as referral, documentation, infection control and
supply chain systems
Createasupportiveworkenvironmentinfacilities byfostering practices such as self-evaluation,
team work, task shifting and attention to patient rights and dignity.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in I
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Overview of On-Site Mentoring Intervention
In light of the situation analysis findings, the Sukshema project developed a mentoring programme
to address many of the quality-related gaps. Sukshema's MNCH mentoring intervention integrates
elements of clinical mentoring with facility-based quality improvement processes to support
PHCs to deliver critical maternal and newborn care services. The project employed a new cadre
of full-time nurse mentors to mentor staff in designated 24/7 PHCs. Each mentor was responsible
for mentoring staff at five to eight PHCs. Typically, nurse mentors visited their designated PHCs
six times in the first year. The nurse mentors spent two to three days at the PHC to provide clinical
mentoring to staff nurses and team-building and problem-solving support for all PHC staff. After
receiving mentor support for one year, mentors adjusted the frequency of their visit schedule
based on the clinical volume of the PHC and the level of performance improvement still required.
In this way, some high-volume PHCs received more frequent visits while PHCs with lower or no
delivery loads received a visit once a quarter.
Mentors used tools and techniques such as observations, PHC staff self-assessment checklists,
clinical audits and patient interviews as aids to identify quality gaps needing to be addressed.
They upgraded PHC provider skills through case reviews, confidential reviews of maternal and
child morbidity and mortality (and near-miss cases), mini-lectures, demonstrations, modeling of
good practice and bedside case discussions.
In addition to clinical mentoring of providers, the mentors worked with PHC teams to focus on
problem-solving around all aspects of the provision of quality MNCH services. Mentors introduced
self-assessment and action planning processes to promote facility-based quality improvements.
Mentors also encouraged PHC staff to workas a team to address specific problem areas such as (but
not limited to) equipment and supply logistics; infection prevention practices; referral practices;
record keeping; staff support; teamwork; and staff attention to patient rights to information,
respect, dignity and friendly services.
Nurse mentors and facility teams specifically promoted interventions to improve referral processes
and ensure continuity of care for referred cases. This included using case sheets to identify cases
needing referral, ensuring updated referral service charts and a documented referral plan for each
facility, more effectively using referral registers and cards, improving provider communications
with referral facilities and improving communications with community-based junior health
assistants (JHAs) and accredited social health activists (ASHAs) upon discharge to ensure proper
follow-up.
The Sukshema project trained nurse mentors in clinical competencies and in how to mentor staff
in clinical skills and service delivery quality improvement. Each mentor was provided with a kit
of training materials and models to use during the PHCvisits.The project also developed specific
tools (including self-assessments and action plan templates) to facilitate implementation and
monitoring of quality improvement activities. Finally, the project introduced a case sheet to help
PHC staff better manage maternal and newborn complications.
Mentoring Intervention Report
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Phase 1 involved launching the mentoring intervention in a subset of 24/7 PHCs in two pilot
districts—Bellary and Gulbarga. The pilot included 54 PHCs in the intervention group and
54 in a control group that enabled the project to evaluate the contribution of the mentoring
programme after one year. The project recruited and trained a total of 11 mentors to provide
support to 54 intervention PHCs in the two districts. The project also had a mandate to scale up
the mentoring intervention in the other six project districts (Phase 2), which entailed training and
employing another 45-50 nurse mentors. Once the evaluation was completed in the pilot districts,
the mentoring programme was also extended to all PHCs in Bellary and Gulbarga districts. The
mentoring intervention was intentionally implemented across all districts to derive lessons about
implementing the intervention at scale.
Collaboration with the National Rural Health Mission
It was anticipated that if the mentoring intervention proved successful, the GoK would establish a
nurse mentor cadre within the government system and institutionalize the intervention in other
districts in the state. Because the mentoring intervention was designed with government scale-up
in mind, collaboration with the GoK at both the state and district levels was essential. Throughout
the developmentof the intervention, therefore, the Sukshema team met with mission leadership at
the National Rural Health Mission (NHRM) and the State Directorate of Health and Family Welfare.
The mission director approved the piloting of the mentoring intervention and sent a government
circular to the two pilot districts in March 2012 to inform them about the intervention. Sukshema's
technical leadership also met periodically with the deputy director for training within the State
Institute of Health and Family Welfareto review the intervention design and share updates at key
junctures. Frequent turnover of leadership at the state level made this coordination and buy-in
from the government more challenging.
Mentoring and Quality Improvement Interventions
In designing the mentoring intervention, the Sukshema project reviewed findings from similar
interventions across a variety of settingsand clinical areas.Thefindings suggested that a mentoring
intervention should include components focused on on-the-job provider training and support,
user-friendly clinical job aids and team-based approaches to quality improvement.
29 i
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnatal
Mentoring interventions.
Published literature on the application of maternal and newborn health mentoring programmes at
scale in lowand middle-incomecountries is limited. Mentoring programmes have been established
to improve delivery of HIV/AIDS care; projects of this type in India, Uganda (Bitarakwate 2009),
Zambia (Morris et al. 2009) and Botswana (Workneh et al. 2012) have documented improvements
in service quality. In Senegal (IntraHealth International n.d.) a mentoring programme known as
Tutorat strengthened nurse and midwife competence in family planning counseling, skilled birth
attendance and post-abortion care (PAC). In Jharkhand, India (Vistaar Project 2012) introduction
of a supportive supervision programme in which medical officers provided support to auxiliary
nurse midwives trained as SBAs contributed to improved use of AMTSL and partographs and
increased access to drugs and supplies. In Ethiopia (Hartwig et al. 2008) a mentoring programme
aimed at health centre managers reported improvement in management skills of hospital leaders
in several management domains.
Quality improvement interventions.
The evidence review found several examples of team-based approaches to quality improvement
that contributed to facility-level improvements as measured by quality indicators. For example,
an evaluation of COPE (a team-based quality improvement approach) for child health in Kenya
and Guinea examined changes in quality over a 15-month period at eight intervention and
eight control sites and concluded that on almost every quality indicator, the intervention sites
performed significantly better than the control sites, with most problems solved without outside
assistance (Bradley & Igras 2005). Health care collaboratives, in which coaches support quality
teams from several facilities to address identified quality gaps, have also improved services. In
Uganda, this approach was used in two districts to improve the provision of newborn resuscitation
at government health centres (Tawfik 2012). In Malawi, health facility teams implemented
a performance and quality improvement (PQI) intervention over a 3-year period to improve
reproductive health (Rawlins et al. 2013). Intervention facilities were more likely than comparison
facilities to have the needed infrastructure, equipment, supplies, and systems in place to offer
reproductive health services. Observed quality of care also was significantly higher at intervention
than comparison facilities for postnatal care and family planning.
Clinical guideline interventions.
Evidence supports the value of usable clinical checklists and guidelines. Checklist-based
interventions can aid management of complex or neglected tasks and have been shown to
reduce harm in health care. A pilot, pre-post-intervention study was conducted in a subdistrict
level birth centre in Karnataka, India between July and December 2010 to evaluate changes in
maternal and newborn health practices (Spector et al. 2012). This followed the introduction of
the WHO Safe Childbirth Checklist programme, a childbirth safety programme for institutional
births incorporating a 29-item checklist. Delivery of essential childbirth-related care practices at
each birth event increased from an average of 10 of 29 practices at baseline (95% Cl 9.4,10.1) to
an average of 25 of 29 practices afterwards (95% Cl 24.6, 25.3; p<0.001). Other research explored
use of clinical practice guidelines (CPGs) for maternal health in Burkina Faso, Ghana, and Tanzania
(Baker et al. 2012). I n all three countries, theuse of CPGs by health workers in practice was perceived
to be limited. The cross-country study suggested the need to prioritise the format of guidelines to
increase their usability and applicability.
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12 Project Tools and Approaches
he project first set forth a framework for improving quality of care and developed a set
of tools and approaches to operationalize the framework. The quality improvement
principles that guided the development of the quality improvement approach included
a focus on patient and provider rights and the promotion of team-based problem-solving using
self-assessment tools and action planning.
AMMA Approach
The project designed a quality improvement framework called AMMA, which means "mother" in
Kannada. The acronym stands for Assess and diagnose, Manage, Measure and Advocate. AMMA
adapts quality improvement approaches such as Plan Do Study Act (PDSA) and performance
improvement (PI), both of which focus on a quality cycle. AMMA offers a similar quality cycle, using
an acronym that is meaningful in the local context so that the cycle is easy to remember and use.
ASSESS: Assess and diagnose quality gaps
MANAGE: Manage solutions to address gaps
MEASURE: Measure progress in closing gaps
ADVOCATE: Advocate for clients'and providers'rights to quality services
The AMMA approach is integrated into all Sukshema project activities. The Sukshema team
developed a matrix (next page) that shows how the AMMA approach can be used at the facility,
provider, system and community levels. The intent was that AMMA would unite clinical and
nonclinical perspectives and function as the "mantra" for the mentors and PHC teams in their
efforts to improve the quality of care at the PHCs.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The AMMA Approach: Assess and diagnose, Manage, Measure, Advocate: Role of Nurse Mentors
Focus year 2
Focus year 1
Individual staff
clinical competencies
Community linkages
System linkages
Assess and diagnose
Assess and diagnose
functioning of PHC
women in labour and
(identification of gaps in the postpartum
against PHC standards i period and newborns,
and patient/provider
using case sheet and
other tools
rights, root cause
analysis using quality
Examples:
improvement [QI]
-AMTSL procedures
tools)
not followed
Examples:
Assess and diagnose
community-based
MNCH services and
linkages to facility—
identify gaps and
opportunities for
improvement
Assess and diagnose
gaps that require
district-level action
Examples:
-Staff vacancies
-Shortage of
magnesiumsulphate
-Women reaching PHC
too late
PHC functioning
ASSESS AND
DIAGNOSE
quality gaps
Examples:
-Drug stockouts
-Lack of equipment
-Low ASHA coverage
(pregnant women)
-Client records
incomplete
-Staff absenteeism
r
- ----------------------- ------ 1
Manage appropriately Manage the solutions
(develop action plan,
how services can be
in sync before labour
raise issues at district| level review meetings)
(preparation for
labour), when coming ■
to the PHC, and
post-delivery
(care and support)
MANAGE
solutions to
address gaps
Manage the solutions Manage appropriately
women and babies
(develop a realistic
! with and without
action plan)
complications
MEASURE
progress
Measure progress
(action plan, record
reviews, audits)
Measure progress
using case sheets,
registers, partographs
Measure progress
Measure progress
(review microplanning (action plan,
resolution of problems
tools, Mother and
Child Tracking System by district)
[MCTS] data, ASHA
performance reviews,
rapid assessments);
jointly examine cases
coming appropriately
and inappropriately
to the PHC and
utilization of services |
ADVOCATE
for client
andprovider
rights to
quality
services
Advocate for quality
improvement (create
a positive, can-do
environment, improve
linkages, increase
client satisfaction)
Advocate for quality
improvement (create
a safe and patientcentered environment
for women and
babies, ensure timely
I referrals)
Advocate for quality i Advocate for quality
r-\arvxcirri’
improvement (ensure !I im
improvement
continuum of care
from home to facility
and back for mothers
and newborns)
o _ _ .........
Mentoring Intervention Report
[S5o3
(encourage
I accountability and
action at system level)
Mentoring Intervention Report
Assessment Tools
In addition to the overall AMMA framework, the project designed tools to assess quality at both
the patient and facility levels. For assessing quality issues at the facility level, the project developed
self-assessment guides that mentors used with PHC teams to assess quality of care and identify
gaps. These guides were based on patient and provider rights to quality health care. Some of
these tools were adapted from baseline quality assessments, while others were adapted from
other projects. In all, there were eight self-assessment guidelines, listed in the following table.
Self-Assessment Guides for PHCs
A.
£
£
£
£
£
£
H
Clients'rights to safe and competent care____________________________________
Providers'rights to supplies, equipment, and infrastructure______________________
Clients'rights to access services and continuity of care__________________________
Clients'rights to infection-free services______________________________________
Providers'rights to information, training, and development______________________
Clients'rights to privacy, confidentiality, dignity, comfort, and expression of opinion
Clients'rights to information and informed choice_____________________________
Providers' rights to facilitative supervision and management
Each self-assessment guide asks a series of questions related to quality standards that PHC teams
review to assess their own performance against quality standards. If the answer to a question is
"yes," then the standard is considered met, while a "no" response indicates a problem to be solved.
Providers also used a record review and patient interview guide as input into the self-assessment
process. Section 4 describes lessons learned about how the tools were received by PHC teams in
more detail.
Case Sheets
Up-to-date, accurate, and comprehensive patient records facilitate case management and clinical
decision-making and referral. The project situational analysis revealed, however, that patient
records were not well maintained. For example, out of 1,038 case sheets reviewed as part of the
assessment, only six had a complete delivery note. Among 593 case sheetsinvolving eclampsia
across the eight project districts, only 146 (25%) were complete enough to enable a clinical review
of how the cases were managed. In an audit of referral records at PHCs, only 55% had time of
admission, 55% had time of referral and only 8% mentioned the name of the person accompanying
the referred patient. Clinical outcomes were only documented in 9% of referrals.
During the situational analysis, the Sukshema project also found that providers did notperceive
the government case sheet format to be helpful as a decision-making tool for clinical care.
The government case sheet included many questions that required written responses but that
providers were less likely to complete, perceiving the questions as more of a reporting burden than
a helpful process. Moreover, the case sheet formatprovidedno guidance on case management.
Given the findings of poor provider knowledge of and adherence to SBA guidelines, the Sukshema
project recognised an opportunity for developing a new case sheet that could serve as a clinical
record, a job aid, and a teaching tool. The project hypothesised that providers would find
value in using the tool to help them follow recommended guidelines and support their clinical
decision-making.
33 1
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
___ r" —
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The project designed the case sheets to function
as a job aid to provide guidance to providers
on the components of care to be followed. As
a teaching tool, the revised case sheets helped
mentors focus discussions on compliance with
clinical guidelines, opportunities for improving
case management and identification of cases
when something may have gone wrong and
ascertaining what could have been done
instead. Creating acase sheet mechanism
for retrospective case reviews was especially
important given that mentors were not present
during all cases and needed to be able to refer
to case sheets to provide teaching. The revised
case sheet also served as a tool for mentors and
programme staff to monitor changes in the
quality of care provided at PHCs.
■
j"’ 1 V '<
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The Sukshema technical team led the
development of this tool in consultation with
other Sukshema staff and clinicians from
University of Manitoba and St John's Medical College (SJMC). Developers referred to existing case
sheets, SBA guidelines, Navjaat Shishu Suraksha Karyakram(NSSK) guidelines, Indian Public Health
Standards guidelines and BEMOC guidelines to prepare the content and flow of the draft case
sheet.
Several considerations guided the design of the new case sheet to enhance its appeal to providers
including that it:
1. Be comprehensive, covering all stages of labour, delivery and postpartum and newborn
care (note: it does not cover antenatal care visits)
2. Follow the logical sequence of patientarrival, initial assessment, admission, labour monitoring
and delivery, postnatal care, newborn care and discharge
3. Be consistent and include clear instructions
4. Comply with the SBA and NSSKguideiines in terms of recommended management protocols
5. Provide clear guidance onrecommended drugs, dosage and administration
6. Provide reminders for providers on when to ask for certain information
7. Include an easy-to-plot and interpret revised partograph suitable for PHCs
8. Provide a summary at each stage to help providers take decisions
9. Minimize requirements for writing by using tick marks
10. Ensure a format that is useful for conducting case audits.
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Mentoring Intervention Report
The final case sheet is nine pages long for normal labour and delivery. As providers identify markers
for complications, they are referred to more detailed case sheets that provide guidelines for more
accurately diagnosing and treating maternal complications. The supplemental case sheets (each
1-2 pages long) cover management of eclampsia, postpartum haemorrhage (PPH), prolonged
or obstructed labour and other complications. The case sheets for complications give detailed
guidance on care protocols, including drug and dosage guidelines that help providers comply
with the recommended management regimens (see text box).
Case Sheet Outline for 24/7 PHCs
Case sheet for normal labour and delivery
■
.
;
■
•
■
‘
.
Section 1: Initial assessment
Section 2: Labour monitoring (including simplified partograph)
Section 3: Delivery notes
Section 4; Postpartum period
____ Outcomes sheet
__
Supplemental complication case sheets
____ A
JC
--- i-------Ji
A:Prolonged/obstructed labour
B: Preeclampsia/eclampsia
C: Antepartum haemorrhage
D: Infection/sepsis
E: Premature rupture of membranes
F: Postpartum haemorrhage
G: Newborn complications
H: Other complications
After obtaining approval from the NRHM director, the project field-tested the revised case sheet in
the pilot districts. Prior to starting the mentoring intervention, the Sukshema team hosted a 3-day
training with staff nurses in all intervention and control PHCs and a 1-day session with medical
officers to introduce the case sheet and provide them with copies to use in their PHCs.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in
llliilis
We note some of the key lessons learned from development of the case sheet below. (Lessons
pertaining to the case sheets' utilization in PHCs are included in the later discussion of mentor
visits.)
The new case sheet followed a logical sequence for diagnosis and management of cases and
provided readily accessible guidelines for managing complications and referrals in an effort
to offer a tool perceived as a valuable job aid rather than a tedious paperwork requirement.
The inclusion of complication case sheets was especially important because PHC providers
do not routinely encounter complications, making it difficult to readily remember care
protocols. Because prior assessments had indicated that providers didn't always know how
to detect and manage complications orwhen to refer, the case sheet was also designed to
support improved referral practices.
Development of the case sheet proved to be an educational process for the Sukshema
team. The process uncovered areas in which the team needed to reach agreement on the
best guidance to provide, especially when source guidelines were not specific or disagreed
or when guidelines did not comply with the best available international evidence. These
deliberations helped ensure a detailed and comprehensive tool uniquely suited to PHCs.
The Sukshema project was able to adapt existing tools to better suit the PHC context. The
case sheet included a simplified partograph, based on the WHO partograph but adapted to
be useful at the PHC level.
