Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Approaches to Improving
Quality of MNCH Services in
Primary Health Centres
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SUKSHEMA
Facilitator's Manual
Volume: 1
Part A & B
<1MlfclrrW-^
Approaches to Improving
Quality of MNCH Services in
Primary Health Centres
KHPT
Karnataka Health Promotion Trust
I StvTT
cue.
SUKSHEMA Trainer
Manual Volume
Part A & B
Approaches to Improving
Quality of MNCH Services in
Primary Health Centres
Sukshema
Nurse Mentors Tra
SOCHARA
Community Health
Library and Information Centre (CLIC)
Community Health Cell
85/2,1st Main, Maruthi Nagar,
Madiwala, Bengaluru - 560 068.
Tel: 080-25531518
email: clic@sochara.org / chc@sochara.org
www.sochara.org
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
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 and St John's National Academy of
Health Sciences
Year of Printing : 2014
Publisher
: Karnataka Health Promotion Trust
IT Park, 5th Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 044
Karnataka, India
Phone:91-80-40400200
Fax:91-80-40400300
www.khpt.org
This process document is published with the support from the Bill dr Melinda Gates Foundation under
Project Sukshema. The views expressed herein do not necessarily reflect those of the Foundation.
Sukshema Project Volume 1
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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 particularly with reference to pregnant women, mothers and new
borns. To facilitate this, the need for dedicated teams to improve and monitor quality is crucial.
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 sheets by 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.
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.
.
1
Smt. Sowjanya, i.a.s
Mission Director
National Health mission
SrLKS.Vastrad, la s
Commissioner
Dept, of Health & Family welfare
Sri..Kuniar Thvnri, IAS
Principal Secretary,
Dept, of Health & Family welfare
List of Contents
Acknowledgements
04
Abbreviations
05
Glossary of Terminology
08
Methods used for training
12
Introduction
16
Part A-Quality Improvement
19
Session 1 A. Sukshema Project
20
Session 1B. MNCH Situation - An Overview
21
Session 1C. MNCH mentoring intervention
23
Session 2A. Quality
24
Session 2B. Quality Improvement
26
Session 3.
29
A.M.M.A approach for Quality Improvement
Session 4A. MNCH mentor-Skills Attitudes Tools
31
Session 4B. Adult learning principles
32
Session 4C. Mentoring Skills: (Psychological, Interpersonal and
Communicative)
36
Session 4D. Mentoring skills - Cultural considerations
39
Session 5A. Managing a Mentoring Visit - Using A.M.M.A Approach at
facility Level
41
Session 5B. Managing a Mentoring Visit - Using A.M.M.A Approach at
Individual Clinical Level
44
Part B - PHC Systems Strengthening
50
Session 1.
Infection Control
51
Session 2.
Strengthening Referral System
55
Session 3.
Supply Chain Management
58
3
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Acknowledgements
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
project's knowledge management strategy and to Baneen Karachiwala who provided independent observation
and interviews of the first 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.
The funding support for development of this manual was provided by Bill and Melinda Gates Foundation.
The following institutions and individuals have contributed to development of volume 1 of the SUKSHEMA
Facilitator's Manual.
Karnataka Health Promotion Trust (KHPT)
St John's National Academy of Health Sciences (SJNAHS)
University of Manitoba (UoM)
Dr LTroy Cunningham, KHPT
Mrs Janet Bradley, UoM
Dr John Stephen SJNAHS
Ms Maryann Washington, SJNAHS
Dr Sanjiv Lewin SJNAHS
Dr K Karthikeyan, Independent Consultant
Dr Manoharan, Independent Consultant
Dr Savitha Kamalesh, SJNAHS
Ms N Gayathri, SJNAHS
Dr Reynold Washington, KHPT/UoM
Dr Lisa Avery, UoM
Dr B M Ramesh, KHPT/UoM
Mr Arin Kar, KHPT
Mohan H L, KHPT/UoM
Dr Swaroop N, KHPT
Dr Krishnamurthy, KHPT/UoM
Sukshema Project Volume 1
Abbreviations
ABO
Blood groups A, B, 0
CVS
Cardiovascular system
A.M.M.A -
Assessing and diagnosing,
managing, measuring and
advocating
DBF
Direct breast feeding
DDK
Disposable delivery kit
DHO
District health officer
DMPA -
Depot medroxyprogesterone
AMTSL -
Active management of the third
stage of labour
ANC
Antenatal care
ANM
Auxiliary nurse midwife
APH
Antepartum hemorrhage
ASHA
Accredited social health activist
ART
Antiretroviral therapy
AWW
Anganwadi worker
AZT
Zidovudine
BCC
Behaviour change communication
BEmONC -
Basic emergency obstetric and
neonatal care
BM
Breast milk
BMV
Bag and mask ventilation
BPL
Below poverty line
CBO
Community-based organisation
CCT
Controlled cord traction
CEmONC -
Comprehensive emergency
obstetric and neonatal care
acetate
DNS
Dextrose normal saline
DPS
District programme specialist
EBM
Expressed breast milk
ECP
Emergency contraceptive pill
EDD
Expected date of delivery
FEFO
First expired, first out
FHR
Fetal heart rate
FHS
Fetal heart sound
FIFO
First in, first out
FRU
First referral unit
FS
Female sterilisation
Gol
Government of India
H/O
History of
Hb
Haemoglobin
CMC
Community health centre
HBV
Hepatitis B virus
CBMWTF -
Common bio-medical waste
treatment facilities
HCP
Health care providers
CMO
Chief medical officer
Hg
Mercury
COC
Combined oral contraceptive
HBsAg
Hepatitis B surface antigen
CPD
Cephalopelvic disproportion
HCG
Human chorionic gonadotrophin
5
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
HIV
Human immuno deficiency virus
MRP
Manual removal of placenta
HLD
High level disinfection
MTP
Medical termination of pregnancy
HMIS
Health management information
system
MVA
Manual vacuum aspiration
HR
Heart rate
NFHS
National Family Health Survey
H2O
Water
NGO
Non-governmental organisation
IM
Intramuscular
NRHM
National Rural Health Mission
Inj
Injection
NS
Normal saline
IV
Intravenous
NSSK
Navjaat Shishu Suraksha
ICTC
Integrated counselling and testing
centre
IFA
Iron and folic acid (supplements)
NSV
No-scalpel vasectomy
IMNCI
Integrated management of
neonatal and childhood illness
PEP
Post-exposure prophylaxis
PHC
Primary health centre
IUCD
Intrauterine contraceptive device
IUD
Intrauterine deat
PIH
Pregnancy induced hypertension
IUGR
Intrauterine growth retardation
PIP
Project implementation plan
JSY
Janani Suraksha Yojana
PNC
Postnatal check-up
JHFA
Junior health female assistant
POC
Products of conception
KMC
Kangaroo mother care
PPE
Personal protective equipment
LAM
Lactational amenorrhea method
PPH
Postpartum hemorrhage
LBW
Low birth weight
PPTCT
Prevention of parent-to-child
LHV
Lady health visitor
LMP
Last menstrual period
MgSO4
Magnesium sulfate
MM
MNCH mentor
MMR
Maternal mortality ratio
MNCH
Maternal neonatal and child health
MO
Medical officer
P/A
Per abdomen
MoHFW -
Ministry of Health and Family
Welfare
P/S
Per speculum
P/V
Per vaginum
MoWCD -
Ministry of Women and Child
Development
QI
Quality improvement
Multipurpose health worker
RCH
Reproductive and child health
MPHW -
81
Sukshema Project Volume 1
Karyakram
transmission
PPV
Positive pressure ventilation
PRI
Panchayati Raj Institution
PROM
Premature or pre-labour rupture of
membranes
RDK
Rapid diagnostic kit
STI
Sexually transmitted infection
Rh
Rhesus factor
TBA
Traditional birth attendant
RL
Ringer lactate
TT
Tetanus toxoid
RPR
Rapid plasma reagin
UTI
Urinary tract infection
RR
Respiratory rate
VDRL
RTI
Reproductive tract infection
Venereal Disease Research
Laboratory
SBA
Skilled birth attendant
VHND -
Village health and nutrition day
SC
Sub-centre
WBC
White blood cell
SDM
Standard days method
WHO
World Health Organization
SN
Staff nurse
3TC
Lamivudine
Units of measurement
- At the rate of - to measure speed
Kg
- Kilogram - to measure weight
%
- Percent - to compare anything to 100
L
- Litre to measure volume
°C
- Degree Celsius - for temperature
lb
- Pound to measure pressure
mcg
- Microgram to measure weight
cc
Cubic centimetre - to measure volume
cm
- Centimetre - to measure length
mg
- Milligram to measure weight
dl
Decilitre - to measure volume
min
- Minute
ml
- Millilitre to measure volume
gm - Gram - to measure weight
mm
- Millimetre to measure length
hrs
Hours - to measure time
mmHg - Millimetre of mercury to measure BP
IU
International units - to measure dose
secs
- Seconds
U
- Units to measure dose
°F
- Degree Fahrenheit - for temperature
KCal - Kilocalories-to measure energy produced
7
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Glossary of Terminology
Abortion: Termination of pregnancy by the removal or expulsion of a foetus or embryo from the
uterus before 20 weeks of pregnancy
Abscess: A localized collection of pus in any part of the body, with pain and redness.
Amniotic fluid: Fluid present in the uterus during pregnancy which protects the fetal inside
Amnionitis: Infection of the protective lining around the baby (amnion or inner lining);
occurs in PROM
Anaemia: Condition caused by low hemoglobin in blood
ANC: Check up done during pregnancy to determine the condition of the woman and fetus
APGAR: The APGAR score indicates the newborn's well-being. It will be calculated at 1 minute and at
5 minutes after birth. An APGAR score of more than 7 is considered satisfactory. Less than 7
APGAR babies need referral to a higher centre for further management
APH: Bleeding in pregnancy (before delivery)
Asphyxia: Condition in a newborn due to severely deficient supply of oxygen to the body when the
baby is unable to breathe normally
Atonic: Lack of muscle tone; loose or soft
Assisted deliveries: Vaginal delivery when the baby's delivery has to be assisted/helped out by using
forceps or vacuum extraction applied to the baby's head
Blurred vision: Unclear or hazy vision, associated with high blood pressure, weakness
Breech presentation: When the buttocks of the fetus are in the lower area of the uterus
Chorioamnionitis: Infection of the protective lining around the fetus (amnion or inner lining and
chorion or outer lining); occurs in premature rupture of membranes (PROM)
Clammy skin: When the skin is cool, moist, and pale. Sign of emergency such as shock, dehydration
CPD: Size or space of pelvis is narrow and does not allow baby to pass through
CVS: System related to heart and circulatory system
Diastolic blood pressure: Lower reading of blood pressure
Depressed/depression: Sadness, no interest in surroundings; may be seen in postnatal period
DMPA: Injectable contraceptive whose action lasts for 6 months
ECP: To be taken by a woman within 72 hours of unprotected, unplanned sexual contact to
prevent a pregnancy
Sukshema Project Volume 1
Effacement: Thinning of cervix at the time of labour
Endometritis: Infection of uterus; after PROM, repeated per vaginal (PV examination, unsterile
conditions, after abortion/ MTP done in unsterile conditions
Engorgement: Filling up/ swelling
Flank pain: Pain in the side of the abdomen below the ribs
Fluctuant: Moving
Floppy: Poor muscle tone, limp
Fetal: Developing unborn baby inside the uterus
Fetal distress: Condition when the fetus is having some problem inside the uterus; detected by
abnormal heart rate (FHR more than 160/min or less than 120/min), or irregular FHR
Fundal height: Height of the uterus which increases with pregnancy and decreases after delivery;
measuring the upper border of the uterus and comparing with the standard in weeks
of pregnancy gives the approximate duration of pregnancy
Gestation: Pregnancy/the period of development of the fetus in the uterus from conception until birth
Gestational age: Age of an embryo or fetus; calculated in weeks
Gravidity/gravid:The number of times the woman has been pregnant
Icterus: Jaundice or yellowish discolouration of sclera (white part of eye) in adult or skin in newborn
Infant: Baby from one month after birth to one year of age
IUGR: Inadequate/ slow growth of a fetus inside the uterus
Jerky movement: Fast movements which are not controlled and that have no purpose. Seen in fits
KMC: Care given to small baby by placing over the chest of mother/parent to provide extra
warmth to the baby
LAM: Used as a traditional temporary method of contraception, when a woman does not have her
monthly periods due to breast feeding
Latent: Developing or present but not visible
LBW: When the baby weight is below 2500gms (standard weight)
Lump: A localised swelling; may be hard or soft
Lochia: Discharge from the vagina from delivery up to a week
Liquor: Same as amniotic fluid
LMP: First day of last menstrual period a woman had before pregnancy, used to calculate EDD
Madilu kit: This is a postnatal kit given to mothers after delivery under a government scheme for
postnatal care of mother and baby
Mastitis: Infection of breast; seen as pain and redness
Meconium: Yellow or green coloured stools passed by the fetal inside uterus or by newborn at birth
9
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
MRP: Done by removing the placenta by hand in condition of retained placenta
Murmur: An abnormal sound of the heart