The case sheet also provided guidance on the type of knowledge and skills providers should
have to manage cases, which informed the subsequent content of the mentor training.
Mentoring Intervention Report
Mentoring Intervention Report
13 Hiring and Training Mentors
he process for hiring and training mentors proceeded after the project finalized its tools
and approaches and determined that the mentoring intervention would largely focus
on building the competence of staff nurses as skilled birth attendants. Staff nurses were
chosen as the recipients of mentoring because Sukshema assessments of maternity services at
PHCs indicated that staff nurses are the primary cadres responsible for providing labour, delivery,
postpartum, and newborn care services. Medical officers (in charge of the PHCs) only assist in
labour and delivery as needed.
Sukshema employed innovative strategies to hire mentors and train them to perform their roles.
Hiring nurse mentors entailed (1) identifying what cadres to use as mentors, (2) recruiting mentors,
(3) hiring mentors, and (4) training mentors.
Determining Mentor Cadre
In designing the mentoring intervention, one of the first critical decisions was to determine the
profile of the mentors. At a minimum, mentors had to be qualified health care providers. The
project decided to employ nurses as mentors for the following reasons:
Peermentor/ngrBecauseofthefocusonstaffnursesastherecipientsofmentoring^ukshema
used a peer mentoring approach involving nurses as mentors.The project hypothesized that
a peer would be a more effective mentor than a medical officer or a specialist physician. This
design was similar to other mentoring interventions, including the SAMASTHAmentoring
programme established by KHRT and SJMC for HIV/AIDS care in Karnataka that engaged
doctorsto mentor other doctors.
Recruitment: Another consideration was that it can be very difficult to recruit medical
officers for the areas in which the project works (as evidenced by the number of PHCs in
these districts that do not have the required number of qualified medical officers). It was
considered easier to recruit nurses forthe positions.
Retention: The project anticipated that turnover among skilled nurses would be less than
among medical officers. (Experience working with medical officers as technical support
specialists in the Key Clinic private franchise model in Southern India found high levels of
attrition as medical officers often left for other opportunities, including postgraduate work.)
<*<?> Cost-effectiveness: Utilizing nurses as mentors presented some cost advantages over
medical officers because of the nurses' lower salaries. This could become an important
consideration in the overall cost of operating this programme at scale within the government
system.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
____________________________________________________________________________________________
Gender considerations: Finally, using nurses—who are most often women—as mentors
contributed to the project's aim of furthering the empowerment of female health workers in
the health care system.
Recruitment Process
The project team crafted a three-tier hiring strategy to identify the best mentor candidates.
Because of the varied skills that mentors needed to possess, the team viewed a conventional
hiring process of screening curricula vita eand interviewing candidates as possibly insufficient to
fully assess candidates7 capacities for the position. The projects need to hire many candidates at
once also offered opportunities for more creative group-based candidate assessment processes.
Information on each level of the hiring process is presented below.
First level of screening
After placing local advertisements in leading newspapers and posting position openings in
nursing colleges and hospitals, the project received 48 applications. Of the 48 applicants, the
project's senior management team selected 22 candidates based on age, sex, and duration of
clinical and teaching/training experience. Nurses above 50 years, males and those who had less
clinical and teaching experience were omitted from this first list.
Second level of screening
District programme specialists (DPS) conducted telephone interviews with the 22 candidates
selected after the first round of screening.This was felt to be an important step, as the DPS directly
supervise the nurse mentors.
Preferred Mentor Qualifications
1
V Nursing background with more than five years of experience conducting
deliveries and handling newborns, preferably at secondary or tertiary-care
level facilities
V Fluency in written and spoken English and local language(Kannada)
V Prior teaching and/or training experience
■
■
■
■
■
■
■
V Knowledge and experience working in government health systems
V Good training and mentoring abilities
V Good communication and leadership skills
V Empathic attitude
V Team facilitation skills
V Working knowledge of MS Word, Excel, PowerPoint and the Internet
V Locally based
V Female candidates preferred
V Willingness and ability to travel to PHCs at least 50% of the time
Mentoring Intervention Report
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Mentoring Intervention Report
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Third level of screening
The Sukshema project organized a two-day residential workshop for candidates that included an
orientation to the project and the position, an exercise involving a group discussion a knowledge
test and a problem-solving exercise. Participants were also asked to prepareandpresenta technical
session. At the end of the second day, each candidate had a one-on-one interview. Assessors used
checklists to aid in objective scoring of the candidates across different competencies. After the
two-day residential workshop, the project offered positions to 13 of the 22 candidates.
Hiring Mentors
Nurse mentors reported to work in pilot districts on 20th June 2012. The district team provided a
general induction for seven days to orient mentors to the project. Mentors also toured PHCs and
FRU hospitals to gain a better understanding of the environment in which they would be working
and the travel involved in the job.
After the induction period, four candidates dropped out after consulting with their families about
thejobrequirements.To achieve the target number of mentors, the project team quickly identified
other candidates from prior rounds of screening and interviewed them by phone. In the end, the
project hired 11 mentors for the two pilot districts, including five for Bellary and six for Gulbarga.
This provided for two more mentors than required for the intervention to accommodate turnover
or non-performance issues. In the pilot districts, the ratio of mentors to PHCs was one mentor for
4-6 PHCs. (Only half of the PHCs were included in the intervention during the pilot phase.) In the
scale-up districts, the project anticipated a ratio closer to 1:10, operating under the assumption
that the mentoring process would be worked out and efficiencies achieved. In practice, the project
has ended up with about one mentor for every eight PHCs across each district.
Hiring successes
The process for identifying and recruiting mentors worked well. The candidates that were
ultimately selected were the best performers on various assessments and evaluations. The project
learned two useful lessons about maximizing hiring success:
Induction period: Having a week long induction period prior to initiating the formal fiveweek job training proved valuable because it gave candidates additional time to learn about
the job responsibilities. Although four candidates dropped outafter the induction week, it
was preferable that they drop out before rather than after the five-week training.
Thorough screening: When the four candidates dropped out, the project team was able to
identify and interview additional candidates. These candidates were somewhat weaker than
those identified through the full three-tier screening process, which validates the value of
the more extensive screening process. Once on the job, the weaker candidates were teamed
with stronger mentorsto improve their competency until they could function independently.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in fwwi
3
Hiring challenges
The pool of qualified candidates was limited becausefew nurseswith midwifery training were
available in the project districts.The project identified several additional challenges:
Lack of relevant experience: Many of the applicants were recent nursing school graduates
who had worked in government or private clinics but had limited experience in labour
and delivery. In their previous employment, many mentors had not had an opportunity to
conduct deliveries nor did they have much clinical practice in their basic training.
Commitment: More experienced or retired nurses who applied for the position were often
ineligible because they were either unable or unwilling to undertake the amount of travel
needed and were less open to learning and teaching others about the latest SBA guidelines.
Intensive hiring process: The process was effective in identifying strong candidates but
required a substantial level of engagement from senior project staff that could prove difficult
to replicate in a government system at scale.
Training Nurse Mentors
This aspect of the intervention included developing the initial training course and training nurse
mentors.
Determining training content
Sukshema developed an induction training whose content and length were based on the learning
objectives for the mentors. Mentors needed to become skilled in quality improvement principles,
mentoring approaches, clinical skills and systems strengthening. In addition, they had to learn
how to conduct mentoring visits to PHCs and understand monitoring, evaluation and reporting
functions.
A variety of considerations shaped the training content and duration. First, it was apparent that
mentors'limited clinical experience would necessitate substantial clinical training. Lack of clinical
practice was also one of the short comings of the government's standard 21-day SBA training.
Therefore, the training included over 100 hours for ward rotations for clinical observation and
practice.
Second, the project's focus on the intrapartum period meant that mentors needed to be especially
competent in managing labour and delivery and maternal and newborn complications. The
training, therefore, did not focus on antenatal care (ANC) or home-based practices.
Third, mentors needed to be well grounded in the concepts of quality improvement, patient and
provider rights and teaching and communication skills. Because these topics are not covered in
basic nurse training, the training needed to allow adequate time to build this capacity.
Finally, mentors needed time to practice their communication and mentoring skills in a work
setting similar to a PHC. Therefore, the training included site visits to nearby maternity homes
where mentors practiced working with clinic staff to carry out self-assessments.
Given the multiple objectives of the training, the project team determined that five weeks were
needed to include all the required components. The Sukshema team prepared a detailed agenda
for the induction training, summarized below.
Mentoring Intervention Report
131BW
lillililliiiB
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-Mentoring Intervention Report
Topics covered
Week
1
SOI
1
Quality improvement approach (AMMA)
Principles and tools in MNCH mentoring
111||- -
/tUv- i
Project philosophies
~2
iI,
j ■,;."
'
Clinical obstetrics: intrapartum and postpartum care
Ward postings in ANC, labour room and postnatal
3
Clinical neonatology: essential newborn care and neonatal resuscitation
Ward postings in labour room, postnatal and neonatal
4
J
Obstetrics and neonatal postings at St John's Medical College and St
Philomena's hospitals
Site visits and practice sessions at 2 PHCs
5
Systems strengthening (infection control, referral, essential drugs, supply chain;
management)
Managing mentor visits: what to cover and when
i
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!,
^Evaluation
Training manuals and materials
The team developed a mentor's manual to form the basis of the induction training content as well
as serve as a field handbook. The team also developed a facilitator's guide specifically for trainers
that outlined how to deliver sessions, including extensive use of participatory processes. As of
April 2014, finalization of these manuals was being completed.
The training manual opens with an introduction of the AMMA concept and the role of mentors in
applying this approach at the facility and provider levels. Next, it delves into clinical content and
practice. It also includes the case sheet, self-assessment tools and other tools that mentors use in
their work. Other training materials includecopies of the Government of India SBA guidelines and
a kit of teaching aids (including a pelvic model, newborn model, bag and mask and other medical
supplies needed for demonstrations). The mentors were also equipped with laminated posters,
flip charts and teaching videos on discs that they could use at the PHCs.
Standardizing the training curriculum
The curriculum development team worked from a standard template that guided writers to:
Not simply list what should be done and how to do it but also focus on why
guidelines are important.
Include not only what to do but also what not to do. Each session contained a list of
do's and don'ts.
Provide examples of how a particular skill can be imparted through different
mentoring techniques (for example, case audits, case studies, demonstrations).
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
41
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Nor
Karn<
Mentor training in pilot districts
The five-week training for the pilot district mentors took place in Bangalore from July 9 to August
9th 2012 at SJMC and Cand also used St Philomena's hospital for some clinical sessions and nearby
private maternity homes for site visits. Seven lead trainers from KHPT and SJMC conducted the
training. Additionally, 21 SJMC faculty members supported the training programme by delivering
sessions and serving as preceptors during ward postings.
All mentors successfully completed the 5-week induction training programme. In addition to the 11
mentors hired, nine DPS from all Sukshema districts took part in the entire training to become familiar
with the intervention because they were responsible for supervising the mentoring intervention's
implementation.
Interviews with mentors and trainers and independent observations provided an understanding
of how participants received the training programme and whe ther it accomplished its intentions.
In addition, test scores provided a measure of competency achieved. Key findings address
participants' understanding of project objectives, the training design, the participatory nature of
the training, tailored training, field visits, adequacy of the training and competency as assessed
by testing.
Understanding of project objectives. Mentors clearly understood that the ultimate goal of the
Sukshema project was to help reduce maternal and neonatal mortality through improving the
quality of care in PHCs. According to one mentor, "The purpose of the training is to make the
participants understand the process of mentoring and the qualities of a mentor. This is important
because when they go into the PHC, they should have better skills and knowledge than the PHC
staff, they should know to communicate well and plan their activities according to the needs of
the PHC."
Training design. According to many trainers and trainees, the flow of the training programme
worked well.The introduction to quality improvement, the AMMA approach and the competencies
required of mentors in the first week provided the context for mentors to then engage with the
clinical content in the subsequent weeks. The last week was an opportunity to bring back the
focus to MNCH quality by addressing system-level issues. Mentors also appreciated being given
reading materials in advance so they could be prepared for the sessions.
Participatory training approach. Mentors appreciated the interactive nature of the training.
Trainers engaged trainees through sessions that included role plays, videos, demonstrations,
case studies, group discussions and bedside clinics. Extensive use of mannequins, case sheets
and other training aids enabled trainees to practice what they were learning. Mentors especially
liked the opportunity to practice skills through skill stations and in ward rotations. As one mentor
summed up, "Before, we didn't know anything. We learned how to interact with medical officers
and nurses. We learned clinical skills." Sessions encouraged participants to ask questions and take
part in large and small group discussions.The observer and trainers observed that many mentors
gained confidence over the course of the training and became enthusiastic, engaged and vocal
participants.
Mentoring Intervention Report
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Trainer demonstrating using a pelvic model
Tailoring training to learner's needs. Because the mentors came to the training with different
knowledge and skill levels, the trainers had to adapt to ensure that everyone picked up both the
content and skills. Gaps between theory and practice were most noticeable.Trainers frequently and
effectively used questioning to assess trainees' knowledge and tailor their teaching accordingly.
Trainers also adjusted by using Kannada for the sessions because mentors were more comfortable
in that language. The doctor trainers were very patient with the participants and were willing
to explain and demonstrate techniques repeatedly without any hesitation.The training observer
noted that trainers gave participants individual attention and were very proactive within group
exercises about making sure that participants had understood the practical part (such as plotting
the partograph). As one mentor stated, "The methods of group discussions were very helpful
in the theory sessions since we get to brainstorm about different issues and discuss them in
detail. With regard to the clinical skills, the demonstrations via teaching aids is good too, as we
get to practice our skills. "Trainers observed that some mentors who had limited experience in
conducting deliveries had strong communication and leadership skills that they were able to
apply in some of the non clinical training activities.
Field visits. Mentors gained confidence from visiting PHCs and conducting meetings to introduce
self-assessment tools. These practice sessions alleviated many concerns or fears that mentors had
about the difficulty of establishing rapport with the PHC team and using the tools.
Adequacy of training. Some of the mentors who were interviewed expressed apprehension about
whether the PHC staff would accept them as mentors.Trainers also worried that the level of clinical
competence would not be adequate for mentors to provide clinical guidance. It became evident
that the five-week training did not provide for enough skills practice and that many mentors
needed to reinforce their clinical skills.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern
HI
lest scores. Test scores provided a measure of the training's effectiveness in imparting knowledge
and skills. The pre- and post-test scores for mentors indicated gains in knowledge levels. The
mean pre-test score for the mentors was 48%, which increased to 74% among those mentors who
completed both tests. Scores for post-tests ranged from 45% to 88%.
An observer also evaluated mentors on several objective structured clinical examinations (OSCEs)
in which the observer marks off whether the mentor hascorrectly completed all steps involved in
the demonstrations. The chart below depicts the relative performance of mentors on obstetric
and newborn OSCEs. Many mentors were able to demonstrate a level of proficiency at the 70% or
higher level for obstetrics and at the 50%-60% level for neonatal OSCEs.
40%-49%
50%-59%
!
____ ___
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2
6
5
Total*............................ J.
13
70%-79%
80%-89%
Newborn OSCE scores
Obstetric OSCE scores
Range
r—-— --------- ——
——--------- —•—
L—_
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.
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Lessons Learned: Induction Training
The nurse mentor induction training for the pilot districts generated several lessons about what
worked well and about challenges and opportunities for improvement when scaling up the
training to other districts.
Training successes
Training design and methodology. Trainers and mentors appreciated the design of the training
programme, with its use of participatory processes and practice sessions. Many mentors
commented that the training materials were helpful for their learning. Curriculum developers
referred to standardised guidance to develop the training content, emphasising participatory
learning approaches that helped provide a certain level of consistency and integration of the
training content.
Reinforcement of project objectives and quality improvement. The Sukshema technical director
and QI specialist were present throughout the training and led morning and afternoon recap
sessions. This helped link the different sessions and learnings together, enabling them to reinforce
the AMMA concept and bring the focus back to how participants could apply their new knowledge
and skills in their mentoring interactions with the PHCs. Mentors developed a good understanding
of quality improvement and the mentoring process.
Training challenges and opportunities for improvement
Curriculum. The curriculum development team perceived unrealised opportunities to integrate
the training segments to better reinforce each other and the overall objectives of the intervention.
For example, there was little reference to the AMMA framework in the clinical and system-level
segments, even though the process of assessment and management is central to clinical teaching.
Mentoring Intervention Report
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Structured training of trainers. Having many different trainers made it more difficult to ensure
that all trainers fully understood the purpose of the training and how each session reinforced the
overall objectives. For example, in ward rounds it would have been desirable for preceptors to
not only provide clinical content to mentors but also demonstrate mentoring skills themselves
and link back to the overall aim of quality improvement. This did not always happen, as some
preceptors were not focused on demonstrating mentoring skills and were not aware of the AMMA
framework. Including a more formalised training of trainers before the commencement of mentor
training would connect trainers to the overall purpose of the training, ensure trainer's familiarity
with the full training content, and facilitate opportunities for reinforcing learning across training
sessions.
Sequence of clinical rotations. The clinical portion of the training was intentionally designed to
cover theory and practice on mannequins in the morning, with afternoon clinical sessions in the
wards to reinforce the morning learning. However, the two-hour segment in the wards was not
always sufficient to observe or treat patients on the topics covered. One mentor commented that
the sequencing of training would be better if participants learned theory before undertaking
clinical rotations, but the schedule did not always allow for this. This mentor noted,
"When we came in at the beginning of the day we did not know much about the subject, but by the
end of the session, the trainer had taken us through all the theory and we understood everything. In
addition, we saw some of these processes in the ward the previous day (normal delivery, preparation of
labour room), so we did have an idea of what the trainer was teaching us. I like to be taught the theory
first as then we are aware of what to look out for in the practical session."
Basic clinical skills. Mentors' lack of basic clinical skills created challenges in ensuring their
competency as mentors. Clinical trainers expected to be able to provide a refresher training that
would build on the mentors' basic nursing training and on-the-job experience. Instead, they often
had to cover fundamental topics because mentors lackeda basic level of knowledge and clinical
expertise. In the clinical ward rotations, some participants seemed very unsure of how to carry out
clinical processes such as abdominal exams. Some mentors struggled with calculations (such as
calculating gestational age from the fundal height), while others were unable to explain concepts
to a doctor when asked. Trainers were surprised that they had to cover basic skills with trainees
who were already certified nurses, some of whom had even undergone the government's 21-day
SBA training.