MVA: Method of performing MTP where suction is created by a manual pump to remove
contents in uterus
Misoprostol: Drug used to cause contraction of uterus and thereby prevent or treat postpartum
hemorrhage; available as tablets of 200mcg; not given to women with asthma
Magnesium sulfate: An anti-convulsant drug used for prevent!ng/treating eclampsia/severe
pre eclampsia without causing sedation in mother or baby
Monitoring: Observe and check the progress or quality over a period of time
Nasal flaring: An increase in nostril size due to any difficulty in breathing
Newborn: A recently born baby
Obstetric: Related to pregnancy
Obstructed: Blocked; unable to come out
Oedema: Swelling due to accumulation of water
Outcome: End result
Pallor: Lack of colour especially in the face; seen in anaemia and long standing diseases
Parity/Para: Total number of deliveries and abortions a woman has had till present pregnancy
Pelvis: Cavity formed by joining together of the two hip bones and sacrum; contains, protects and
supports the intestines, bladder and internal reproductive organs
Perineum: Area around vagina and the anus in females
PIH: Increased blood pressure (more than 140/90 mmHg) without proteinuria in a woman
after 20 weeks gestation
Preterm: Pregnancy less than 37 completed weeks gestation
Pre-referral management: Activities carried out to stabilise the complicated cases before
referring to a higher centre
Presentation: That part of the fetal lying over the pelvic inlet which would be first to come out at delivery
P/S: Using the speculum to view the vagina and cervix
P/V: Vaginal examination
Prolonged: Long duration/delayed
PROM: Rupture of membranes (bag of waters) before labour has begun; can be before 37 weeks premature or before delivery - term or mature
Puerperal: The period immediately after delivery to 42 days
Purulent: Containing pus
Pustule: A small boil over skin filled with pus; a pimple
Retained: To hold in a particular place; not coming out
ia_
Sukshema Project Volume 1
RPR: A newer blood test to screen routinely for syphilis in pregnant women
RR: Rate of breathing in one minute
Respiratory distress: Condition in which patients are not able to breathe properly and get
enough oxygen
SBA: Person (doctor, nurse, ANM) trained in pregnancy, delivery, postnatal and newborn care
SDM: Used as a traditional temporary method of contraception where a woman tracks the days of her
menstrual cycle and avoids unprotected sexual contact on fertile days of the cycle
Sepsis: Condition where infection from any site spreads throughout the body
Seizures: Convulsions, fits
Spontaneous: Without any effort or natural
Sterilization: A procedure to make free from live bacteria, virus or other microorganisms, used for
cleaning needles and surgical instruments
Stillbirth: Birth of a dead fetus anytime after the completion of 20 weeks of gestation.
Syphilis: A sexually transmitted disease which in pregnancy may cause congenital defects in the fetus
Systolic blood pressure: The upper level of blood pressure
Tender/tenderness: Pain felt if touched
Term: State of pregnancy which has completed 37 weeks
Transverse: Lying across
Traction: Pulling force
Tubectomy: It is a female sterilization procedure where a part of the fallopian tubes is cut.
It is a permanent method of female sterilization
Umbilicus: A scar where an umbilical cord was attached
Unconsciousness: Person not responding to calls, stimulus
Uterine massage: Gently rubbing the uterus after the delivery of placenta to help the
uterus contract and become hard
Uterine tone: Tightness of uterine muscles
Vasectomy: A surgical procedure performed on males in which the vas deferens (male tubes) are cut.
It is a permanent method of male sterilization
VDRL: Blood test done routinely for syphilis in pregnant women; similar to RPR test
Vertex: Normal presentation of the fetus in which the head lies at the opening of the uterus
Voiding: Emptying the urinary bladder
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
VI
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Methods used for Training
Several participatory methods will be used for training. This is necessary since all participants are
adults and thus following the principles of learning, it will be experiential and thus presumably
more permanent.
What is it
Method
Case Scenarios/Case
studies
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Participants study
briefly a situation
that either describes
a problem and then
develops possible steps
to solve the problem
Participants discuss
related issues that arise
from the case scenario
When to use
Other important
points
The situation presented
To encourage
in the case scenarios
participants to apply
is comparable to
j
their knowledge
and skills to similar
one experience by
participants. Details
to problems and
situations that they may in the scenario will
encounter on the job or be just enough to
enable participants to
elsewhere
recommend solutions/ i
discuss related issues or ;
actions
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Generally case scenarios j
are more extensive than
hypothetical situations
and raise more
issues. Give enough
time to facilitate as
much discussion
as possible within
the predetermined
objectives
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Sukshema Project Volume 1
Demonstration
Facilitator demonstrated To improve the skills or
the steps of a procedure competencies
in an artificial
situation to familiarise
participants with it.
Discussion
Facilitators exchange
ideas for the purpose of
reaching a specified set
of objectives
This method follows
the principle - learning
by doing is more
permanent. A major
part of the training
is dependent on
demonstration of how
to do certain procedures
on the mother, new
born or how to
document information
on the case sheets. It
is important that time
is given to participants
to practice the same so
that they are confident
in doing the procedure
especially if it is a new
skill. Checklists could
be used to assist them
to monitor their own
progress.
i
This method could
be most useful if
1
To improve
predetermined
communication skills
objectives are made.
To test progress towards It could allow the
participants to openly
learning objectives
express their opinions
on a subject as well as
listen to the opinions of
others thus facilitating
learning through
exchange of ideas
To increase knowledge
This method is one
of the commonest
methods used in
training.