Clinical practice opportunities. The training did not provide adequate opportunities for mentors
to practice delivering babies. Mentors were not allowed to directly conduct deliveries in St John's
Medical College. Moreover, because SJMC largely provides tertiary obstetric services, it did not
offer good examples of the cases typically encountered in PHCs. Although trainers arranged to
use another clinical site (St Philomena) that provided normal deliveries, the delivery load was low
so mentors still did not get to attend deliveries.
One month following the training, the project arranged for a one-week clinical rotation for mentors.
Mentors were assigned to one of three hospitals to conduct deliveries, but the delivery loads were
not sufficient to give every mentor an opportunity for skills practice, and hospital staff wanted to
be sure of the mentors'skills before entrusting them with deliveries. In the end, few mentors were
able to deliver babies—and that only towards the end of the week when providers at the facilities
felt comfortable in letting them do so.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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Ongoing Training
During both the pilot phase and the scale-up to all project districts, the project has provided for
ongoing capacity-building of mentors beyond the initial five-week training, using clinical postings,
on-the-job support and refresher trainings.
Clinical postings
In response to the identified need and request from mentors that they have more clinical
experience, the project sought to build in a 5-day clinical posting every quarter for all mentors.
Finding adequate clinical training sites to provide mentors with practicum training in labour
and delivery posed a significant challenge. Hospitals that did not know the mentors or their
competencies were reluctant to allow trainees to practice their skills. It sometimes took several
days of observation for the clinical staff to gain enough confidence in the mentor's knowledge to
entrust them with patient care, yet by that time the week's posting was nearly over.
Initially, Sukshema arranged with the Vijayanagar Institute of Medical Sciences (VIMS) Medical
College in Bellary to provide practicum training for mentors in the pilot districts. The mentors
had a one-week rotation in the labour room seven months after they started serving as mentors.
During the posting, each mentor conducted an average offour deliveries by themselves and
assisted in more than ten. In general, the VIMS postings met the objective of increasing clinical
experience. One mentor indicated that the posting at VIMS "was very good as we did a lot of
deliveries and were able to practice episiotomies and suturing, so we now feel more confident
in helping nurses at the PHC in these skills. "The hospital proved to be a good place to see many
complicated obstetric cases, providing mentors with a better understanding of the presentation
and management of these complications.
Some practices in the VIMS hospital
went against the guidelines for PHCs or
followed different guidelines altogether,
which was of some concern to mentors.
The lack of compliance with infection
control protocols at the hospital,
including lack of water in the labour
room, did not present a good example
for infection prevention.
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Mentor feedback on VIMS clinical postings
We were happy with the exposure to the deliveries
that we could conduct.The exposure to complicated ;
and 'bad' obstetric cases (like severe PPH, eclampsia,
IUD), though upsetting, was clinically relevant :
and a new experience. The hospital had different
infection control practices, which were hot what
we had been taught. We wish someone was there
to supervise us continuously. The newborn care is:
not concentrated on and no one would listen to us
when we told them. We don't know why we had to ;
do stuff other than deliveries like putting an IV line j
or drawing blood. But overall we gained experience J
and confidence and could do quite a number of |
procedures in addition to deliveries. We also now
know how difficult it might be for the staff nurse to ;
fill the case sheet during busy days.
In the scale-up districts, all mentors
were sent in batches to VIMS and a
government hospital in Bijapur, until the
VIMS leadership changed and no longer
wanted to provide a clinical practice
venue. The project team then identified
additional training sites for practicum
training (and continues to evaluate
practice site options at present). One
training site, Gulbarga General Hospital,
worked well due to its high volume of J
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deliveries and appreciation from the nurses at the facility for the mentor's support in assisting
with deliveries. At that hospital, mentors also reported that they were able to update district
hospital nurses'knowledge and skills pertaining to partograph use, AMTSL procedures and other
protocols. Mentors conducted at least five deliveries independently and assisted in many more.
A District Program Specialist at Gulbarga General Hospital noted that the head of the obstetrics
and gynaecology department-—not initially enthusiastic about having mentors posted at the
hospital—ended up thanking the project because the mentors were so knowledgeable and
helpful.This department head also indicated her willingness to allow mentors from other districts
to use the facility for future practicum training.
Clinical posting results were less successful in another district where the project placed mentors
in a busy taluka (sub-district) level first referral unit. Because this FRU lacked equipment, drugs,
and supplies and did not have good infection control practices, it was not a good environment for
refreshing mentors'clinical skills.
On-the-job support
Roughly two months after the five-week training in the pilot districts, two different 2-person SJMC
teams travelled to each pilot district for a support session and on-the-job capacity-building for the
mentors. Each team consisted of a neonatologist and an obstetrics nurse. On the first day of the
two-day visit, the SJMC staff each accompanied one mentor to a PHC for a mentoring visit. Other
mentors were divided up to also attend one of the mentoring visits as observers and learners. At
the end of the day, SJMC staff provided feedback to mentors on what they were doing well and
areas for improvement. On the second day, the SJMC team provided training and demonstrations
to the mentors in a classroom setting.These support visits have since continued every four months
in the pilot and scale-up districts.
Refresher training
The project also sponsored refresher trainings for mentors, with the experience in the pilot districts
providing information about how best to do this. In the pilot districts, mentors participated in
a two-day refresher training in Bangalore in January 2013 carried out by Sukshema staff and
consultants. The objective of the refresher training was to provide opportunities for mentors to
use case studies and demonstrations to build their capacity in clinical mentoring techniques. As
described by one mentor, "The [refresher] training showed us how to introduce case studies as a
mentoring approach, how to evaluate case sheets and pre-referral management."
Mentorsalso participated in a second two-day refresher course in May 2013 in Bangalore.The course
was designed based on input from the mentors regarding the topics to be covered. In particular,
mentors requested more guidance on what to do in situations that were not clearly covered by
the SBA guidelines and information abouttopics including prolonged and/or obstructed labour,
pregnancy-induced hypertension (PIH), gestational diabetes, obstetric procedures, and newborn
complications. Mentors were also able to practice suturing skills. Mentors reported that this training
was helpful in addressing doubts and covering other complications. The project subsequently
extended this type of refresher training to mentors in the scale-up districts, sometimes combined
with on-the-job training during PHC visits.
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Summary
The projects hiring and training approaches for developing this new cadre of nurse mentors
have contributed to the development of a motivated and well-performing mentor workforce.
Because the skills available among nurses interested and qualified for the mentor role were
generally limited, continual efforts were required to build mentors' capacities and confidence
over time. The five-week induction training imparted basic knowledge and skills, but mentors
also needed continuous reinforcement and skill-building through on-the-job support and clinical
postings. Recognizing the intensity and frequency of the training required to support mentors
will be an important consideration in determining how this programme can be scaled up with
in a government system that typically does not deliver this type of continuous professional
development.
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14 Mentor Visits in Pilot Districts
his section documents the first year of implementation of the mentoring programme
in the 54 intervention PHCs in the pilot districts. Specifically, this section recounts what
happened during each round of mentor visits and highlights successes, challenges, and
lessons learned.
Schedule of Mentor Visits
Each mentor was responsible for providing mentorship at 4-6 PHCs.The initial expectation was that
mentors would visit their assigned PHCs once a month for the first three visits, after two months
for the fourth visit and quarterly there after. Each visit was expected to last two days. Between
visits, mentors'duties included completing trip reports, periodically checking in by phone with
the PHC site coordinator and participating in team meetings and continuing education.
The schedule for the mentor visits was influenced by the Sukshema team leaders prior experience
in the SAMASTHA project, in which they observed that PHC staff and facility processes seemed to
show improvements after four visits. After selecting four as the minimum number of visits required,
the duration of the Sukshema project and the need to scale up the intervention in all eight project
districts influenced the upper limit of how many visits might be expected in a year, given that the
project would have just one year to reach the same level of intensity in the remaining districts.
The overall concept was to have six visits per year, concentrating the first four visits over a fivemonth period and scheduling the later visits over longer intervals. The greater frequency of visits
during the early stages was intended to facilitate rapport and allow mentors to conduct initial
assessments and develop action plans. After the fourth visit, the quarterly mentoring visits would
focus more on maintaining improvements.
Allowing two days for each mentoring visit was expected to ensure adequate time to address
PHC-level issues and conduct provider mentoring. Based on mentor feedback and observations,
however, the project team determined that two days were not enough to provide sufficient
opportunity to interact with all staff nurses in the context of staff nurses' rotating shifts, their need
to attend to patients, and other factors. From the third visit onwards, mentors spentthree days at
each PHC. The schedule and duration of mentor visits in the pilot phase are outlined below.
Visit
First mentor visit__
Second mentor visit
Thk?!
visft
Fourth mentor visit
Fifth mentor visit
Sixth mentor visit
When conducted
Duration of visit
Aug-Sept 2012
Oct 2012
Dec 2012-Jan 2013
Feb- Mar 2013
—
April-May 2013
Jun-Jul 2013
2 days___
2 days
2-3 days
3 days__
3 days ___
3 days
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Sukshema developed guidelines for mentors on how to carry out clinical mentoring, including
discussion of teaching and/or mentoring techniques. The guidelines also included session plans
for the first six mentoring visits and provided a bulleted list of content to cover in each session.
First Mentor Visit
Structure of visit
In the first PHC visit, mentors were expected to build rapport with PHC teams, initiate use of
self-assessment tools and support PHC teams in developing an action plan to outline steps
for correcting problems identified in the self-assessments, the primary outcome from the first
meeting. The mentors were not expected to do much clinical mentoring in this first visit, delaying
clinical mentoring until the mentors themselves had had a chance to gain more clinical experience.
First Mentoring Visit
1. Introduce herself to medical officer (MO)'or medical officer in charge (MOIC)
2. Facilitate PHC team meeting to introduce AMMA concept and discuss patient and provider
rights .
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3. Help PHC staff fill out self-assessment tools A, B, & C and conduct case sheet audit and
client interviews
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4. Observe patient care in PHC and provide clinical support as needed
5. Facilitate team meeting to develop action plan
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With few exceptions, the mentors were able to take the PHC teams through the first set of
assessment tools and the case sheet audit. Mentors supported PHC staff to carry out client
interviews as well. After completing the self-assessment tools, mentors met with the PHC teams
to develop an action plan. This usually happened at the end of day 1 or during day 2 when the
team could reconvene. In two instances, mentors were unable to complete the action plan with
the PHC team at the end of the visit because the MO was not available to sign off on it.
During the first visit, mentors also spent some time with staff in patient care and provided guidance
on clinical practices where able. Mentors observed current practices and identified gaps to focus
on in subsequent visits.
To facilitate communication between mentoring visits, mentors worked with the PHC teams to
identify a site coordinator for each PHC. This coordinator became the mentor's point of contact for
any follow-up and scheduling of future visits. The site coordinator could be anyone who showed
interest in the position. In the pilot district PHCs, site coordinators were staff nurses, pharmacists,
or lab technicians. Medical officers were not chosen as site coordinators.
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First visit successes
According to interviews with mentors and project staff and observations of visits, many aspects of
the first mentor visit went well.
Rapport with PHC teams. Establishing rapport with PHC teams happened more easily than might
have been expected. Mentors expressed and demonstrated confidence in building rapport with
PHC teams and carrying out the mentoring visits. In some cases they confronted initial resistance
and had to prove their credibility. For example, one mentor shared how the MO asked her technical
questions for 45 minutes and communicated his satisfaction with the mentor's knowledge by
then instructing his staff to learn from her. In another example, nurses asked the mentor about
her background and on learning that she was a staff nurse referred to her as "sister." By the end of
the day, after appreciating her level of knowledge, the nurses started referring to her as "madam."
Many of the staff nurses in PHCs are young recent graduates (hired contractually) who are aware
of their lack of experience and are happy to receive additional support. In one direct observation,
it was clear that the PHC team appreciated the support provided through the mentoring
programme. They seemed to enjoy meeting together as a team and working in small groups. The
staff interacted well with each other and a cordial supportive tone permeated the meeting.
Flexibility and responsiveness. Mentors were able to work with and around clinic activities to
mentor PHC teams. For example, if the outpatient department was busy, onestaff nursemight
attend patients while the mentor worked with the other staff nurses called in for the visit. Mentors
were usually able to find times when nearly all staff could sit together for assessment and action
planning processes.
Quality improvement.
PHC teams were willing
to engage with mentors
in QI sessions.Typically,
the first session lasted two
hours and involved all staff,
including the MO, nurses,
pharmacists, lab technicians,
and Group-D support staff
(i.e., housekeeping). PHC
teams remarked that they
rarely met as a team and
welcomed the chance to do
so. At times it was difficult to
engage the Group-D staff in
larger discussions, but they
participated in small group
work.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in
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Self-assessment tools and action plans. Mentors found that PHC teams were able to use the self
assessment tools and that these tools helped teams identify where they had problems. As one
mentor noted,"Most of the staff at the PHC claimed they know everything, but after administration
of self-assessment tools, they found gaps in knowledge." Several mentors described how PHC
staff used the tools to identify a lack of knowledge about how to diagnose and manage maternal
complications. The mentors ensured that the areas marked with an X on the self-assessment
checklists (indicating a gap) were included in the PHC action plan. One of the quality assessment
tools—the client interview guide—did not provide useful information. First, providers were
somewhat uncomfortable in administering the survey to patients. Secondly, patients generally
indicated that they had no complaints or suggestions for improving the PHC. This response
could have been an indicator of low expectations for PHC services as much as an expression of
satisfaction. Mentors recommended that the tool be translated into the local language to make it
easier to use, which was subsequently done.
Ability to identify gaps. In addition to PHC team members, mentors themselves were able to
identify existing shortcomings in providing quality MNCH care. Mentors reported finding gaps
common to many PHCs including:
Wide spread practice of labour augmentation
Lack of drugs, especially magnesium sulphate and vitamin K
Incorrect and incomplete case sheets
Lack of toilets and running water in some PHCs
Shortage and absence of staff in some PHCs
Poor infection control and injection practices
Inadequate referral processes
Direct patient interaction. One of the initial unanswered questions about the mentoring
programme was whether mentors would be able to participate in direct patient care given that
deliveries might not happen during mentor visits. (This was the experience during the baseline
data collection process.) Fortunately, mentors were able to directly observe and assist in patient
care with women in labour or in postnatal wards, which provided an unmatched opportunity
for teaching and mentoring. All mentors observed deliveries during their first and subsequent
mentoring visits, including deliveries involving complications, and were able to support staff
nurses to manage them. In the first visit, each mentor was able to attend 2-3 normal deliveries
during the course of visits to all her PHCs combined and several mentors encountered women and
newborns with complications.
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First visit challenges
Mentors'assistance in direct patient care i
PHC leadership engagement. The mentors' |
experiences in initiating an effective During their first PHC visits, mentors were able
first PHC visit depended in part on to provide several types of direct and immediate
support to staff nurses:
>
the level of engagement of the MO. In
several instances, the medical officers
A mother presented with preeclampsia and:
were very supportive of the intention |
the staff nursedid not know howto handlethe:
of the mentoring intervention and took
complication, so the mentor demonstrated:
immediate action to resolve problems
how to provide an injection of magnesium?
identified through the self-assessments
sulphate.
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and team meetings. For example, several
MOs used untied funds to replenish drug
A newborn required resuscitation^ and the‘1
supplies during or within days of the |
mentor demonstrated how to use the bag;
mentors'visits. Another MO acquired cord
and mask to resuscitate the newborn,
clamps that the assessment identified as I
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mother
presented
with
anaemia,
and;
lacking. In other instances, however, the
the mentor was able to guide the staff on,
MOs did not participate fully in the PHC
appropriate steps to follow.
team meetings or were absent during the
development of the action plan. In some
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PHCs there was no medical officer in place, and PHC management was assigned to an MO in charge
of another PHC in the area. These MOs often did not focus much attention on the additional PHC.
Patient expectations versus clinical best practice. Labour augmentation was a common practice.
Staff nurses indicated that patients often insisted on it and they found it difficult to comply with
the guidelines as a result.
Mentoring skills. Observations of first visits suggested that mentors needed help developing
their skills in applying different adult learning methodologies. Although mentors were doing an
admirable job given their limited experience as trainers, it was clear that their performance in
facilitating group discussions and effectively using teaching aids could be enhanced. Mentors also
needed help building stronger communication skills. For example, several observers commented
that mentors talked fast and did not pause to assess nurses'understanding or encourage questions.
Observations concluded that mentors also needed more support and specific guidance on how to
convey the AMMA concept of quality improvement to the PHC teams. Mentors explained that PHC
teams did not seem to grasp the concept of AMMA.
Case sheets. In conducting audits of case sheets in the first visit, mentors observed that PHC staff
were not always using case sheets and when used staff were not completely or correctly filling the
sheets out. In one PHC, staff members were unaware of the complication sheets that form part of
the case sheet tool. In other cases, staff only filled out the labour section but did not complete the
history or outcomes sections. Some providers either complained about the length of the case sheet
or reported that they were too busy to fill it out. Mentors attempted to convey the importance of
the case sheet to providers but acknowledged that this needed to be an ongoing process.
OSH
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Second Mentor Visit
Structure of visit
The second visit took place one month after the first visit. The intended structure of the second
two-day visit is outlined below. Mentors prepared for this second visit by performing
demonstrations with models in front of their colleagues to sharpen their training skills.
Second Mentoring Visit
1. Review first visit action plansand progress
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2. Facilitate completion by PHC team of remaining self-assessment tools (D-H)
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5. Conduct training with models, demonstrations, case sheets, and videos
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Interviews with mentors who had conducted a second PHC visit in Bellary in late September
2012 found that the second mentoring visit took place as planned. Mentors worked around the
ongoing clinic operations to meet with the PHC teams when convenient and to cover the content
of the visit. Mentors reported that PHCs had made progress on the action plans developed in the
previous visit. As one mentor noted, "In the second visit they were implementing things properly
that had been X marks in self-assessment in the first visit."ln one observation, the PHC team had not
been able to procure the drugs and supplies identified as lacking in the action plan but indicated
their intention to do so now that funds had become available. In another PHC, the mentor noted
that staff nurses had not been using the radiant warmer or using slippers in the labour room in
her first visit but now were doing so. One mentor recounted her second mentoring visit as follows:
"In one PHC it was busy and a delivery was happening so I guided all three staff nurses on how to
conduct delivery and do AMTSL. The woman came in at 7cm so we had the PHC team meeting
after the initial assessment and then we all moved back to the labour room when she reached
10 cm. The nurses had wanted to do augmentation because it was not progressing, but I said
'Remember what we talked about last time' and so convinced them not to do it. I advised the
nurse to put the baby on the mother after delivery for breast crawl. The staff said, 'It worked so
well we will do it like this from now on.'The nurses were using the case sheet and partograph while
attending the delivery. They also did the first two hours monitoring correctly."
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The Story of a Second Mentoring Visit
When the mentor arrived for the first day of her second mentoring visit at a PHC in Bellary
District, a delivery had taken place just 30 minutes before. She Immediately took the
opportunity to show staff nurses how to do breastfeeding initiation and post-delivery i
assessment"! called all staff nurses together and told them how to do it How they should ;
wash hands, wrap baby, position and attachment for breastfeeding. I used case sheet to show
how to do monitoring."
Next a woman arrived with premature rupture of membranes (PROM), which requires referral. ;
The mentor explained, "I taught the nurses how to do initial management through the case
sheet They called the ambulance right away and it arrived sooner than expected while the
nurse was still doing stabilization. The ambulance staff got angry telling the nurses to bring
patient" The mentor went out to the ambulance, brought the ambulance nurse in, made him .
observe the patient, and explained her situation so that he would know the condition of the
patient he would be transferring. The mentor explained how the ambulance nurse asked,
"Who are you?" When she explained she was a mentor, he settled down. "I told him what he
needed to understand about the patient," she related.
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After lunch, the lady health visitor and medical officer went out for the ASHA monthly meeti ng
that takes place just outside the clinic with 18-20 ASHAs. The mentor took the opportunity ;
to address the ASHAs for 45 minutes. "I asked them about what they do during antenatal j
care and stressed on need for TT [tetanus toxoid shots] and medicine [iron and folic acid
tablets or IFA]. I spoke about the importance of institutional delivery and 48 hours stay and
the importance of their responsibility after delivery. I reviewed the home visit schedule with ■
them and told them to educate mothers about looking for danger signs and the importance
of breastfeeding."
The PHC was very busy that day as the MO had been absent for two days. There were many
patients in addition to the ASHA meeting. As a result, the PHC team was not able to assemble ■
for a team meeting with the mentor until late in the day at 4:45 p.m. She went on to recount,
"We discussed on the last action plan that had 6 points and reviewed it. They had implemented
all things in the action plan."The mentor then gave out the remaining self-assessment tools,
with one person working on each tool. 1 told them to think for the whole staff as you fill out."
The mentor moved into the action planning phase after the self-assessment process. Some
of the items identified with an X on the self-assessment tools were taken care of immediately. •
The mentor explained that the puncture-proof container had rusted, so the MO suggested a '
new way to dispose of sharps. The PHC team also filled up the referral directory (another item
identified as missing in the self-assessment). Other items in the new action plan included
syringes for vitamin K, training on corticosteroids, and training on newborn resuscitation.
On the second day of the visit, there were no deliveries.The mentor used the time to provide '
training on newborn resuscitation, demonstrating with the doll. Staff nurses then performed
demonstrations in return. The mentor also taught staff about phases and stages of labour and
assessing for pelvic adequacy, demonstrating on the pelvic model. Nurses again did return i
demonstrations.
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The Story of a Maternal, Newborn, and ChildHealth (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Second visit successes
Teaching models.Mentors used training models effectively to carry out demonstrations. Staff
nurses appreciated the opportunity to practice with the newborn and pelvic models. While some
staff were initially reluctant to demonstrate with models themselves, many mentors reported
encouraging nearly all staff to do return demonstrations. One mentor noted, "I was able to tell
them about stages of labour using the pelvic model and overall they could understand but
one nurse didn't know anatomy parts so getting her to talk and do return demonstration was
hard." Another mentor explained that while staff knew some things about stages of labour, there
wereknowledge gaps that the demonstrations with the pelvic model helped address. She noted,
"They knew pieces but not the whole picture."
Judgement in identifying gaps. Mentors added items to the PHC action plan based on their own
observations of needed improvements. As one mentor noted,"! reviewed case sheets and found
seven referrals for newborn resuscitation in the previous month, so we included training on
newborn resuscitation in the action plan. The mentor explained that six items on the action plan
came from the self-assessment tools and she added two based on her own observations.
Improved use of case sheets. Mentors who made second visits remarked that case sheet use had
improved since thefirst visit All nurses in one PHC were using case sheets, including the partograph.
At the second visit, the mentor found only three gaps: incorrect use of partograph, not filling out
complication case sheets fully and not completing or providing all counseling before discharge.
Mentoring Intervention Report
Mentoring Intervention Report
In another PHC, this mentor reported that nurses were filling out case sheets through delivery but
not usingthe case sheet as a job aid for providing postnatal and newborn care following delivery.
Increased practice ofAMTSL. By the time of the second visit, mentors reported that staff nurses
seemed to better understand and practice AMTSL. In at least one PHC, nurses also indicated that
they were no longer providing augmentation. However, the nurses avoided confronting women
and their relatives with an explanation of why augmentation was risky by instead starting an IV with
saline. One nurse even shared how the pregnant woman attributed her increased contractions to
the drug working (which was only a saline drip).
Second visit challenges
Overcrowding. In one observation of a mentor's second visit, the PHC patient ward was overflowing
because a tubectomy camp was in session.The overcrowding compromised the quality of care for
women coming for delivery and discouraged staying at the facility for 48 hours post-delivery.
Patient volume. At some PHCs with high delivery loads, it was hard for mentors to get time with
staff. In other PHCs with low patient volumes, staff were available but opportunities for bedside
mentoring and demonstration on patients were few.
Lack of compliance with care protocols. Mentors reported confusion among some staff nurses on
following protocols and poor compliance with waste management and pre-referral guidelines.
Third Mentor Visit
Structure of visit
The third mentor visits took place one and a half months after the second mentor visit. The third
mentor visit focused on clinical practice. The structure of the visit was as follows:
Third Mentoring Visit
i. Meet with PHC team to review progress on action plan since second visit.
2. Conduct audit of 10 case sheets of normal deliveries and all complications and review
with staff nurses to provide guidance on proper use and documentation of case sheets.
Assess any improvements from earlier visits in the use of the case sheet.
3. Provide clinical mentoring as per the training plan developed by the mentors for PHC staff,
covering the following topics:
Antepartum and postpartum haemorrhage
Premature rupture of membranes
Prolonged and obstructed labour
Low birth weight
Newborn asphyxia
57 1
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Third visit successes
Technical knowledge and rapport. According to project staff who observed the third mentoring
visit, mentors demonstrated sound theoretical knowledge of skilled birth attendance. At this
point, mentors were very familiar with the case sheet and able to guide PHC staff through its use.
Mentors continued to display good rapport with PHC staff, especially nurses. "Staff nurses seem
happy that we are coming," noted one mentor.
Teaching skills. Mentors seemed comfortable teaching in a classroom setting and using flip
charts and other classroom teaching aids. However, project staff observed that mentors required
additional skills-building support to use other teaching methodologies such as case studies,
bedside demonstrations, mentoring during deliveries, case audits, and discussions.
ImprovedPHCpractices. Mentors perceivedimproved practices in some PHCs. For example, in one
PHC (visited in November and again in January), improvements were observed in the organisation
of the labour room and equipment as well as inoverall cleanliness. Project staff also reported
increased availability of drugs and supplies. Mentors noted that AMTSL was being widely practised
while the practice of labour augmentation had diminished. Nurses were more routinely giving
vitamin K and using radiant warmers for newborns.
Mentorship between visits. One mentor noted, "Whenever nurses or MO see a complication
they are calling us and we advise them to follow the guidance on the complication case sheet.
Mentoring Intervention Report
Mentoring Intervention Report
This level of interaction between mentor visits is very encouraging as it indicates that PHC staff
were more aware of the need to manage complications and were seeking assistance on how to
do so.
Case sheet acceptance and use. Mentors indicated that staff were becoming more used to the case
sheet but nurses still were not always using it as intended. Many nurses wereei ther not filling out
the case sheet or filling it in after delivery. According to mentors interviewed, some nurses saw
the case sheet as a job aid, while others saw it mainly as something they were supposed to fill out.
"These nurses come up with many excuses for why they don't fill it." Nurses in busy PHCs found it
hard to find time to complete the case sheet.
Mentors saw completed complication
case sheets for many complications,
including prolonged labour, PPH, PIH,
and preeclampsia. Use of complication
case sheet H (for everything else)
was also frequent. Mentors reported
finding 1-2 complication case sheets
per PHC since the second visit. In
some instances, the complication had
led to referral while in other cases the
complication was managed at the
facility.
Patient-focused teaching. Mentors and
project staff reported that encounters
with pregnant women and recently
delivered women in the PHCs offered
opportunities to provide bedside
teaching and demonstration. For
example, in a 1-day PHC visit to a
clinic in Bellary, the clinical project
consultant and two mentors were able
to interact with a woman in labour,
a woman in the postpartum period,
and a woman in the active stage of
labour and demonstrate correct SBA
practices with the staff nurse on duty.
Organization of drugs in labour room
Two mentors interviewed about their third visit experience shared that they encountered five
maternal patients in four of the 11 PHCs they visited. One mentor reported working with nurses
as they saw antenatal patients to demonstrate how to do an abdominal exam.
One mentor was able to guide PHC staff on how to manage a referral for a newborn suffering from
intrauterine growth retardation."! showed nurses how to use the complication sheet and how to
refer including the need to call the FRU and how to counsel family members about the referral
and follow-up." Another mentor recounted her experience in identifying and referring a mother
suffering from anaemia:
59
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
"In one PHCI found a case of anaemia. A mother delivered after 15 minutes. I asked staff if they
did all the monitoring and they said yes and that all parameters were normal. The mother looked
pale and was restless and unable to feed her baby. I advised them to do a blood test and found
her Hb [hemoglobin] levels at 4.5. Also BP reading fell and her pulse was high so nurses started IV
and prepared for referral to a higher-level facility for blood transfusion."
When asked whether staff would have recognized this complication without her intervention,
the mentor responded that staff attitudes were that anaemia was common and not a cause for
concern. The mentor brought all staff together to review how to manage such cases.
Availability ofdrugs and supplies. Mentors observed that most PHCs had essential MNCH medicines
and MOs had been very supportive in getting needed drugs and supplies. Vitamin K, which was
not available when the intervention began, was present in most PHCs by the time of the third
visit. On the other hand, some PHCs continued to lack equipment and supplies. In one busy PHC,
there was no episiotomy kit and nurses resorted to the unsafe practice of using a blade to remove
stitches. Another PHC in this district continued to lack running water, which contributed to a low
delivery load. The mentor suggested some stop-gap measures, but actions by the district would
be required for a more sustainable solution.
Third visit challenges
Busy PHCs. Some PHCs were very
busy, and mentors found it difficult
to retain the attention and focus of
staff to provide teaching under these
conditions. Two mentors interviewed
reported that six of their 11 PHCs were
always very busy. Nurses had to treat
many patients and were less apt to
fill out case sheets or follow expected
protocols during these times. In busy
PHCs, mentors also could not interact
with most nurses at the same time
and had to repeat their teaching
on an individual level whenever a
staff nurse was free. Teaching also
got disrupted. This situation was
exacerbated when tubectomy camps
or other "campaigns" were taking
place because all staff tended to be
fully engaged in those efforts with
less time for other patient care. In
busy PHCs, management encouraged mentors to extend their third mentoring visits to three or
four days rather than the two-day duration of previous mentor visits to ensure completion of the
visit's planned agenda. Extending the visit also enabled mentors to reach more staff since in some
cases all staff were not available in the initial two days. One mentor related meeting with staff until
8:00 p.m. or 9:00 p.m. to cover the visit topics and other issues.
Mentoring Intervention Report
Mentoring Intervention Report
... .•
Postpartum care. Mentors reported that nurses did not monitor patients after delivery at the
recommended intervals of every 15 minutes for two hours. One observer noted that the newborn
care component of the case sheets also was not used as often as the other parts of the case sheet.
Referral practices. PHC staff and mentors noted that referrals were some times hard to manage
because there were not good FRUs to refer to and ambulances were not always available. Mentors
reported that families also sometimes resisted referral. Nurses did not always contact the FRU in
advance when referring a patient.
Infection prevention. Mentors observed that by the third visit, labour roomswere cleaner and
sterilization had improved. Some PHCs had acquired autoclaves. Still, there was considerable
scope for improvement. Some PHCs reported doing sterilization but when mentors checked, the
autoclave was not working. Waste management and waste segregation remained problems.
Sense of teamwork. Mentors explained that some PHCs were still in the process of adopting a
more team-focused approach to their work. In one PHC, a mentor reported that staff seemed
to blame each other rather than work as a team to address a problem. Although some drugs
were not available,the nurse did not ask the pharmacist to address the situation because of the
perception that he would nothelp. Mentors explained the value of teamwork, but the prevailing
culture worked against this in some PHCs.
Pace ofchange. Another challenge was managing mentors' expectations about the pace of change
in PHCs. Because some practices and behaviours were deeply entrenched and resistant to change,
there was a risk that mentors could become discouraged if they did not see results from their
efforts. Some mentors expressed their suspicion that nurses performed according to expectations
only when the mentors were present, citing the example of continuing inappropriate use of labour
augmentation in mentors'absence.
Fourth Mentor Visit
Structure of visit
As in previous visits, mentors prepared for their teaching topics one week in advance of conducting
the visits. They also met again as a team after the first round of fourth visits to review the visits,
share experiences and make any adjustments needed before carrying out the remainder of the
fourth mentor visits. Mentors in one district related that they practised doing role plays and
processing case studies that were then included in fourth visits. In order to have sufficient time to
work with the PHC teams, these and subsequent mentor visits were formally extended to three
days (compared to visits 1-3 which took place over two days). In a few cases, mentors visited for
four days. It took about six weeks for all PHCs to be visited.
Mentors reported that fourth visits went according to plan. They typically started off with a group
meeting to review the PHC's action plan and readminister the self-assessment tools (A-C) used
in the first visit. During the fourth visit, mentors also carried out demonstrations and return
demonstrations with nurses using real patients whenever available. All mentoring visits included
a discussion on the complications based on the case sheet audit.
61
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
I
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Fourth Mentoring Visit
1. Work with PHC teams to revisit the self-assessment tools (A-C)
2. Provide mentoring and demonstrations on the following clinical topics:
Preterm labour
Pregnancy-induced hypertension, preeclampsia, and eclampsia
Maternal sepsis
Newborn sepsis
Infection control
3. Collect case sheet data and review case sheets with staff nurses
Fourth visit successes
Sustained quality improvements. Mentors noted that previous improvements such as maintaining
drugs and supplies, improving the labour room, managing referrals, using case sheets and
discontinuing labour augmentation were being continued. These changes had taken hold with
in the PHCs.
Comfort level with self-assessment tools. In this visit, mentors again facilitated the self-assessment
process with PHC teams and reported that PHC staff were now very comfortable and adept in using
the tools and understanding their purpose. As one mentor summarised,"In the first visits PHC staff
found them somewhat difficult to understand but by fourth visit they were very comfortable using
the tools again and it was much easier to convince them to do the assessment." Mentors noted
that there were many fewer "X" marks after completing the self-assessment tools during the fourth
visit because earlier issues had been addressed. For example, PHC staff indicated greater comfort
in handling complications whereas this had been identified as a gap in early visits. Likewise,
drug and supply shortfalls had largely been addressed. Areas still needing attention (common
to many PHCs) included use of
corticosteroids, procuring an O-size
mask for ambu-bag and proper
preparation and use of chlorine
cleaning solutions. Mentors also
noted that staff were still deficient
in providing timely and complete
postnatal care counseling.
Action planning. Mentors noted
that the process of reviewing and
developing action plans was well
entrenched by the fourth visit and
staff had taken ownership of the
process. In some PHCs, staff were
identifying gaps and writing out
the action plans on their own.
Mentoring Intervention Report
111
1
Mentoring Intervention Report
■
Use of case sheet. Mentors reported that PHCs were doing better using case sheets by the
fourth visit. About half of PHCs were filling out case sheets correctly although still not in a timely
manner, often completing them after delivery. The postnatal care portion of the case sheet was
the most often incomplete. The PHCs that were not completely filling out the case sheetwere
either short-staffed (one PHC had only one staff nurse) or had high patient loads and very busy
staff. Staff understanding and appreciation of case sheets had improvedby the fourth visit,with
staff telling mentors that it had been useful in improving their knowledge. There wasa change in
attitude among most staff nurses from the early visits where they perceived case sheets to be a
documentation burden.
Delivery guidelines. During the fourth visits, mentors were able to assist and observe deliveries
and assess how well nurses were handling normal deliveries and complications. At one extreme, a
mentor visited a PHC that had seven deliveries in an 8-hour period. Another mentor observed four
deliveries in two PHCs, including two cases that required referral. Mentors indicated that they did
not need to give much support to nurses for normal deliveries and the nurses performed all steps
correctly. No labour augmentation took place. Mentors also observed that nurses demonstrated
their ability to support mothers in initiating breastfeeding.
Management ofmaternal and newborn complications. According to mentors, PHC nurses seemed
much more comfortable and confident in handling maternal and newborn complications and
referrals. Mentors who attended deliveries in the fourth visit noted that even for complications
nurses were able to handle the cases and followed referral protocols. One mentor noted that
nurses followed the referral protocol (calling the referral facility and filling out the referral form)
but needed support in pre-referral patient management.