..
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It is important to ensure
that all participants take
part in the discussion.
This is best done by
dividing the whole lot
into smallergroups.
_________________________________________________________
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Mini lecture/
presentation
Facilitator speaks to a
group from prepared
notes or using slides
To increase knowledge
and to convey
information, facts or
concepts
Mini lectures are an
efficient way to deliver
information. The
biggest disadvantage
of this method is that
communications
is usually one way
- flowing from the
facilitator to the
participants.
The participation of the
participants is limited.
It is used when a new
concept is introduced to
the participants.
Question answer
session / brainstorming
/quiz
Facilitator prepared
questions pertaining
to a topic; then asks
questions in a series to
the participants in order
to reach the predefined
objectives
To increase the
participants
introspections and
internal inquiry
To increase the
participants ability to
collect information
through analysis
This is an efficient
way to encourage
self-learning and
participation. It helps
to generate ideas
quickly and fluidly while
permitting freedom
to express any idea or
thought. It could have a
snowball effect as one
person's thought may
help another person's
thought process and
thus increase learning.
■j
It is important to pay
■
attention to every
response of participants j
as this will encourage
their participation____
Role plays
This is a simulation
technique and involves
participants to imitate
or act out a situation
Sukshema Project Volume 1
It allows participants
to practice and thus
think about situations
even before they
To encourage
encounter such
participants to apply
situations in real life.
their knowledge and
It could be interesting
skills to problems
to participants. It may
like those they may
take time and thus clear
encounter in the real life guidelines must be
To sensitise participants given to participants
to issues that they may of what is expected of
them
be uncomfortable to
address
To increase one's own
awareness of one's
thought processes
videos
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Facilitator uses videos
to help participants
comprehend a concept
/ procedure better
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To provide an
opportunity for
participants to practice
how they would
communicate on the
job to the patients
(preferably a day before
the role play is to be
enacted) and how much
time is allotted for the
role play. It is best if
feedback is taken from
the participants who
enacted as well as from
those who observed
the role play on what
worked well and what
could be improved.
To sensitize participants
on issues / demonstrate
procedures that are best
learnt by seeing and
hearing
It is an efficient way
to get participants to
reflect on concepts
that seem abstract or
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difficult to comprehend I
or to reinforce steps of a ■
proced u re that is vital. 5
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It is important to check j
for sound and need for ?
other equipment such j
as DVD player, speakers, |
etc to be effective
.
It is also important to
be familiar with the
video for it to be used
efficiently.
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Introduction
Materials: LCD, PowerPoints, Flip chart, Marker pens, baseline assessment of knowledge forms,
participants'manual, SBA Handbook, NSSK.
Session time: 2 Hours 10 minutes
Training methods: Ice-breaker, introduction of group members through a game
Session Objectives:
By the end of the session participants will have
Introduced themselves to other participants and trainers
Reviewed course core competencies
Reviewed participant training material, the schedule and logistics for the training
Set ground rules to be followed during the length of the course
Completed the pre-test
Participated in a short exercise to determine previous knowledge about care during
labour/delivery/postnatal and neonatal period
Teaching steps
Introduce
the reason
for the
training
Duration
1. Introduce yourself. Welcome participants. Ask participants to
introduce themselves using either one of the below methods
❖ You would need a ball or a paper made ball. Ask participants
to stand, stretch and form a circle as this is known to increase
learning. Pass the ball to the participant next to you/throw the
ball in any direction. Ask the person who received the ball to
introduce herself mentioning her name, qualifications, place
from where she comes, nursing experience and an interesting
experience she has had in her workand end by finding some
"adjective" to describe herself based on the name, e.g. SwathiSweet/Simple/Silent.Then ask him/her to throw the ball
randomly to another person. The same continues till all have
introduced themselves.
2. Ask them "What are your goals for training?" (Slide 3). Wait for
responses. Affirm their points and highlight that it is important as
mentors that they
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Sukshema Project Volume 1
30 minutes
❖ Are confident in provision of care during delivery, labour,
postnatal and neonatal period - theory and practical
❖
Become familiar with the tools and techniques used for
effective mentoring
❖ Use skills for mentoring based on need on a one to one basis or
as a group
❖ Monitor progress made
3. Inform participants the core competencies expected after the training
(Slide 4). Highlight objectives of the training. Ask participants if they
had any added objectives. Note the same in the flip chart.
Training
logistics
1. Orient them to logistics such a food times, toilet facilities, training
sites, expectations etc with them
2. Explain to participants that "ground rules"are the expectations of
both the participants and facilitators on what they will do to help
the training go smoothly and meet the course objectives (Slide 10).
Reinforce that the ground rules will be used throughout the training.
New rules can be added to the training as needed. Brainstorm
ground rules with participants. Record the responses on a flip chart
or blackboard and post where everyone can see.
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Possible ground rules:
❖ Arrive on time for the beginning of each session and after each
break.
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❖ Keep each session on time.
❖ Switch off mobile phones while in the training room
❖ See each other as equals in the training room.
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❖ Share experience and expertise.
❖ Feel free to ask questions at any time.
❖ Only one person will speak at a time.
❖ Provide everyone the opportunity to contribute to ensure that
the quieter voices are heard.
❖
No sidebar conversations or sub-sessions. Comments will be
made to the whole group.
❖ Provide constructive feedback to each other.
❖
No smoking in the training room
❖ Agree on when to use Hindi or other local language.
❖ Check often to see that everyone comprehends the
information.
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
1
3. Explain the concept of "parking lot" is a way of acknowledging and
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recording discussion themes or ideas that might take too much time I
to fully explore, or are related to, but not critical for the discussion.
These topics are usually important to the participants. Paste a piece
of flipchart paper at the front of the room.Tell participants that this
is the parking lot, where the group will put interesting topics or
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questions that are taking up too much time or are related to but not
critical for the discussion. The topics are written on paper and sit in
the "parking lot" until time is available to discuss them at the end of !
the training, during breaks, or in a later session. Once a "parking lot"
topic has been addressed, it will be crossed off the list.
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Pre-test
4. Distribute the baseline assessment (pre-test) and personal profile
sheets. Instruct participants to circle the single best option or
complete the needed information.