Observation and assessment of newborn complications was harder for mentors to assess,
especially in low-volume facilities. Two mentors were not able to observe newborn resuscitation
with a real baby. Another observed and assisted, giving the nurse 65% marks for following correct
procedures.
Referral processes. Mentors and PHC teams
reported that referral processes were more
systematic since the mentoring programme
started. According to mentors, most PHCs had
posted referral directories and nurses were
calling referral facilities in advance. Nurses were
also tracking the outcomes of the referrals,
either through communication with patients
or ASHAs. Mentors also noted that staff nurses
were better able to identify cases to be referred.
Previously, nurses referred "blindly" without
first diagnosing the likely complications or
preparing the patient for referral.
'
Using case sheets
k
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i
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.
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■
"Case sheets are elaborate and informative1
.x-i
i__ - rl .■.< . I- 4. j.
xL:
and help nurses know what to do on the ;
spot and take decisions. The mentor forces
us to fill case sheets. Now we are filling 6 but t
of every 10 cases. Nurses and the meditai :
officer use Complication case sheets for 15__ ________ i __ _ .2 ii.'
>*•.. _
. i
i
20 referrals per month. Case sheet helps |
with referrals and saves time because it
provides all needed information to send to
the referral facility. It is especially important:
when referring to VIMS because the person
you talk to on phone about referral may not
be on duty by the time the patient arrives? '
l?d„take±cJsi°ns-.The.me±.r_f?rce!
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-Bellary medical officer
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63
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
8
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Fourth visit challenges
PHCleadership. Especially in PHCs with inadequate leadership (either no medical officer in charge
or managed remotely by a medical officer from another PHC), it proved difficult to encourage
a sense of teamwork. It was also hard to convene the full team in PHCs that had high volumes.
Mentors estimated that 40% of their PHCs had inadequate teamwork. PHCs that embraced the
concept of teamwork from the beginning were more likely to continue this approach.
Root cause analysis. Part of the self-assessment and action planning process was an analysis of
root causes intended to help PHC teams solve long-term problems and build a culture focused on
quality improvement. However, the approach proved challenging to use in a meaningful way with
some PHC teams. One mentor asked PHC teams during the fourth visit why they did n't use root
cause analysis and the PHC staff responded, "I forgot." This was different from earlier visits when
PHC staff often answered, "I don't know how." By the time of the fourth visit, PHC teams knew
what to do but did not always do it.
Mentors used root cause analysis to
problem-solve with staff, for example,
using"why why why"analysis to address
lack of night security. A mentor used
this approach to assess why a PHC was
not keeping its labour room clean.
She noted that the root cause often
identified by staff was the poor attitude
of the Group-D staff. Another mentor
explained that when she asked "why
why why" too often, it resulted in staff
blaming each other or fighting amongst
themselves.
Infection prevention. Infection
prevention continued to be an issue.
While staff nurses sometimes had improved instrument sterilization, problems persisted with
general hygiene and cleanliness, typically the responsibility of Group-D staff. "In one PHC the MO
is fed up with the Group-D staff and told me do whatever you can do to improve things," noted
one mentor.
Post-delivery stay. Mentors indicated that the duration of post-delivery stays had not increased
much in any of the PHCs over the course of the mentoring intervention. Even when PHCs provided
food, mothers were not staying the recommended 48 hours. Women often went home early to
observe rituals and cultural practices in their communities. When mentors asked patient swhy
they did not stay, patients pointed to the lack of toilets, running water, and night time security
at PHCs and not having someone to look after their children at home. Patients also reported not
seeing the need to stay at the facility.
Mentoring Intervention Report
Mentoring Intervention Report
Fifth Mentor Visit
Structure of visit
In the fifth visits, mentors continued to work with PHC teams and staff nurses (see table on next
page). In one district, the mentor team reviewed fourth visit findings to plan the focus for the fifth
visits. Mentors particularly prioritized the need to target slow learners and new staff. They also
determined the need to focus on system issues, especially lab tests and planned to highlight how
to make practical use of the AMMA approach.
Fifth Mentoring Visit
i. Work with PHC teams to revisit remaining self-assessment tools (D-H)
2. Provide mentoring and demonstrations on the following clinical topics:
Monitoring of labour, delivery and the postpartum period
Antepartum and postpartum haemorrhage
Premature rupture of membranes and prolonged or obstructed labour
Low birth weight
Newborn asphyxia
3. Collect case sheet data and review case sheets with staff nurses
Fifth visit successes
Understanding ofPHCs and staff. By the fifth visit, mentors had a keen understanding of their PHCs
and individual staff nurses and were able to objectively assess facility and provider strengths and
shortcomings. Mentors readily classified PHCs as"good,""average,"or"poor"and were able to back
up their assessment based on PHC performance relative to guidelines and use of the case sheet.
As one mentor explained,"Good PHCs include nurses whose knowledge and skills have improved;
they are handling complications and referrals and doing a good job filling case sheets correctly
and completely. Average PHCs have nurses who are not confident in filling the complication case
sheets and managing complications. Mentors also noted that PHC performance was worse when
the medical officer was not supportive or when the PHC team included nurses who were slow
learners or had poor attitudes or newly posted nurses who had not been mentored previously.
When asked to assess their PHCs, nearly all mentors said they had two to three good PHCs, two
average and usually at least one poor PHC that had not demonstrated much improvement. It is
noteworthy that mentors were able to maintain this level of objectivity and understand that poor
performance did not reflect so much on their mentorship skills as on circumstances beyond their
control.
Tailored support for new nurses. In cases where new staff nurses had joined or nurses had returned
after leave, some mentors intentionally planned their visits to have more time with these nurses.
One mentor went a day early to one PHC to work one-on-one with the new nurse on staff.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
■
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in .,
lAAAii
i Karnatal A-^ / A .J c
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:
Teaching skills. Observation of a mentor visit and reports from mentors themselves indicated that
mentors increasingly provided bedside mentoring and tailored their teaching to nurses'specific
needs. In previous visits, mentors had often provided demonstrations, but now they ensured that
nurses did the demonstrations first and then guided them as needed. In one observation, a mentor
had three occasions to work with a nurse to help a patient initiate breastfeeding and persisted in
coaching until they were successful. In another case, the mentor helped the nurse to manage the
referral process when a baby was not feeding.
Case sheets asprimary clinical teaching tool. Mentors indicated that they had to spend considerable
time with staff in early visits to help them understand and use the case sheet. They had integrated
the case sheet into many of their subsequent mentoring activities, using it to review the case sheet
audit with staff, do case reviews, and provide a focus for discussions, especially of complications.
"We are using case sheet to teach topics more than just explaining it." Mentors estimated that
at least one day of their three-day mentoring visit was devoted to case sheet activities. In one
observed delivery, the mentor supported the nurse to go through the case sheet thoroughly. The
nurse took the mother's history, carried out the physical exam, filled in the partograph, conducted
the delivery and managed the third stage according to all the procedures in the case sheet and
filled it in as she went along. It was also apparent that this was easier to do because the mentor
was there to assist in small tasks during the delivery; it would have been more difficult for the
nurse to fill out the case sheet and conduct the delivery if she was alone asis often the case.
Communication among PHCs. Mentors shared several examples of how medical officers had
communicated with each other to resolve problems. In one case, the PHC team had repeatedly
failed to get an O-size mask. The mentor recalled that one of her colleague's PHC had managed to
procure a mask and contacted her for the information to share with her PHC. The MO at that PHC
said," You just give my number to that other MO directly and I will tell him how to get the mask
and since I know the supplier well I can be sure it is delivered directly to his PHC." Another mentor
reported that one of her PHCs needed an adjustable light, and she told the MO about another PHC
that had one. Because the MO knew the other MO, he called him directly to get information on
where to get the light.
Contact between mentor visits. The strength of the mentoring relationship was evident in the
mentor-staff interactions that took place between visits. Mentors reported receiving a call from
one of their PHCs nearly every day. "We have a good relationship with staff so they freely call."
They called with questions about how to calculate gestational age, or asked about a particular
complication. Mentors noted that nurses were now seeking information and wanted to know
more about topics not covered in the case sheet or SBA guidelines. A few mentors indicated they
while received fewer calls between the fourth and fifth visits than during the early days of the
programme, the questions they received at this juncture were more complex. In addition, nurses
often called mentors after they had managed and referred a complication to confirm that they
had done so properly.
Complication management. In recounting their fifth visits, mentors shared that PHC staff were
now using most complication case sheets and noted this as an improvement since the fourth
visits.
Mentoring Intervention Report
Fifth visit challenges
Persistent problems. In the fifth visit, PHC teams used self-assessment tools D-H. Although the
assessments identified fewer gaps, some issues remained that were common to many PHCs:
5
Providing nourishing food for patients
Infection prevention (this was more often identified and added to the action
plan by the mentor than by the PHC team itself)
Incomplete referral directory and contact details
Night security for staff and patients.
Patient-centred care. Nurses' interpersonal communication with patients was slower to change
than their clinical performance. In one observation, the nurse did not interact with the patient
in the labour room except to ask history questions on the case sheet even as the mother was
experiencing contractions. She did not scold or slap the patient but neither did she talk to the
patient during delivery, explain the progress of labour, or comfort her.
Staff resistance to mentor support. Mentors noted that even at the fifth visit, nurses welcomed
mentor support. "By fifth visits they are happy and still look forward to us coming."There were
exceptions, however. One mentor said two PHCs were somewhat resistant to further visits
(and not necessarily the busy PHCs). An other shared that nurses were happy to participate if they
were on duty, but if she called to say she was coming they wouldn't come if they were noton duty.
One mentor reported that staff at one PHC were tired of her visits and saw her as a burden. "They
have so much work, they say,' We are tired, please come another time."This particular PHC (rated
poor) had high volume, lacked an in-charge MO and lab tech and had a nursing staff that lived so
far away that they were less willing to remain to interact with the mentor. Although the mentor
went at night to meet them when they had more time, they usually wanted to leave to get back to
their families. The medical officer did not provide any leadership to encourage their participation.
r
Medical officer and
staff nurses with
mentor
__________________________ Gf
The Story of a Maternal, Newborn, and ChildMealth (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme
• .
Understaffing and staff turnover. Several mentors had one to two PHCs that were very busy in part
because of staffing issues and it was often these PHCs where improvements in clinical care were
less obvious. For example, one PHC had only one staff nurse because two others had been asked
to resign due to retroactive withdrawal of the authority to hire them on contract at the district
level. Mentors also reported that PHC staff came and went and they frequently had to bring new
team members up to speed. In one PHC, impressively, a recently returned nurse demonstrated a
high level of knowledge and skills because her colleagues who had been present for the earlier
mentoring visits updated her, but this did not always happen, especially when nurses were not on
duty together.
Static number ofdeliveries. At the fifth visit, improved quality had not yet translated into improved
volume, although there continued to be wide variation in patient volume among PHCs. In the
pilot districts, 85% of all 24/7 PHCs had fewer than 20 deliveries a month, while five had 40 or
more. Quality of care may have been less in those facilities dealing with high volume.
Compliance with postnatal care guidelines. Mentors and nurses both stated that it was difficult to
comply with the guidelines for postnatal care check-ups at 15 minute intervals. This was identified
as a challenge early on in the programme and continued to be so nine months later. One mentor
saw five postpartum mothers during her fifth visits and observed that nurses were missing many
messages in their postnatal counseling. She demonstrated how to do postnatal care and used the
case sheet to remember all messages, but staff found it hard to do in high-volume facilities. Nurses
also did not always have the case sheet with them when checking on mothers. Mentors estimated
that only about half of their PHCs gave postnatal care messages correctly and they expressed
some frustration about the inefficacy of reminders in promoting improved practices in this area.
As one mentor commented, "Just reminding staff to give messages is not enough."
Staff attitudes. Some nurses resisted receiving support from mentors and had poor attitudes and
practices. This was especially true of older government nurses. For example, in one observation
the senior nurse did not participate in the mentor meeting with nurses even though she was at
the site.The mentor tried to assist her in a delivery, but the senior nurse did labour augmentation
and left the mother just after delivery without giving breastfeeding support or other postnatal
care. The mentor had made many attempts over multiple visits to work with this nurse, but she
was not interested in changing her practices.
Facility locations and upgrades. PHCs that were soon to relocate to new facilities were more
reluctant to invest in equipment or focus much on quality improvement, preferring to wait until
they shifted facilities. Three PHCs in Bellary were due to become higher-level community health
centres with newer and bigger facilities (although not necessarily staff increases). One PHC in
Gulbarga was in a badly rundown facility but moving in five months to a new health center. In
this case, the MO was willing to spend funds on drugs and movable equipment and supplies to
improve the quality of services in the interim.
Linkages to appropriate referral facilities. While complication management and referrals had
improved, mentors found that staff were automatically referring patients to the next highestlevel facility even if that facility did not have the capability to provide the care required. Many
taluka hospitals were not able to provide the advanced care that they were supposed to be able
to provide because they lacked specialty staff. One mentor had problems because three of her six
n
Mentoring Intervention Report
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Mentoring Intervention Report
PHCs were closer to referral facilities where patients could safely travel but would not receive their
benefit from the government's JSY programme. In another PHC, the closest FRU was in a different
district, but that hospital informed the PHC that they did not want their patients. Finally, in some
cases PHCs referred directly to the district hospital for Caesarean sections or PPH, but patients
resisted and wanted to go to the closer taluka hospital.
Two Mentors Recount A Fifth Mentor Visit
Mentor B described her fifth mentoring visit to a
low-volume PHC which she rated as "good." She
met with the full PHC team and reviewed the
action plan from the previous visit, which was
kept at the PHC. The team went through self
assessment tools D-H. She shared, "The first time,
staff said 'What a headache,' but second time they
have used them they say it is very helpful and
'We can fill them out.' The PHC teams reported
improvements and in this round they found
nothing left to improve. Next she discussed
clinical topics with the nurses and the in-charge
doctor. During the review she used the pelvic
model and doll to demonstrate prolonged and
Mentor A also completed the case sheet audit and obstructed labour and showed a video on stages
of labour.
discussed gaps with the nurses.
On the second day, Mentor B observed a nurse
On Day 2, Mentor A covered the fifth visit clinical
attending a delivery. "I give her 80% marks. She
session over a 3-hour period. She used examples taken did most things right but forgot to put the baby
from the case sheet and presented case scenarios when on the mother after delivery." The nurse filled
covering the topics. She continued the clinical session out the case sheet and partograph. The mentor
in the afternoon, but there were frequent interruptions assisted as needed, including showing her
as the nurses had to attend the OPD. All three nurses correct attachment for breastfeeding, discussing
eye care and demonstrating how to wrap the
participated in the second day.
baby. "The nurse did 70% and I did 30%."She also
On the third day, Mentor A worked with the one nurse observed the nurse perform postnatal checks
on duty. She looked at the referral register and saw every 30 minutes.The mentor demonstrated how
to do an abdominal exam on an ANC patient. She
that four cases had been referred, but only two had
also spoke with Group-D staff and the night Dai
case sheets. She reviewed the lab room and discussed
(unskilled traditional birth attendant) on waste
supplies. She also spent time with a postnatal patient management.
in the ward, visiting the patient by herself at first to
ask her what she had been told in terms of postnatal
counseling, and then visiting the patient again with
the nurse to demonstrate and fill in gaps that the nurse
had missed. "I would give the nurse 50% marks for
postpartum counseling. She missed some messages
about danger signs."
Mentor A described her fifth visit to a PHC that she
considered as a "good" performer. She started on day
one discussing the previous action plan with the entire
PHC team, with the exception of the lab technician,
who was on leave. She talked about client and provider
rights and spoke about the AMMA approach. She
worked with nurses to fill out the self-assessment tools.
"By the fifth visit there were far fewer X marks. Staff also
noted that supply issues had improved, saying "Earlier
we used to discuss with MO about missing supplies
but he didn't do anything, but now when we tell him
supplies are lacking he gets them."
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
W5 8
Sixth Mentor Visit
Structure of visit
The sixth mentor visits took place from June to July 2013 in both districts. In addition to covering
the items listed below, mentors focused on encouraging PHC staff to internalize and sustain
quality improvement processes on their own.
Sixth Mentoring Visit
i. Work with PHC teams to review and develop action plan
2. Conduct case sheet audits
3. Discuss clinical topics and system-level issues with a focus on:
Infection prevention
x?* Lab tests
4. Carry out demonstrations and observe return demonstrations of episiotomy suturing
Sixth visit successes
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Regular action planning. During the observations,
it was noted that one PHC team had action plans
organized in a file and referred to them to report
on progress against activities listed. The PHC team
indicated that they met every two weeks to review the
action plan.
Staff-initiated solutions. In one PHC, staff made their
own charts with postnatal care messages that they
posted above the observation bed so they would
remember messages. They wrote the chart in Kannada
so that literate patients could also read and understand
it. In their self-assessment process they also identified
additional equipment to procure not mentioned in the
tools, such as a fan and a refrigerator for the labour
room; this is an indicator of the extent to which staff
in this facility embraced the quality improvement
process.
Nurse shows Madilu kit of baby
supplies provided by
government to BPL women
DI_______
Mentoring Intervention Report
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A Busy Day for a Mentor during aSi)«hMentor Visit
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;The day started with a PHC team meeting with all sUff (including Group-D staff) to review
the PHC's action plan and patient and provider rights; All participants actively engaged in
. the discussions and responded to the mentor's questions;.
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The mentor then supported the nurses to do demonstrations of newborn resuscitation and
pelvic examination using models in the labour room, which was clean and well organized.
The nurses performed all procedures well. ;] U} '
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Next the mentor and nurses went to th,e lab to have the lab technician teach them how to
do a haemoglobin test, whichwas something the nurses had asked for previously. The lab I
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One nurse demonstrated the
suturing technique while ' ■
another nurse assisted and the
mentor provided guidance
as needed. The nurses said
that about 20%-30% of cases
required episiotomy.