60 minutes
5. Collect the same after 60 minutes and try and evaluate their
performance within an hour of the same. This will give an idea of how
much the participants know about the topics.
Summarize 6. Reinforce that they already know a lot and that the training would
only build on what they know
7. Distribute the training materials: SBA Handbook, NSSK, Hand-outs
and participants manual. Inform them that the materials will serve
as references for the training. Orient them briefly on how to use the
^book_________________________________
Sukshema Project Volume 1
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 1 A: Sukshema Project
Materials: LCD, Power point presentation
Session time: 1 Hour
Training methods: Didactic lecture
Session Objectives:
By the end of the session the participant will be able to:
Explain the goals and objectives of project Sukshema in the context of NRHM
Comprehend the broad gaps identified in the project during planning phase
Describe the interventions (solution levers) implemented as a part of implementation
design
Teaching steps
Introduction
Project goals
1. Ask any participant to read out the objectives of the session
(Slide 6)
2 minutes
2. Explain the goals, objectives of Sukshema project (Slide 7-8)
20 minutes
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Duration
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Project phases
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Summarise
Planning phase
❖ Implementation phase in which the project is presently
in, with special focus of the technical package through
rnentorin9_________ __
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4. Invite participants to seek clarifications
5. Conclude with key messages
Sukshema Project Volume 1
8 minutes
Session 1B: MNCH Situation An Overview
Materials: LCD, Power point presentation, hand-out
Training methods: Didactic lecture + individual exercise + group discussion
Session time: 60 minutes
Session Objectives:
By the end of the session, the participant will be able to:
List the common causes of deaths in mothers and newborns
Identify the timing of the common causes of maternal and neonatal deaths
Describe the urgency needed in attending to these causes of deaths
comprehend the maternal and neonatal health situation in Karnataka state and in the
specific northern districts
Identify the role of a nurse mentor in assisting PHC staff to improve quality of maternal
and neonatal care
Teaching steps
Introduction
Underlying
reasons
1. Ask the participants to read out the objectives of the session
(Slidell).
Duration
2 minutes
2. Brainstorm with participants, "what are common causes of deaths
of mothers and newborns in India?" Note points on the flip chart.
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3. Highlight with power point main causes of death of mothers and
newborns (slide 12-13); Differentiate between direct and indirect
causes of maternal deaths
❖ Direct maternal causes: related to the fact that the mother
is pregnant
❖
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Indirect maternal cause: mother dies due to an accident or
a major injury or sickness not related to her pregnancy
❖ Cause of neonatal death: hypothermia, low birth weight or
born before term (preterm)
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
4. What is the timing of these deaths In mothers and newborns?
Explain to them the timing of these deaths (Slide 14)
.
6 minutes
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❖ more than 70% of deaths among mothers occur in the first
week of which half occur in the first day (day of delivery)
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Delivery
location
Local context
Summarize
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❖ 90% of deaths among newborns occur in the first week of
life of which most occur in the first day of life.
_____________ ____ _____________________________________ ______
5. Ask the participants if they are aware of what are the different
types of deliveries based on the location where it happens and
10 minutes
list it on the board. Now with the help of (Slide 15) explain the
different locations.
6. Explain why we in Sukshema project must act to improve
maternal and newborn health Explain to the participants that
Sukshema project conducted an in-depth situation needs
assessment at all levels of MNCH care and the results of the
assessment showed various gaps. Explain the levels of the gaps,
the objective fd change and the Solution category. (Slide 16)
___________________________________ ___________ _ ________
7. Invite participants to share their comprehending of the session
content and summarize at the end
20 minutes
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Sukshema Project Volume 1
Session 1C: MNCH Mentoring Intervention
Materials: LCD, Power point presentation
Session time: 50 minutes
Training methods: Didactic lecture and discussion using PPT.
Session Objectives:
By the end of the session the Participant will be able to:
Understand the rationale and goals of RMNCHA Mentoring Intervention
Reflect on the broad roles of the mentor in the Nurse mentor intervention
Teaching steps
Introduction
1. Ask one participant to read aloud the objectives of the session
(Slide 18)
Goals of
RMNCHA
Mentoring
2. Revisit the assessment findings regarding the quality of RMNCHA
care in North Karnataka and the various factors influencing the
design of the intervention. (Slide 19-23)
Interventions
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Summarize
______________
_ ______________
Duration
10 minutes
15 minutes
3. Explain the goals and Objectives of the On-Site Mentoring
Intervention (Slide 24)
;
____ ;_________________
4. Explain to the Participants the...various the various stages of the
intervention planned. Specifically, explain the details of the roll
out of field visits soon after the training, the requirements of
20 minutes
mentors in terms of PHC allocation, frequency of visits, duration of
visit, broad activities during the visit, etc. (Slide 25-26).
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5. Ask participants if they have any doubts or clarifications
5 minutes
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 2A: Quality Improvement
Materials: Case study colour markers, chart paper, LCD, power point presentation
Session time: 1 hour
Training methods: Case study Group activity, discussion and PPT.
Session Objectives:
At the end of the session the Participant will be able to understand:
Z
What is Quality Improvement in Northern Karnataka context?
Z
Why is it important to focus on quality improvement?
The focus and approach of QI efforts in Northern Karnataka context.
Introduction
Teaching steps
Duration
1. Review the objectives of the session. (Slide 28)
5 minutes
2. Ask them to go through the Case study (Slide 29) while one
Case study:
volunteer reads aloud the case study.
what and
why, Quality
A district X reported high number of maternal and newborn
Improvement?
deaths during the year 2010-11. The Annual Health Survey data
showed that there was high proportion of home deliveries in
the district during the same year.The district officials prioritized
the following three areas in the annual plans (PIP) for the year
2011-12
❖
Increasing the number of facilities in the district
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❖ Hiring and training of contractual staff for the facilities
❖ Improved transportation
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3. years after the intervention (2013-14), the institutional delivery
rates improve significantly from 40% to 65%; yet the reductions
of deaths were slow and less than what was expected. What could
be the possible reasons why the maternal and newborn deaths in
the district did not reduce as expected?
Sukshema Project Volume 1
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4. Allow the participants to discuss in small groups. Facilitate the
discussion and sharing in a way that all groups are able to share
their understanding of the reasons for deaths. Facilitate thinking
and discussion about different areas pertaining to quality that was
missed out in the district plans. Finally, categorize them all under
the three areas - Provider, Client and Systems. Reinforce that
quality improvement has to address all the three facets to really
make a difference in terms of outcomes (Slide 30).
!
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5. Follow up with the evidence around the Importance of quality;
invite sharing of their understanding about the terms'access'and
'coverage'. Emphasize that quality improvement efforts have to
complement efforts toward improving access and coverage in
order to impact mortality. (Slide 31).
Karnataka
context, QI
strategy and
focus
6. Check with the participants if they know of any other quality
improvement initiatives in the region and country. List them
and facilitate discussion on what facets of quality are addressed
as well as the approach, scope and focus in these initiatives. At
the end, reinforce that each initiative has its own place, there
is no one best model to address quality and we are attempting
to address quality in a very comprehensive way; we have to
acknowledge and appreciate other initiatives but we as nurse
mentors should be convinced why we are addressing quality
under all the three facets, (slide 32)
20 minutes
7. Share the context and focus of mentor in the North Karnataka
context; the use of onsite mentoring with the help of dedicated
nurse mentors as the strategy to improve quality in North
Karnataka context.
8. Emphasize the focus on 5*5 matrix as well as the critical services
during delivery and postpartum period, (slide 33) Finally reinforce
the overall focus of quality improvement efforts, the approach
and tools, (slide 34 - 36)
Summarize
Share the slide on key messages and invite the participants to
read the slide. Check if they have any questions and clarifications
regarding the topic, (slide 37)
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 2B: Quality Improvement
Materials: Scrap paper, materials, sticks and waste bottles, etc.; Fevecol glue, Chart paper strips, cello tape
(1 inch), colour markers, chart paper, LCD, Power point presentation
Session time: 2 Hours 30 minutes
Training methods: Group activity discussion and PPT.
Session Objectives:
At the end of the session the Participant will be able to:
Explain what'Quality Improvement'is and its role in RMNCHA mentoring intervention
at the health facilities.
Explain the advantages of adopting Quality Improvement process.
Enumerate and understand the Quality Improvement Principles.
Z
Understand that Clients and Provider's Rights are critical to improve quality services.
Understand Self-Assessment and teamwork empowers providers.
Z
Understand the benefits of adopting a mentoring approach.
Teaching steps
Duration
1. Ask any participant to read out the objectives of the session with
the help of (Slide 39).
Introduction
2 minutes
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Quality
Improvement
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2. Divide the participants into four groups and inform them that
they will do a group activity for 15 minutes.
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❖ Ask them to take a photo with their mobile of all the scrap
that they have been given.
❖
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They are then given 25 minutes to make a colourful object
/ doll or any other object They can take the equipment
from the facilitator table at any time during the activity.
If a group has already taken any of these items, they can
request the othergroup for it.
❖ Once they have completed the activity ask them to take
...................
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another photo of the finished product
_ ____ _________________________ ,_____________________________
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Sukshema Project Volume 1
40 minutes
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❖
Now ask them to share their results and inform that they
have adopted a very simple basic quality improvement
process. Discuss the process they went through during
this exercise. All participants can now focus on the process
of using simple daily articles that when put together in a
creative manner results in a decorative article. Similarly the
process of mentoring a facility requires the nurse mentor to
help the facility staff understand that improvements can be
made with simple reorganizing their functioning systems
and in-house clinical knowledge, skills and practice.
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3. Ask one of the participants to read the definition of Quality
Improvement from the PPT (Slide 40) and ask them to relate it to
their activity,
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4. Explain with the help of (Slide 41) that QI is a process of
improvement and it is importantly an on-going process that has
scope to go on improving.
5. Explain that there are two terms used in the intervention name
that they need to have a good understanding of:'On-Site'and
'Mentoring'. Ask the participants what they understand by'OnSite'and write it on the board. Now repeat the question for
'mentoring'and do the same. Once they have given their answers,
with the help of (Slide 42); explain the concept and relevance of
to the participants. Explain to the participants (Slide 43) what is a
principle?
____________________________ ______
Quality
Improvement
Principles
6. Inform the participants that there are certain principles of Quality
Improvement and ask them to read it from (Slide 44).
Client's and
Provider's
Rights
7. Inform the participants that they will do a group work.
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10 minutes
❖ Tell them to imagine that they need to go to the PHC for
some medical help (not only RMNCHA related). Each group
will require a group leader and someone who represents
PHC staff. Stick two postings "client rights" and "patient
rights" on the wall so that all can see it.
❖ Ask them to list out on chart paper all the things they
expect from that PHC (7 Minutes).
❖ Then ask the group leader (role play the sick person) and
the other person (role play a facility staff) from each group
to stand up. Request the Sick person leader to hand over
the chart paper to the PHC staff person.
❖
Now the group should work together to list on chart paper
what they as facility staff need to provide the services listed
in the first chart (7 Minutes).
❖ Once they have competed this ask each group leader
to come forward, share their answers and place them
according to the Clients rights (sick person chart) and
Provider Rights (Facility staff chart) posting.
to Improving Quality of
60 minutes
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
8. Remind participants that the exercise reflects the components
that need to be attended to have satisfied Clients and Providers.
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9. Now explain that there are many expectations from any person
who walks into a health facility and to remember it easily they
can be classified into 5 Client's Rights and three Providers" rights
as shown in (Slide 45). Ask the participants if they have any
questions on the different classifications and answer doubts.
SelfAssessment:
(Definition
Process
Benefits)
10. Ask participants what they understand of 'Self-assessment' and
then get a participant to read the definition from (Slide 46).
Explain the process of Self - Assessment using (slide 46).
Teamwork
12. To introduce the concept of benefits of Teamwork divide the
participants into 3 groups and get them to stand in a line about
10 meters away from the tables. Place a set of jigsaw puzzles
(one for each group) and let do a relay with each participant
getting 30 seconds with the jigsaw. Once a round is finished for
allparticipants get them to look at their jigsaw. Now give them
7 minutes as a group todo it together. After 7 minutes ask them
what was different. To solve the problem.
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10 minutes
11. Brainstorm with the participants the benefits of self-Assessment
and then get a participant to read the benefits from (slide 47).