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The mentor next asked
nurses to review a case study
that required them to plot
information on a partograph,
which they did
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Finally the nurses and labour room Group-D staff demonstrated preparation of a chlorine
solution, donning mask, apron, and utility gloves to do so and describing steps in the
process. Nurses worked as a team in filling the bucket with the required amount of water
and the mentor gave instructions to the Group-D staff on how to use the solution to clean
the labour room.
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The first day's visit ended in the early afternoon upon request of the nurses as they had
managed six deliveries in the previous 36 hours without any rest. (This PHC typically has
15-20 deliveries/month). Despite their fatigue, the nurses enthusiastically participated in
all demonstrations and conveyed a sincere desire to improve service quality. They were
proud of the improvements they had made in their PHC.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
.
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
III J
Mentor Visits Summary and Conclusions
In its first year of implementation, the mentoring programme rolled out much as expected.
Mentors were able to keep to their visit schedules, cover the content planned for each visit and
support providers on the job and through group-based problem-solving. Mentors grew into their
role, demonstrating increasing levels of technical competence and self-assurance in carrying out
their responsibilities. Mentors also built strong relationships with PHC teams. The project learned
more about the differences between PHCs and incorporated these learnings into the scale-up,
which is described in the next section.
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Mentoring Intervention Report
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Mentoring Intervention Report
... .......... :
5
Scaling Up the Mentoring
Programme
he project extended the mentoring programme to the other six Sukshema districts starting
in October 2012. In July 2013, the intervention expanded further to include all PHCs in the
pilot districts. As of July 2013, the mentoring programme covered 284 PHCs (24/7) with a
total of 53 mentors. The scale-up of the mentoring programme followed a similar process as in
the two pilot districts. This section briefly describes the scale-up process and highlights where
modifications were made to the pilot design. The section concludes with a discussion of how the
programme has fared in the scale-up districts.
Mentor Recruitment and Training
The project recruited mentors for the six scale-up districts and the expanded coverage in the
pilot districts based on the same qualifications as in the pilot districts. The project hired 1-2
more mentors per district than required to accommodate staff turnover. The hiring process was
shortened to two days but continued to include group-based activities to help the project team
assess the suitability of candidates. To respond to the challenge in the pilot districts of mentors
having to travel to distant PHCs, the project was more explicit in the scale-up districts about
requiring mentors to live closer to their PHCs and hired only mentors who were already living in
those areas or were willing to relocate outside the district capital.
Mentors in the scale-up districts also underwent a five-week induction training in three batches
at St John's Medical College with the same trainers who trained the pilot district mentors. The
training schedule was as follows:
District
Bidar
Yadgir
Bijapur
Raichur
Number of Mentors Trained
Bagalkot
Koppal
Bellary
Gulbarga
6_
1_
1_
5
£
5_
6_
1_
Dates Trained
Oct 2012
Oct 2012
Nov 2012
Nov 2012
Jan 2013
Jan 2013
Sept 2013
Sept 2013
______ j
The scale-up district induction training did not include a practical session on visiting PHCs and
facilitating the team-building and self-assessment process. Instead, mentors in the first scale-up
batch went to Gulbarga and carried out this exercise in PHCs with the Gulbarga mentors. In the
other training batches this was not done due to the need to scale up the programme rapidly.
73
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
_______________________
Following the induction training, mentors were immediately posted to clinical settings for further
clinical experience.This modification to the training was in response to the pilot district experience,
in which mentors expressed the desire for more hands-on clinical practice than they were able to
get in a tertiary teaching hospital. Scale-up district mentors were posted to a mission hospital
in Mysore and were able to do some procedures and deliveries to enhance their clinical skills.
Even with this modification, mentors said that during their 7-day posting they were mostly able to
observe rather than conduct deliveries.
Mentor Visit sin Scale-Up Districts
The project made some changes to the programme design based on lessons from the pilot
districts. In the scale-up districts, each mentor was expected to cover 7-8 PHCs, with three days set
aside for each PHC visit from the start. (In some cases, the first visit was still structured as a twoday visit to introduce the programme.) The other change was that mentors visited the PHCs every
two months rather than clumping early visits closer together. Mentors followed the same visit
plan and content as for the pilot districts. The table indicates the start date of the programme in
each district and the number of PHCsper district.The intervention covered in total 385 PHCs that
provide 30% of total deliveries in northern Karnataka. By December 2013, all scale-up PHCs had
received at least six visits.
District
Month mentoring
intervention
started
Number of
PHCs
Bagalkot
Feb 2013
39
---- ---- T----------- :
Bellary
Pilot Aug 2012
Scale-up Aug 2013
81DAR
GLtfiARGA
BJJAPUR
YADGIR
dtw
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RAICHUR
)PPA1
8EUAI
Bidar
Nov 2012
Bijapur
Dec 2013
------------ _____
Pilot Aug 2012
Scale-up Aug 2013
X
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Feb 2013
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Raichur
Dec 2012
__________.
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Yadgir
Nov 2012
42
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48
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42
Tailoring visit schedule according to PHC delivery volume
With the project scale-up of mentoring to all PHCs, the wide variation in PHC patient volume
became even more apparent. Given the project's goal of achieving measurable impact at a
population level, the project team decided to intensify the mentoring support in high-volume
PHCs and lessen the frequency and duration of mentor visits to PHCs that consistently reported
low delivery loads.
■21________
Mentoring Intervention Report
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Mentoring Intervention Report
Si
The distribution of PHCs by delivery load is shown below for each district and conveys the wide
variation that existed. Data indicated 20 high-volume PHCs accounted for 19% of all PHC deliveries
in the eight districts. High-volume PHCs (Category A) had at least 40 deliveries per month. PHCs
classified as Category B facilities handled 20 to 39 monthly deliveries and low-volume PHCs
(Category C) had 19 or fewer monthly deliveries.
24/7 PHCs: Deliveries per month by district
District
Gulbarga
Bidar . ..... .. ----------......
Yadgir
__
Raichur
-. ........... ----------Koppal
;__
Bagalkot
______
Bijapur
_____
Total ;;
%
l!__
.......j
Category C: 0-19
Category B: 20-39
PHCs
Deliveries
PHCs
Deliveries
; ■' •319^
12
39 ___
411;
________
71~
9
569'___
Category A: > 40
PHCs
Deliveries
190___
1
___ 0
284 __
; 265
___ 5
2
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36
238;
......
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297 __
350 __
33
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____ 264
298
2800;
77.4
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Under the revised visit schedule, two experienced mentors together visitedCategory A (high
volume) PHCs for three days every month. For category B PHCs, visits continued at three days
every two months, but the project specifically assigned more experienced and well performing
mentors to those PHCs. Low-volume facilities also receiveda mentor visit every two months, but
the duration of the visit could be less at the mentor's discretion. After one year, these low-volume
PHCs moved to a once-a-quarter mentor visit. In the scale-up districts,a few PHCs were found to
be conducting no deliveries for various reasons (e.g., staff shortages, limited infrastructure). In
those PHCs, mentors visited for one day every quarter to determine whether they had resumed
conducting deliveries.
The flow chart below illustrates the general structure of a standard mentor visit. Mentors modified
the sequence of activities as needed to adjust to the workflow of the PHCs on any given visit.
75
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
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The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
Flow of a typical mentor's visit
briefing the purpose of the visits
Self assessment exercise I
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PHC teems develop action'j
plans to solve gaps
I
Provide on the Job coaching
using case sheets, models,
demonstrations,etc
Ml
Debriefing meeting
I
Scale-up districts followed the established process for planning and carrying out PHC visits, which
included preparatory work, periodic reviews after each mentor had conducted 1-2 PHCvisits,
and a final review once each round of PHC visits was complete. Interviews with mentors in the
three scale-up districts visited indicated that visits proceeded as planned, including use of a team
approach, completion of self-assessment tools, development of action plans, clinical mentoring
demonstrations, and case sheet reviews.
Lessons Learned: Programme Scale-Up
Intentionally creating an enabling environment
The project learned from its experience in the scale-up districts that engendering interest in the
programme requires more orientation and direct engagement with district leaders. It is important
to put effort into introducing the mentoring programme through official channels, from the
district health officer (DHO) level on down to the PHC level, which will create a more conducive
environment for mentors to initiate the programme and also builds support for using the case
sheet.
In the pilot districts, medical officers and nurses were aware of the mentoring programme
because they had participated in a refresher training (3 days for nurses, 1 day for MOs) in which
Mentoring Intervention Report
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Mentoring Intervention Report
the mentoring programme and the case sheet were introduced. This refresher training was part
of the evaluation design for the pilot districts and was not, therefore, replicated in the scale-up
districts. The Sukshema team had also made frequent visits to the pilot districts before and during
the initial rollout of the mentoring programme. As a result, district leadership and PHCs were likely
more aware of the project from the start.
In the scale-up districts, the DPS and the central team had briefed district program me managers
on the mentoring programme and they in turn were expected to brief the MOs in their districts.
The DPS also had brief phone calls with each MO to announce the mentor visits, but these short
conversations may not have been sufficient to effectively communicate the aims of the project or
the projects collaboration with the government in the mentoring effort. During the Sukshema
project scale-up, there was also major turnover in the DPS positions,and the new district
programme specialists may not have been as well known to district leaders.
As a result, mentors in the scale-up districts seemed to encounter more difficulties inestablishing
rapport and credibility than in the pilot districts. In two scale-up districts, mentors reported the
difficulty of initially establishing rapport with PHC teams. In Bidar District, several mentors noted
that they faced skepticism from PHC staff because of the project's status as a nongovernmental
organization (NGO) project. Nearly all mentors stated that "In the first visit nobody accepted us.
PHC staff reportedly were suspicious that mentors were coming from an NGO and feared they
were there to inspect their performance and report back to the district. PHC staff also commented
that NGOs were not there for the long term/'The whole first visit was a struggle to build rapport,"a
mentor commented. Another mentor said that "Nurses weren't giving time and before they used
TIL,.
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to try to escape and
give excuses when we
wanted to meet with
them." Several mentors
explained that they
also had to spend time
explaining the Sukshema
project and its objectives.
One
mentor
noted,
"Though I told them, not
all were clear about the
project and did not take
it seriously." They had to
explain the project again
in subsequent visits.
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
77
_
The Story of a Maternal, Newborn, and Child Health (MNCH) Mentoring Programme in Northern Karnataka
In Koppal District, most mentors said at least some of their PHCs were not welcoming. I met with
the MO and he told me, Why you have come?"The staff didn't listen or cooperate. They said,' We
have work to do, we can't come for your meeting.'They said,' Why all these tools you have brought?
Why this case sheet it is so long?" Another mentor stated that her PHCs made her wait for more
than an hour before they would see her and also told her, "Don't waste my time."This response
was by no means universal, however and some mentors indicated that other PHC staff were more
willing to try the mentoring process. Some staff seemed to appreciate the mentor because it was
the first time someone was showing interest in their work.
Mentors in Raichur District did not raise as many concerns about rapport building. Several mentors
said of their first visit there that they were initially anxious and scared but generally found the PHC
staff to be welcoming and they were able to quickly establish good rapport in most cases. They
attributed this to the advance preparation with the DHO.The district monitoring and evaluation
(M&E) specialist in Raichur (who had been with the project since its inception) arranged a meeting
of mentors and the DHO before the firstmentor visit. The DHO then prepared a letter for each
Taluka Health Officer (THO), which mentors delivered in a meeting. THOs spoke to all MOs before
the mentors'visits.The M&E specialist also called each MO and informed them that mentors would
be coming. Additionally, after the second round of visits, all mentors also attended the monthly
MO meeting to explain the mentoring programme and case sheet, which built support among
MOs to encourage their staff to cooperate with the mentors.
Gaining case sheet
acceptance
Since medical officers and
nurses had not been previously
introduced to the case sheet in
the scale-up districts, mentors
had to explain the tool and
win PHC staff over to its value.
Mentors introduced the case
sheet in the first visit (often
on day 2). One mentor stated,
"I explained that this is a good
way to document things" and
outlined other benefits and
tried to convince them of the
importance of the case sheet.
As in the pilot districts, PHC
staff initially said the sheet was
long and often perceived it as
a reporting requirement rather
Mentor conducting case sheet audit
with nurses in scale-upPHC
than a job aid. In the second visit, mentors observed that nurses were filling out the case sheet but seeing
perceiving it more as a documentation process. "They were simply filling the case sheet rather than using
the case sheet," explained one mentor. By the third visit, nurses were more convinced of its value and
were using case sheets as they saw patients. Nurses and medical officers "are saying it is useful." Mentors
reported that some nurses saw the complications case sheet as a duplication of effort since they were also
filling out a referral sf hjttf sf
9
Mentoring Intervention Report
N f oipgohUbif saT oqpo’Sf qpsu
Tvqqpsqohli jhi .v\pranf!CI Dtip!bev\bodf !r vbrjizljn qspv\f n f ou
U f!i jhi .v\pmnf !Q Dtidxf hzltvddf f ef eljoiqqDvyejohln psf !tvqqpsdip!cvtz!Q Dt/!l b/yohlix p!
n f oipstlyjtjdblQ Dlbdu f !tbn f !yn f Ibnpxfe’u f n liplejvyef !vq!u f !sftqpotjcjijtyftlboelu fz!
were better able to reach out to busy PHC staff. Mentors reported observing improvements in
staff performance after the high-volume PHC strategy was implemented. The more frequent visits
also were helpful in encouraging staff to use the case sheets and complication case sheets more
often. Observations confirmed that mentors were differentiating their support, with one mentor
x psi johidrptf rzilxju !u f iovstf !po!eviz!xi jrfilu f !tf dpoeln f oipslippl lifbcfi johltf ttjpot!x ju !
the other off-duty nurses. This division of labor also allowed for more one-on-one teaching. For
example, in one session each mentor sat separately with a staff nurse to review the case sheets
fbdi Iovstf !i beli boerfie/l
PHC staff valued the extra
bcLfoLjpo! u fz! sfdfjvtfe!
<#)n !
li f!
n f oipst/!
Jbifa/yfxt! xju ! ovstft!
and medical officers in
ixplpcju sff !i jhi .vpran f!
cjxjijiyfttoitjif elgpvoelu bd
staff were happy to have
n psf! c^f r vf od n foips!
tvqqpsu-lboeli bvyohlixp!
n f oipst Ibdblijn f Ibnpxfe!
ib
staff nurses to more fully
qbsydjqbif/! Pof! ovstf!
t ibif e-! TFbsrjf si x f! ejeoid
hjvtf! jn qpsdxxff! ip! u f!
n f oips! bt! x f! x f sf! \/\f sz!
cvtz!boe!jdxbt!i bselip!
hjvf! buf oqpo/! Opx ! pof!
Ik p!n f oipst !x psi johlpof po pof !x ju Iovstf t!!
n f oipsldboi f rqlxju PCE!
evgoh!vjtjdip!i jhi Jvprvin f !Q D
boe!rtxpvs!boe!u f !pu f si
mentor can teach so it works much better.'The other PHC had only two staff nurses overwhelmed
czlblef iptf sz!rpbe!p(j81!qf sin pod -!tp!u f Ibeejcjpobrtjoif ±dijpot!xju !u f !n f oipst-!xi jrfili fnqg/rA
were also considered burdensome. One nurse who had just finished a 12-hour night shift and
ef iptf^elu sff !cbcjft!xbt!voxjnjn)h!ip!lpjo!u f In foipstlgjslu f Itfdpoelebzlpcju f !n f oipsjoh!
x/ytjtfU ftf lovstftlxfsf Ixpsl johljolbolvoefssftpvsdfelQ Dlxju lijnufiliplopltvqqpsd^n Id f INP-!
sftvrxjohljolijm jif eln py\/\bijpo!ip!jn qq^vf Ju f js!q±dijdf t/
Dpotjt if odqbnf so!pc|QI D.r vbrjizljn qspvtf n f ou
As in the pilot districts, mentors and PHC staff in the scale-up districts pointed to improvements
in the labour room and drug supplies as some of the first signs of quality improvement. Many of
li ftf !jn qqovtf n foit’xf sf !jotiju/if e!cz!u f !ii jaelpsfgwsu !vytji/!N ptdopibcra-lu f !p^iboj{bqpo!p(j
______________________ tr
U f !Tipsz!p^b!Nbif90bnOxcp90-!boe!D jra! f brd !)NODI *!Nf oipsjoh!Q=ph±n n f !jo!Opsu f aoJLbsobibl b
U f !Tips:!p^b!Nbif sobrriOf x cp9O-!boe!D jre’l f bra !)NODI *'Nf oipqohiQ’phsbn n f !jo!Opsu f soiLbsobibl b
fi
focpvsl^pn t!i be’jn qsDvtfe-Sxju Irfittldpohf tcjpo!boe!hsf btf sldrfiborpf tt/!S/tiz!ef rprfsz!tf it!i be!
cf f o!sfqrbdf e!xjii !of x !jotia/n f oit!boe!sbejbodx bsn f st!i be!cf f olsf qrbdf e!ps!sf qbjsf e/!Q Dt!
i belpyzhf o!boe!hf of ±q)st!b\AbjrtacrfV
Jb’.cpu !u f !tdbrf].vq!boe!qjrpdejtiqdit-!tjn jrbslqdodijcif t!x f !sf tjtLboUipIdi bohf !boe!n f oipst!
identified comparable factors in the work environment that compromised the provision of
qbyfoudfoiEfe!rvbijiiz!dbsf !jo!cpu !izqft!pcjejtiqdd/!Nfoipstlopife!u bdjo^dqpo’qsfvfoqpo!
practices remained deficient even after multiple visits. Postnatal care was also not practiced to
standards. Other challenges influencing the provision of high-quality care related to patient
bujuzeft!boe!cf i bvjpvst-Sodroiejohtef rtazt5o!dpn joh’iplu f i fbra !cjxjrpz!)j/f/-!x bjijohlvoLjrlriQcpvs!
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Njttf e!pqqpsuJojiE!gDslcf uisn bobhf n f odpcjdpn qrjtibypot
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clarified the correct procedures for diagnosis and management of these conditions.
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multiple complications, nurses did not know which complication case sheet to fill out and/or did
not want to fill out multiple complication case sheets.
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As evidenced by the variable number of complication case sheets filled out, the tracking of referrals
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the case sheet data, it was difficult to discern whether these referrals were managed properly.
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follow-up was to reduce staff automatically referring patients without any assessment, also known
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mentor visits. Mentors offered several possible reasons why nurses might refer normal deliveries
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ovstft1!tiboejoh*-!opdx boijohliplcf lejtu/scfelbdojhi dboe!rfj{joftt/Tpn f lovstftHofz-!n foipst!
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complexities of effectively managing referrals and indicate that clinical and community practices
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Critical role of medical officer support for evidence-based practices
Observations and staff interactions in some PHCs found that MOs were not always on board with
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developed to implement the intervention resulted in a smooth and efficient implementation
process. In just a five-month period, the mentoring programme was extended to all eight project
districts. Overall, mentors in these districts observed levels of staff engagement and improvement
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MRU
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N bobhf n f odTiB/du/sf
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issues as they arose. Project consultants also periodically conducted site visits and offered advice.
Bdu f tejtiqddrfivf nfolejtLEjddq^oh^on n f Itqfdjbijidx btlsftqpotjcrfilgjsU f !n fotpgohjoif SAfoypo!
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Coordinate field visits for staff, trainers, consultants and other visitors
Interface with district officials and report to Sukshema leadership about the mentoring
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The DPS also coordinated with other district-based project staff, including the M&E officer and the
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offices.
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voef sd3l f o’boeipctf SAbijpot____
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profile
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staffing details; portions to be
vgebifeln pou m____________
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drjiDjdbrini f oipsjoh-!jodroiejoh ’.
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if bdi johiifdi ojr vft’ip’vtf’boe!
n f oipst
session plan for first six visits, with
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f bdi !tfttjpo_________________
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staff at each PHC have been
plan for PHC staff
mentored on specific MNCH topics
gps!3123.3124
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f bdi !\Ajtjdip!vtf !bt !sf cf sf odf ’jo!
qrhoojoh!g/u/sf h/ytjit____________ :
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n f oipst !po’b!qbsgdvrteia D-’l f qd
in her PHC file; allows mentor
ip!sf dpss.'di bohf t!pctf SAf e’jo!
vij$bypo!joejdbipst !pvf sign f__ i
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li f ’drjojdbdm f oipsjoh!dpn qpof od
pcju f j^Aftjdiplf otvd7 !jddpvf st’.brrh
dsjijdbrfopqjdt!boe!u bdbrrim f oipst!
bsf !dp\/\f sjoh!tjn jrbs!ipqjdt!jo!u f?
tbn f hAjtjii____________________
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staff they have mentored and
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i________________
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di f dl ij&u
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po.'n foipsjoNqqsvyef e-’jef oijc^’
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I opx rhehf !boe!tl jrrinbqt’ip!
dpvtf s!jo!n f oipsjoh’tf ttjpot-’boe!
n f oipsjohMjtju
epdvn f odief oetljoln bobhjoh!
dpn qrjdbijpot_______ _________
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D bsdpo!f ttf oujbrh List of first and second-line drugs
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gjsln foipstlboeEQT____________ ------------------------------------------------i---------------------------------- ;---- Tiboebaelgpan bdipltvn n bsj{f tebib!
Npou rritvn n bsz! Matrix that summarizes findings
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n f oipsliqqlsfqpsct_____________
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pctf 9Ajoh!d f Ibdgvjijf tip^d f lovstf! n pojipstejtiEjdurfW rftvqqpsdiplu f
n foips______________________ mentors during field visits_______
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efgvtfelcBDn Idbtf Iti ffdtvn n bqftId bdd fin foipstlqsfqbsfelevgohlfbdi Ipcjd fjsMjtjd/INfoipstI
submitted the completed case sheet summary to the district project data entry officer after each
visitand the officer then entered it into the project database. The Sukshema M&E team prepared
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had been filled out since the last visit.They also counted the number of pregnant women <
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but for whom there was no case sheet Finally, they asked staff nurses about any deaths or
still births that may have occurred, because these were not always reported in the official
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boelxi fu fslpslopdii fzlxfsf Ijolrbcpvs
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xijdilufzlxf^l^^e-ydbqqijofocrff
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It typically took 1-2 hoursfor mentors to .review the registersand case: sheetsand fill out the
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n pojipqohlboelpu fslqqoh&n n bqdljogjgi bqpo/!U f lEQTIdppsejobif elu f tf In f f gohtlxjd Id f I
support of the M&E officers.
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DPS and mentors met as a group to review the objectives of the specific mentor visit, practised
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U f !Tipsz!p^b!Nbif sobrOxcpso-’boe’D jre!l fbra !)NCO *!Nfoipqoh!Q=phsbn
8./. i I
role plays and demonstration sessions and reviewed findings from previous visits to establish
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n foipst Idpn qifufelgovsi In f oipslwftjdipIbnrtG Dt*-!u f lif bn Ihpdiphf li f stbhbjolip!^vyfx Id fjsl
f yqf sjf odf t Iboelejtdvtt Id bnrfiohf t Iboeli px liplsftpnrf Id f n ZIU f kfd ojdbrfnf bn !^>n ITvl ti f n b!
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had also been scaled up, project staff managing this intervention component also took part in the
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its first internal review meeting with mentorsand DPSs in September 2012 in Hospet after most first
visits to PHCs were over. The Sukshema leadership and technical staff participated in this review.
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f yqf sjf odf Iboelpctf SAfcnjpotld vt IcJosflU f lifd ojdbrttf bn Ijoigjevdfeltpn f Ipcjd fin bobhfn fod
tpprtief t dsjcf elbcpwf levsjohld jt It f ttjpo/
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n f oipst Id f lebzlcfgj^ld f Isfvyfx In f f ijoh/Ubld f Isfvyfx In f f qoh-ld f lifbn lejtdvttf eljoqvd^n I
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n f oipst/l!
In February 2013, leadership organized a five-day technical review involving international and
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interventions and the monitoring and evaluation framework on the first day and then traveled
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came together in Hospet for a final day to share observations and recommendations.
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The project team at the district level was expected to interact with the district health office on
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health officer (RCHO), district programme officer, district programme management officer (DPMO),
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n f f ijohlrtatif elix pltpld sff li pvst levsjohlx i jdi Id f lEQTIqqjMjefeli jhi ijtni itlpcjd fin foipsjoh!
qq^hdin n f Iboelti bdelsf dfodebib/
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share findings from the mentoring programme, raise issues that might require a district-level
response(such as procurement or staffing) and solicit input and recommendations from the DHO.
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because of DPS staff turnover. In all districts, DPS and M&E specialists also tried to attend the
monthly district medical officer meetings, although they rarely presented at this forum.
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supervisory staff and a point person to coordinate and oversee the mentoring programme. The
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The project experienced considerable staff turnover in the DPS position in all districts. Since the
project started in January 2010, most districts have had three different DPSs.This turnover creates
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consistent relationships with district officials. There does not appear to be an underlying reason
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hpvtfaon f odpslgoslqf stpobrtaf btpot/l
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Cfdbvtf pcjd f MoboijdjqbifeECinivsopvf sli f IqqaWdii beLplefuf rpqbEQDn bobhf n fodiEbjojoh!
tf ttjpoluplf otv^ !u bdu fz!i twf !ii f idrvjtjif Irvbfjnzijn qqowfn fodboeldrjmjdbrttopxrfiehf !boe!
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training and were then placed in the field to shadow another DPS for 1-2 weeks before taking on
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Nfotpslsf if Oljpo
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von bsgfelxpn fo!)xi pli bwf lipldpotfoelxju Icjxi jnnlpcKdijpot*!boe!g)s!n bssjfelxpn folxjd I
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because of the travel required), project staff indicated that few mentors had resigned for work
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u df Ipcjii f !psjhjobrt22!ovstf In f oipst Isfn bjof elx ju Id f Iqqatfdif!
Vtjoh!ebib!ip!u f Ig/rrfitdqpif oqbrn
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n bobhf n fodboeljn qspvrf n f odIJajijbnm-kpsIfybn qrfi-!u f IqqaKddjoif oef elipljoqvdbnrtebibl^n I
dbtf Iti f f it Iboeltf rgbttf ttn f odipprWcvtiu jtlxbtlcvsefotpn f Iboeld f lebtblxfsf bpiivtf g/rftJ f I
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discrete information. With these revisions, mentors delved deeper into specific information fields
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sf tpvsdf t lipli jhi wproinflQ Dt/
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>7 Voices of PHC and District Staff
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opif e4!Bqbsdcg)n !T(B!iEbjojoh-!ovstf t!i bvtf !op!f yqptvsf !ip!of x Jjogpsn bypolboe’u f !n f oipst!
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skills and support them and felt that the mentoring programmewas filling this important gap.
Medical officers described the purpose of the mentoring programmeas improving quality and
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I n the words of one medical officer,"Mentoring has been really good for us "Another MO stated,"! am
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n bef Iblrpdp^di bohftltjodf In f oipst!
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i btljodsfbtfelboeld fzli bvf Irhbsofe!
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o_____
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good thing because it is skilled oriented and helps with implementation. It is different from other
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u pqDvhi Ijolqqovyejohldbsf/lBtlpof lovstf Itdxfe-ITXf lejeoidl opx In vdi Icfgpsf Iboelopx Id f I
n f oipslif rririvt !i px lipleplf bcfi Id johlboelf yqrtajot lx i zlxf lepld ftf Id joht/IU fin f oipslsf n joetl
vtlbcpvdd johtlxf Igpdif LflBlsfdvsqohln fttbhf Ic^n lovstftlx btld bdiNf otpqohli btli frqfeljo!
of itf slvoef stiboejohljolbltifqx jtf In boofsli px lipldpoevddef ipf qf t/ll bvyohltpn f pof If yqrtajo!
these steps is very beneficial." A nurse in another PHC similarly stated:
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qbsq>hsbqi /IXf Ibrtplrfbsofeli px lipin bjoibjolea/htltplxf lepoids/olpvdpcjtipci Iboeli px lip!
I ff q!c£>n qijabypoll jiifi
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arranged the labour room and know what drugs to keep there."Staff in one PHC, while appreciating
the mentor support, remarked that it was hard to always find time for the mentor, especially when
only one nurse was on duty or the OPD was busy. Nonetheless, nurses and other PHC staff praised
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Tpn f IQ Dtlg/nonlfn c&dfeld f Ibqqspbd ft!
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benefits, a nurse stated: The NRHM case sheet
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dbtf Iti ffitIbsf !i frqg/rfi
Nurses and medical officers nevertheless pointed out the challenges in filling out the case sheet,
especially when staff were busy. In a high-volume PHC, nurses explained that it was easiest to fill
pvdu f !dbtf !ti ffdpolii f !n psojohlti jgJxi fo!ixplovstft!xf st!po!eviz/!Pof !NP!tf dpn n foefe!
shortening the case sheet since "the case sheet is helpful but it is tedious work for staff."
Pof lovstf Ifyqrtajofeljojcjbrti ftjLbcjpoIipIn bobhf !dpn qijtibijpotlcvdopifeiu bdu f Idbtf !ti ffd
n bef Ijdqpttjcrfilipln bobhf Idbtf t/!Ti f Ihbvtf Ibolfybn qrfilp^blCQ Idbtf Isfdfouzln bobhf elboe!
sfcjsefe/!Pof lovstf Idpn n foife-liFbajisIxf !g)dipdip!btl Ibcpvdqsftfoijohldpn qrtojoitlcvdxf lep!
tpln psf If btjralopx Ixju Id f Idbtf Iti ff ifIBopu fslovstf Iti bsfeli px !ti f IsfdfjvfelbldbrrtagDn Ibo!
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the patient. Still another nurse stated, "Now we are more confident to manage complications
__________________ a
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Illi
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tibaJpcjii f !n f oipsjoh!qsph£>n n f/
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PHC teams said they were doing better diagnosis for mothers and newborns. One medical officer
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support them as needed. Nurses and medical officers indicated that they have stopped labour
bvhn foibqpo/
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if a baby is preterm and how to use the referral case sheet. A medical officer noted that newborn
sf tvtdjibcjpoli beljn qqjvife/
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f otvqohles/htlboeltvqqijftlxf sf IbmbztlbwbjriDcrfi/IPof lovstf lopuf e-TiEsyhltvqqraljt Ihppelopx I
boelxf II opx Ixi bdes/ht Iipli bwf IjolrtcpvsIqDpn Iboeli px Iiplben jojtif slu f n ZIBopu f sIQ D!
if bn Idpn n f oif elpolu f Icf ufsldppsejobijpolxju Iqi bsn bejtitlgpstes/ht/IQ Dif bn tlbrtplopife!
jn qqjvtfn foiiljolu f Ibwbjrfcjijozlpcjrfcldtilljolu f Irtcpvslqspn /
Of uf slsf if ssbritiztif n t
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the ambulance and fill the referral case sheet."
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In several of the PHCs visited, staff took pride in pointing out improvements they had made
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available and labeled. Staff also said they had improved infection control.
TvqqpsifcpsINf oipgoh!Q=ph±n n f
Tibi fi pnafstlxfsf Ibtl feljcju fzlu pvhi du fin f oipsjohlqqjhdan n f Ijtltpn fu johlu bdti pvra!
of Idpoqovf elpsljyu f zkjjwp^e!n psf Ipcjblijn f .cpvoelef tjholjolx i jd Id f IQ DIx pvraloplipohf si
offelu f Itvqqpsdpcjbln foipsIIBrrtii ptf fjoifa/jfxfeld pvhi id f Iqqshsbn n fx btlhppelboelti pvna!
continue. One medical officer explained, "Monitoring is required so we don't forget to do things
boeln f oipsjohli f rqtlxjd Id jtfi
:2 I'ii f !Tips!pc|b!NbLf sobrOx cpso-!boe!D jre! fbra !)NODI *!Nf oipsjoh!Cfeph±n n f IjolOpsii fsolbaobibl b
Pof! ovstf! f yqrtajof e! u f! v\braf! pcj u f! n f otp^oh! q^h&n n f! pv\f s! sf £fti f s! ik>jojoht;r1 Jb!
refresher training you get lots of books and one-time training, then it finishes while mentoring
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support to district resource persons (RPs) who are identified from the community to act -J
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community intervention in Bagalkot and Koppal, RPs were project staff, but this was modified
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% effectiveness in reaching out to pregnant and recently delivered women and newborns ;
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modified and introduced in the remaining districts in January 2014. In Koppal and Bagalkot
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community staff in those districts had a longer history of both components being in place. As of
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__ _-.... -__ _____ w
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n f oipsjohlboeldpn n vojizljoifaaf ogpolc^n qpof odln f dpodf !b!n pod Ijolf bdi lejtiEjddlll jt!
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were not present in this forum, which was for project staff only. In some districts, facilitation of the
meeting rotated among the DPS, DCS and M&E officer. The project also tried for a short time to
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According to project staff, the district coordination meetings tended to vary from district to district.
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These joint meetings helped build a sense of connectedness among project staff. As one mentor
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and CCs jointly prepared action plans for their PHCs and district-level staff (DCS, DPS, DCM, M&E
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Coordination was complex because mentors and CCs serve different areas. CCs work in only
one taluka, while many mentors work with PHCs in 3-4 different talukas (especially after the
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taluka and each mentor looked after eight PHCs. CCs had to coordinate with 2-3 different mentors
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_____________ IL
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.
•.
;
•
Challenges and solutions identified through joint action planning
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Lack of drinking water. Acquire or repair water filters in PHC through action planning
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Home births: 3-6 in PHC service areas each month. Mentors to find out more about :
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in specific villages.
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! Lack of PNC ward. Encourage MO to get drapes and curtain off a portion of the general
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In Gulbarga, while CCs and mentors scheduled joint visits, they often found it difficult to actually
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efforts. In Yadgir, the district community intervention and mentor teams sat together for a full day
to discuss issues for each PHC. Mentors were asked to think of PHC-specific issues that CCs could
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which pointed out the need to better inform the community about PHC services and staff. In this
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di bnfoohf t If odpvodsfe/l
Fybn qrfit!pc|Dppsejobijpo
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about the PHC because staff had stopped giving drugs to speed up labour, so they were now
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counseled staff nurses at that PHC to stop labour augmentation.
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mentors and CCs identified low-volume PHCs and worked together to see if they could increase
deliveries. In one PHC, the mentor identified that hardly any deliveries were coming from certain
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U f !Tipsz!p^b!Nbif sobrOxcpso-’boe’D jra!l f bra !)NODI *!Nf oipgoh’Qphsbn n f!jor.
■
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For example, in Gulbarga, participants identified water as a problem in five PHCs. The mentors
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the GPs toaddress it. Water problems were fixed in four of the PHCs.
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Q O'!
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its final year, it will be important to develop clear guidance on what role mentors can play in
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Sufficient time for coordination meetings
The effort to hold monthly district coordination meetings between the full mentoring team and
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together to ensure integration of efforts and strengthen systems. Moreover, because PHCs report
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community intervention efforts, but mentors did not have interaction at theTHO level. In some
cases, THOs can actually be an impediment to PNC improvement, so it is important to find ways to
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through direct interaction could include staff allocation decisions, accountability, transport issues,
supplies, or other factors that affect all PHCs in a taluka. At the same time, it is critical that no
project staff be seen as blaming any staffer directly reporting performance issues to the THOs,
which would jeopardise their credibility and trust with the PHC staff.
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ijn f iypf t______
_________________ a
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■
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the pilot district evaluation findings. In addition, information on the cost of implementing the
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confirmed findings from the qualitative process documentation. Highlights through March 2014
include findings about variations in delivery load and use of case sheets.
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nurses had completely filled out a case sheet for 65% of all PHC arrivals. This compares to just 12%
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in use of cases sheets. The proportion of normal case sheets filled as a percent of total arrivals
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from a PHC should have a completed complication case sheet that identifies the nature of the
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case sheets filled out as a proportion of total referrals reported (derived from the referral and
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of complication case sheets filled out as a subset of total referrals ranged from 19% in Bagalkotto
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N f oipsjoh Lbtf 94 ocjpo’Sf qpsu
N f oipgohLbif arf oypo’Sf qpsu
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diagnosed with any complication. It is possible that some PHC staff referred women who could
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and been told by staff to go on to a FRU.