13. Emphasis the principle that when they work together, they
discuss and understand the problem better and have a faster
way to solve their problems. Ask the participants what they
see in (Slide 48). Ask the participants what they think of this
picture in the context of 'Teamwork! Discuss this further with
the participants recalling points from participant manual on
teamwork.
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14. Show (Slide 49) and ask the participants if this is teamwork. Then
explain that each staff doing their own work DOES NOT result in
quality but show (slide 50) it is when all staff considers'all work is
their work'. Explain that like in the 1st picture when staffs help each
other as a team, some may get the direct benefit while other may
not.
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15. Ask a participant to read (Slide 51) on the benefits of Teamwork.
Advantages
of adopting
Quality
Improvement
16. Ask the participants to fist the advantages that they can identify
with the process of QI and list it on the board. Request one
participant to read the PPT (Slide 52) and ask them to identify the
points they have missed.
8 minutes
17. Ask any participant to summarize the advantages.
Summarize
18. Summarize the session by asking participants to highlight the
main points covered in the session and if review the session
objectives to see if all have been met.
Sukshema Project Volume 1
5 minutes ;
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Session 3: A.M.M.A Approach for
Qualityimprovement
Materials: Colour markers, chart paper, LCD, Hand - out - A.M.M.A. approach Table, Power point presentation
Session time: 1 Hour 15 minutes
Training methods: Modular reading, discussion and PPT.
Session Objectives:
By the end of the session the participant will be able to:
Understand and explain the components of A.M.M.A. approach for Quality
Improvement.
Describe the different functional levels at which the A.M.M.A. approach will be
implemented.
Teaching steps
Introduction
1. Ask any participant to read out the objectives of the session
(Slide 54). Let the participants to sit in 4 groups.
A.M.M.A.
approach
2.!. With the help of the PPT (Slide 55) introduce the A.M.M.A.
approach to the participants and ask them if they have any
questions.
____________
Functional
levels of
A.M.M.A.
approach
Duration
2 minutes
.
10 minutes
.
!
3. Ask them to think of the discussion they had on client and
provider rights and try to identify where this approach could be
directed? List their answers on the board / flip chart and then
show them the PPT (Slide 56) on the levels of A.M.M.A. approach.
4. Group activity:
❖
Distribute Hand Out 3.1: How to use the A.M.M.A. approach
at different levels:
60 minutes
❖ Ask participants within their groups to identify any simple
problem at a health facility and discuss how they could
apply the A.M.M.A. approach to handle the problem.
❖ After 15 minutes get a representative of each group to
come up and share. Explain any doubts they may have.
❖ Congratulate them for the good effort and hard work.
Summarize
_____
5. Ask any one to summarize what they understood on the A.M.M.A
approach and another on the level of A.M.M.A. approach. Review
the Session Objectives to see if both objectives were understood.
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Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Table 3.1: The A.M.M.A Approach: Assess and diagnose, Manage, Measure and Advocate
What to do?
ASSESS &
PHC level
Individual
staff level
Assess and diagnose
Assess and diagnose
Assess and
Assess and
diagnose how
diagnose by
Community level
System level
DIAGNOSE
by identifying the
by screening for
quality gaps
gaps in service
danger signs among
linkages are
identifying the
provision and using
women in labour,
currently working,
problems and the
the process of a
during delivery,
identify the gaps
probable cause of j
root cause analysis,
women in the
and probable
those problems
diagnose the
postpartum period
causes for these
that need to be
probable causes of
and neonates
gaps
addressed at a
higher level
those problems
Manage by
Manage by
Manage the issues
identifying
to be addressed
MANAGE
Manage by
solutions to
beginning to identify providing routine
address gaps
potential solutions
care or pre-referral
solutions to the
at district level -
in an action plan
management for
problems and
these have to be
and implement
complications in a
implement the
discussed in fora
them according
rational and timely
solutions identified such as monthly
to the timing and
manner
in a timely and
review meetings.
rational manner
responsibilities
outlined in the
action plan
MEASURE
Measure by
Measure by
Measure by
Measure any
progress
constantly monitor
monitor progress in
constantly
changes due
their progress in
improving patient
reviewing the
to action at the
addressing issues in
care
progress made
higher levels
in strengthening
the action plan
linkages
Advocate by
Advocate to create
Advocate for a
for client &
become champions
a safe and client-
continuum of care
provider rights
for further quality
centred environment for mothers and
to quality
improvement in
for women and
newborns from
improvement
services
different areas
neonates
home to facility
which itself
and back
can increase
ADVOCATE
Advocate
constantly
for quality
accountability at
higher levels.
Sukshema Project Volume 1
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Session 4A: MNCH Mentor - Skills
Attitudes Tools
Materials: Colour markers, chart paper, LCD, Power point presentation
Session time: 1 Hour 15 Minutes
Training methods: Brainstorming and discussion.
Session Objectives:
By the end of the session the Participant will be able to:
Understand the basic skills and attitudes required to be an effective mentor.
Z
Identify the basic skills and attitudes of a mentor at each functional level.
Teaching steps
Introduction
1. Ask any participant to read out the objectives of the session
(Slide 58)
2. Tell the participants to recollect what they learnt about
mentorship and write key points on the board.
Skillsand
Attitude of a
Mentor
Duration
2 minutes
3. Brainstorm with the participants "what are the skills and attitudes
the participants think they will require to be a successful mentor".
Write their answers on the board.
4. If they have not mentioned then ask them if the mentor could be
a FRIEND? Discuss this point with them.
5. Explain to the participants that a mentor (as discussed earlier
in A.M.M.A approach) has to function at four levels and to be
successful at all these levels she may have to use different skills
each time. Ask the participants if they can identify different skills
and with the help of (Slide 59) discuss the skills and attitudes.
70 minutes
6. Ask the participants to turn to their manual; Table 4 - The A.M.M.A
Approach: Assess and diagnose. Manage, Measure, Advocate
for Quality Improvement: Knowledge, skills, tools and resources
for RMNCH+A mentors to implement the A.M.M.A approach
for quality improvement at different levels. Ask the participants
in turn to read the Knowledge, skills, Job aids and Resources
sections for each of the levels and inform them that they need to
get very familiar with this content.
Summarize
7. Ask any one to summarize what they understood on skills and
attitudes of a mentor and ask them if they are ready to learn more
on these skills and attitudes.