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98/:
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Of the total arrivals in labour, the maternal complications identified increased by one percentage
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maternal complications, it was somewhat surprising that there was less identification of PPH. This
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212
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■
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The monitoring data also indicate that staff were learning how to properly diagnose complications
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Ttbhf !biix i jdi !sf $ ssbrtix f sf !n bef ;!& !ejt t^cvijpo!!
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Yadgir
Raichur
Koppal
Gulbarga
Bijapur
Bidar
Bellary
Bagalkot
Total
0
20
■ Referral at initital assessment
N f oipsjoh ’Jbif s/tf oijpolSf qpsu
40
60
■ Referral in labour
80
■ Referral post-delivery
...1
. MB
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Yadgir 1
Raichur
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Bijapur
Bidar
Bellary
Bagalkot
Total
0.0
10.0
20.0
30.0
■ Referral in initial asssessment
40.0
50.0
60.0
■ Referral in labour
70.0
80.0
90.0
100.0
■ Referral post delivery
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9/11
21/11
23/11
25/11
■ TyrrfcjsLi t
__________________________ G3
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1
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provider knowledge, and practices (as verified by clients) over a period of one year are highlighted
cf rpx /!B!g/rrii wbroibijpolsf qpsdjt lbwbjrtcrfiltf qbdoif m'l
Staff Nurse knowledge of AMTSL
47
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r
31
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every indicator, the intervention sites performed statistically significantly better than the control
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Furthermore, intervention site staff not only performed better in terms of identification of
complications but knew significantly more about how to manage those complications.
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but little actual difference between intervention and control sites, especially when the practices
reported by staff were compared with postpartum client interviews. It is difficult to explain why
u jt!n jhi di bvtf Jpddvsef e-!cvdjdn bzlcf !ii bdu fin foipstli belopdi belfopvhi kjn f liplgpdvtlpo!
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Consistent with the perceptions of mentors and PHC staff, PHCs were much better equipped in
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to the increasing strength of the NRHM programme and the district health department offices.
Laboratories improved overall, but staff in intervention sites were more capable of managing
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and in many cases the differences were highly statistically significant. The biggest differences
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to manage all emergencies than were control sites in 2013 (see figure on previous page). The
team self-assessment approach of involving all PHC staff in problem solving and action planning
appears to have led to an ability to find solutions to longstanding drug shortage issues.
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to affect more systemic problems such as staff shortages, the physical state of the PHCs, or services
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216 i
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2013 appeared overall much less satisfied with these comfort issues than those interviewed in
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lower staffing levels in 2013 might also have played a part. The number of medical officers in the
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Furthermore, government financial incentives appeared to be less available everywhere in 2013,
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induction training for mentors and district staff. These formed 12% of the total intervention
costs (31,18,000 INR or 53,759 USD). The annual costs included the staff salaries and travel,
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where mentoring had taken place. Fewer differences could be seen with respect to postpartum
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These results must be interpreted within thecontext PHC staff's poor baseline knowledge, the fairly
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PHC staff can improve their knowledge to a certain level through training, and that PHCs can
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mentoring takes this knowledge to a different level, making staff feel supported and motivated
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competence and confidence to handle maternal and newborn care.
sa______
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- -....... .V * >
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u f!i jqoh!qq?df ttlgpdvt !po!sf ds/jyoh’dboejebdt!x i plbsf !pvihpjoh!boe!f olpzljoif ±dijoh!xju !
qf pqrfi!boe!tvqqpajoh!u fn kplqfscpsn/
B!g3dvtfe!id)jojoh!qqDhdDn n f !c£n cjofebcju !b!tuapoh!tztcf n !g)s!pohpjoh!idDjojoh!boe!tvqqpsd
can prepare a capable and effective mentoring workforce. U f !6.x f f I Ji&jojoh!qn f !x bt!
sufficient to impart the basic skills required to be a mentor, but the mentors also needed continual
po.ii f ,lpc!tvqqpsdboe!sfjog)9df n fodu qDvhi Idipjdbriqsbdqdf Iboelsf gfti f di±jojoht!ip!g/nm!
efvtf rpqlu fjsltl jnrtf
Tfrgbttfttn f od qspdf ttf t! boe! if bn .cbtfe!bdqpo!qrboojoh!bsf Isfrvjsfe! iplbd jfvtf irvbrjiz!
jn qspvtfn fod!U f!Q Dt!)ftqfdjbra’u ptfbcju !tvqqpsijv\f !NPt!jo!di bdif*!f n cdDdfeld fldpodfqd
pejr vbijuzljn qspvtf n f odboelpx of e!u f jslqDrfiljoIx pd johlbt Iblif bn lipIqqDbdyvtf ra’jef oq^lboe!
resolve problems. The teamwork process enabled PHC staff to see how everyone contributes to
quality and how staff are dependent on each other. These achievements (noted in preceding
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n f oipsjohlboeli belopdjodmef elifbn .cbtf e!r vbijnzljn qqjvtf n f odqspdf ttf t/
218
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q^jvjef t!b!sf dpaeip^dbsf’.Lp!x i jci !cpu !n f oipst!boe!ovstf tldboltfcf sflJJbrtplqqavyef t!b!sjdi !
tpvsdf !pc|ebib!ip!n pojipsll f zlisf oetltvdi !bt!n bobhf n f odpcjdpn qrjdbcjpot-lsf cf sdjrHboelqbqf od
outcomes. Many staff nurses found the case sheet to be a useful job aid, but because it represented
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bepqifelczlu f IHpwfson f odpcjLbsobibl blpslpd fst!g>slvtf IbUtdbrfn-ljdx jnrfrf !jn qpsLbodipbvjflaljo!
support structures to help providers use it as intended. It will not be sufficient to simply distribute
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and policy-makers. Issues that are common to many PHCs can be identified and strategies tailored
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complication case sheets, information on the incidence of different complications and how they
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their efforts where the need for improvements is greatest.
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improvements tended to occur in facilities that had strongly dedicated medical officers who were
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of care at PHCs where the medical officer is indifferent to improving quality is severely limited.The
bctfodf !pc|N Pt !jo!n bozkjxjjijijf t !boe!qbsugn f !n bobhf n f odczIqbsqbnonlefqvifelNPtljolpu f si
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I jhi .wprom f !CI Dtlsfrvjsf !u f In ptdtvqqpsdlU f Ic^rvf odz!boe!joifotjiE!pcj!joif dadqpolxju !
n foipstltff n tlipIdpoisjcvLf !ip!jn qspwfell opx rfiehf !boe!tl jrrtflU jt !qq)n qtf eld f IqspKddtp!
jodsfbtf Id f levdxjpolpcju fin foipslyjtjdpvtf sgn f Iboeltplqqawjef Ibeejqpobritvqqpsdtpli jhi .
volume PHCs to allow sufficient interactions with PHC staff to take place. In PHCs with low to
n pefdsif Ivprvin ft 1)21.31 lef rjmfsjftlqfsin pod *-!b!tjohrfi!n foipslxbtlhfofdjnmlbcrfiliplxpsl I
drptf rzlxju lovstft Ijolu f 14.ebzlvytjif
II f!EI PtlsprfiljtMjibrlQpIcbibratf In f oipsjohIqqjh&n n f Ijn qbddlll f!EI Pljtljolblvojrvf Iqptjypo!
iplbttf tt Iboelbddpold fin bozljttvf t Id bdn foipstlcsjohlgjsrbselbcpvdQ Dlqfsgjsn bodf Iboe!
di brrfiohf t/!U qavhi Id f lejtisjddsfwjf x In ff ijoht-IEI Ptlrfibsof elpcjqqjcrhn t Iboeliqf eltplbeesf ttI
them. For example, in Bellary after the DPS and mentors repeatedly raised the issue of staffing
shortages at high-volume PHCs, the DHO instituted a staff allocation system that deployed nurses
cqjn I rpx .wprwn f IQ Dtliplcvtjf sIQ Dt/I I pxfvf six i jrfild f I El Pt I tf f n f eliplbqqsfcjbif Id f I
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the PHCs. In an ideal scenario, district authorities could enlist mentors to support PHC staff in
219
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II
N f oipgoh !Jbif 9Af oypofSf qpsu
jn qrhn f oyohlofx !qpijdjftltvdi Ibt!ti jt!pof/!Nf oipst-!ipp-!dpn n f oif e!u bdEI Ptbcf sf bejngroh’ip!
give feedback on specific PHCs but had not come to appreciate mentors as part of the support
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Jbifhsbijpo! xju I hpvtfsonfod sfqpscjoh!
g)sn t!boe!tztif n t!jt!of f ef ekpfcvjreltvqqpsd
cpslofx ! sfqpscjoh! gDsn bit/!The field visits
found that PHC staff face considerable
sf qpscjoh! evsefot/! Gfsu f s4 dpog/tjpo! jt!
joiqDevdfelxi fo!n vnjqrh!g)sn tlbsf ’jolvtf/!
Gjbs! fybn qrN n foipst! f yqrtajof e! i px ! li f!
government partograph is different from
the Sukshema partograph in how it is filled
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thatthese efforts are well coordinated with
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El P!offet!ip!c£n n vojdbif !ip!Q Diifbnt!
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ofx!
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increasing the onus on nurses to fill out
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to be specific with nurses and MOs about
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fybn qrh!Jb!sfrbjpo!ip!dbtf !ti ff d-!u f !ofx !
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state and district officials, with appropriate permissions and circulars. In the pilot districts case
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staff about formats to use. While Sukshema project did little in the way of automating any of the
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boeiqptuDbibrW^ !boe!cjsu Iqriooojoh/
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strengthening PHC leadership, addressing staff shortages and improving the quality of services
21:
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■J
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63
solbsobibl I
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Tztuf n .rfKAf rfaf dpn n foebijpot
System-level recommendations focus on improving staffing and the quality of services available
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Match staffing levels to service utilization.^ f Icrbol f dqpi)dz!pc|d sff lovstftlgaslfvtf sz!35CB!CJ D!
results in staff in PHCs with high patient loads being overstretched and often unable to give
sufficient time and attention to women in labour or during the postnatal period. Strategies to
address this could include increasing staff at busy PHCs and having two nurses on duty at a time.
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as the World Health Organization's (WHO's)Workload Indicators of Staffing Needs (WISN) might
help identify staffing requirements aligned to patient load.
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jn qbdd cfcbvtf I p£|jli!gxlvt! po!35CB! Q □/! Ji
Xju pvd jn qqjwf n f od! bd uf! GEM rfwfnfi
am concerned thgt talukahospitak staff are
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- a
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of the importance of 48-hour monitoring and ensuring that staff provide this level of monitoring.
This will also require staff to provide good patient-centred care during the 48-hour stay so that
patients perceive the benefit of remaining in the facility. It is ironic that women manage to stay in
the facility for five days for a tubectomy but do not remain for 48 hours after delivery.
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behaviour changes to benefit mothers and children. Areas to focus on through community-level
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N f oipgoh ’Joif
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leave prior to that, effective
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diminished in the pilot districts, making it vital to engage in concerted and sustained efforts to
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Dpochntjpo
The mentoring programme is proving to be an effective intervention to improve the quality
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implemented at scale in a short period of time and staff have been accepting of mentors and the
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and to increase the capacity and confidence
of staff nurses. PHC staff also reportpositive
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of benefits and rewards, apathy and
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Tawfik, Youssef,Annie Clark. 2012. Improving newborn resuscitation in Uganda. Presentation at the
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MA Tolle. 2013. Evaluation of the effectiveness of an outreach clinical mentoring programme in
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The costs are largely related to staff (salaries, travel, per-diems), capital and material costs
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■’^s! The costs are finally categorised into one-time and recurring costs. One-time costs include
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regularly such as staff salaries, travel, review meetings, etc.
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to the PHCs of northern Karnataka. They were supported and supervised by a programme officer
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trainings and handholding support in the field. While the clinical consultants supported the
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run the trainings and coordinate the handholding visits. This part of the cost analysis includes staff
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degree (MSc) in nursing. The annual salaries offered to them ranged between 1,44000 INR (2,483
USD) and 216,000 INR (3,724 USD) depending on their qualifications and experience; hence an
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medical doctors with master's degrees in public health (MPH); they were each offered an average
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qvcrjdli fbra
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qbsugn f 'drjrojdjbotItvqqpsif eln bovbrtefvf tpqn f ou-ldpoevddp^isbjojohtlboeli boei prajohlu f I
mentors in the field. Under this section, only their time related to travel for handholding the nurse
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The DPS travelled for 10 days in the field to supervise and monitor mentoring visits and for this a
vehicle was hired at the rate of 2000 INR (35 USD) per day. The visitors to the field (management
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bddpn n pebijpo!boe!qfslejf n t!bsf Idptif eldpotjef qohlu bdu f IRJtqfdjbijlidistMf rriie!cpsl6!ebzt!
bln pod -Id fin bobhf stlbc pvd9!ebzt Ibln pod If bdi Iboelu f Idrjuajdbrinf bn In fn of st !)jo!qbjst*!gps!3!
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teams was 91,08,812 INR (157,048 USD). The total staff costs sum up to 2,05,56,812 (354,428 USD)
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This includes the costs incurred in purchasing laptops for staff, communications, and development
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(26 USD) were incurred by each staff person every month. The printing of case sheets and manuals
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howto manage and monitor the nurse mentor programme in the field which cost in total 128,000
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and supervise the mentors in the field through planning and review meetings, field support and
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and district staff, which form 12% of the total intervention costs (3,118,000 INR or 53,759 USD). The
annual costs include the staff salaries and travel, communication and printing, and events such as
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I1IP-
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L-,
Category. . Subcategory;
'
■
c
<11^
________
Staff costs
i
£
!
I
II
Nurse
mentors
salary
15000
53
1
12
9540000
164483
- -----------------
travel
3000
53
1
12
1908000
32897
salary
30000
8
1
12
2880000
49655
Management
team
District
program
specialist
travel
20000
8
1
12
1920000
33103
District M&E
: specialist
salary
300Q0
8
0.2
12
576000
9931
Technical
Manager
salary
50000
2
0.8
12
960000
16552 80% time costed
z
O
-6
dZ2.
1
Quality
Improvement
specialist
.
14000
2
1
12
336000
M&E
specialist
II!
;;7,7€T||
salary
110811
1
0.7
12
930812
16048
70% time costed
travel
9500
1
1
12
114000
1966
9500 INR for 8 days trip a month; includes travel
accommodation and per diems
salary
55000
1
0.2
12
132000
‘'i
-e; ’ ■
.1
z
o
Clinical
support team
i
Training
coordinator
salary
50000
1
0.5
12
300000
5172
Clinical
consultants
consultancy
2500
8
4
6
480000
8276 4 mandays (2 consultants for 2 days) every two months for
each district
CT
.Z'7 — ,7|
2276 20% time costed
5
e.
travel
5000
8
2
6
480000
>
accommodation and per diems
5793 1400INR for 8 days trip a month; includes travel
zr
□
j
7
travel
8
20% of time costed
—
o
I
o
JZ.
2.
22
8276> 5000 INR includes travel, accommodation and per diems for
one consultant per trip OF two days
€
TntaLStaff
■
■■
Cost analysis of mentoring programme in eight districts of northern Karnataka
, Calory
i
I
£
C
{ Sub category.. U
3
OS
Capital and
|
material costs
K
§
Laptops
50000
11
comunication
1500
11
1
12
Printing
tt gr"''1_
■
550000
9483 50000 INR per laptop for 8 DPSs, 2 managers and QI specialist
198000
3414 1500 INR per person for 8 DPSs, 2 managers and QI specialist
1085000
18707 costs of printing 72000 case sheets and 100 manuals during the
year; actuals considered
i
8
6=
s
Z
o
s'
■
Induction
training for
mentors
Mentor
costs
550000
Trainers
costs
1000
Training for
district staff
•
I
37931
■
lasting 30 days of training costed 550000 INR and includes venue, j
food, hotels, clinical postings, travel, training kits ____________ j
8000
Clinical
refresher for
mentors
2200000
4
2
16
30
1
4
1
240000
128000
4138 the trainers from St Johns were consultants @ Rs 1000 for their
session per day; each day, about 2 trainers were involved apart
from the training coordinator; each training lasted 30 days and we
had 4 batches
4569 Each mentor recieved a clinical refresher during the year.This was
conducted in 3 batches for 3 days each to cover 53 mentors; it
costed 5000 INR per mentor that includes travel, accommodation
and perdiems..
5000
Trainers
I costs
1000
3
3
3
27000
466 1000 INR per session per trainer per day; 3 trainers for each of the
days in 3 batches of refresher training
Clinical
posxings for
. mentors
7000
53
1
1
371000
6397 Each mentors attended 5 days of postings in a year; for each
mentor it costed 7000 iNR that includes the travel, accommodation
and perdiems
Plannning
and review
meetings
2000
8
1
12
192000
3310 2000 INR per month per district (roughly 500 INR for each weekly
meeting)
TqtaTeSit'7
.rnstS ■. * . • L
1
1
265000
i
&
f
2207 The DPSs and M&E specialists from each district were
trained which costed 8000 INR per staff that includes travel,
accommdation and per diems; the training was done in-house.
Mentor
costs
53
§
□
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Cost analysis of mentoring programme in eight districts of northern Karnataka
Sub-cateQOiy:' TJnk ■i Fetceutage . No of
urtits
timeZNoqf >
C
frX
A
I
Total Costs
I£
Contingency
costs @5%
total costs
8
I
Total
Intervention
costs
27103453
467301
Costs per
district
3387932
58413
□
Costs per
mentor
511386
8817
f
Start up costs
3118000
53759
. 23985453
413542
X
£
S’
Annual /
' recurring
Sum of total staff, total capital and total event costs
25812812 445048
1290641
22252
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IntraHealth
INTERNATIONAL
sukshema
Because Health Workers Save Lives.
Improved Maternal, Newborn & Child Health
.BECAUSE OF U6
University
. ^8
qf Manitoba
St John's National Academy of
Health Sciences
l<ar*una tru^t
20 years of Integrated Rural Development
- Media
15503.pdf
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