3 minutes
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 4B: Adult Learning Principles
Materials: LCD, Power point presentation, Hand-out on Adult learning (Hand-out 4B-2.1 and 4B-2.2)
Session time: 60 minutes
Training methods: Interactive PPT,Group activity, with brainstorming
Session Objectives:
By the end of the session the Participant will be able to:
Understand that children and adults have a different learning style.
Enumerate and explain the basic adult learning principles.
Teaching steps
Introduction
1. Ask any participant to read out the objectives of the session
(Slide 61).
Children and
adults have
a different
learning style
2. Use the story of the "puddle of water" to explain this (slide 62)
❖
Duration
3 minutes
!
Imagine it had rained heavily yesterday. You are walking
on the street and you encounter a large puddle of water...
what will you do....and how will you get across?
❖ The usual responses would be "we would walk around it to
get across"....
❖
Now ask... "Imagine the same scenario... but now imagine
a child with his school back pack walking along the street
and encounters the same puddle of water... what do you
think the child will do?"
■
|
5 minutes
1
❖ The usual response would be "The child will jump into the
water..."
❖ Ask" why the difference in the responses from the adult
and the child?*... brainstorm
❖ Conclude with the key message "There is a difference.... the
way adults learn is different from the way children learn"
Assumptions of
Adult Learning
3. Explain the adult learning principles using the PPT (Slide 63) and
distribute Hand-out 4B.1: About Adult Learning. Ask participants
to read out each point and discuss the information with them.
Ask the participant what they as mentors can do to observe these
guidelines while working with facility staff.
Sukshema Project Volume 1
iJ
4. Group Activity: Let participants sit in their groups. Give them
Handout 4.B-2.
❖ Ask them to discuss in their groups and identify to which of
the assumptions does the statement relate to.
❖ After 5 minutes project (Slide 64) with each statement and
check with participants whether they have understood the
assumptions of Adult learning.
50
minutes
5. Summarise "Treat adult learners with respect. Encourage
discussion and participation. Rather than being the teacher with
all the answers, try and be the facilitator who helps them to learn
for themselves. Both you and they will then have a much more
rewarding and enjoyable teaching-learning session"
Summarize
6. Ask any one to summarize what they understood on adult
sfcfe i k ,h,m*.
2 minutes
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Hand-out 4 B.1: About Adult Learning
Part of being an effective instructor involves understanding how adults learn best. Compared to
children, adults have special needs and requirements as learners. Andragogy (adult learning) is a
theory, pioneered by Malcom Knowles, that holds a set of assumptions about how adults learn.
This section will describe these principles and how they can be applied to improve the effectiveness
of teaching-learning sessions.
1. Adults are internally motivated and self-directed
Adult learners resist learning when they feel others are imposing information, ideas or actions
on them. Your role is to facilitate a staffs'/participants' movement toward more self-directed and
responsible learning as well as to foster the staff's internal motivation to learn.
For learning to occur, adults have to do things. They must get involved and work at tasks
andexercises. They learn by doing and making mistakes and then discovering solutions for
themselves. Adults want to be consulted and listened to. Although trainers need to give direction
at times, this should be the exception rather than the rule.
1. Adults bring life experiences and knowledge to learning experiences
Adults like to be given opportunity to use their existing foundation of knowledge and experiences
gained from life experience and apply it to their new learning experiences.
2. Adults are goal oriented
Adult learners become ready to learn when "they experience a need to learn it.... in order to cope
more satisfy!ngly with real-life tasks or problems" (Knowles, 1980).
3. Adults are relevancy oriented
Adult learners want to know the relevance of what they are learning to what they want to achieve.
Adults prefer to focus on real life, immediate problems rather than on theoretical situations.
Adults see learning as a means to an end, rather than an end in itself.
4. Adults are practical
By interacting with real patients and their real life situations, staffs move from classroom and text
book mode to hands-on problem solving where they can recognize first-hand how their learning
applies to life and the work context.
5. Adult learners like to be respected
Respect can be demonstrated to staff by mentors by showing interest, acknowledging the
experiences that the staff, regard them as a colleague who are equal in life experience and
encouraging expression of ideas, reasoning and feedback at every opportunity.
Sukshema Project Volume 1
Hand-out 4B.2: Six Assumptions of Adult Learning - Group Activity
The six principles of adult learning:
1. Self-directed
2, Bring life experiences
3. Goal oriented
4. Relevancy oriented
>
5. Practical
6. To be respected
Discuss in your groups and identify: to which of the above principles does the below mentioned relate to.
1
Lead the staff toward inquiry before supplying them with too many facts.
2
Provide real case-studies as a basis from which to learn
3
Encourage them to answer questions from their own experience
4
Encourage questioning and discussion
5
Tell adults about the purpose and benefits of the session and about the
process you intend to follow._________________________________
6
Increase the staff's awareness of the need for the knowledge or skill
presented
Encourage use of resources such as libraryjournals, internet and other
department resources.
7
8
Promote active participation by allowing staffs to try things rather than
observe.________________________________________________
9
Encouraging expression of ideas, reasoning and feedback at every
opportunity
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 4C: Mentoring Skills
(Psychological, Interpersonal and Communicative)
Materials: Colour markers, board/flip chart, LCD, Power point presentation
Session time: 2 Hours 50 minutes
Training methods: Group activity, discussion and PPT.
Session Objectives:
At the end of the session the Participant will be able to:
Understand the difference between Teaching and Mentoring
Understand the qualities of an effective mentor.
Understand the importance of rapport building and ways to build rapport with staff
Learn interpersonal communication skills for effective mentoring.
Identify within the mentor characteristics that contribute or can be negative to
effective mentoring
Teaching steps
Introduction
Duration
1. Ask any participant to read out the objectives of the session
(Slide 66)
2. Ask the participants to recollect what they learnt about
mentorship and write key points on the board.
3 minutes
Difference
between a
teacher and a
3. Ask the participa nts if they know what the difference between
a Teacher and a Mentor is. Write their answers on the board and
then with the help of lhe (Slide ST), discuss the differences.
Congratulate them If they were able to g« some point correct.
Importance of
rapport building
4. Inform the participants that to be a good mentor there is a basic
step required. Ask them I they know what it is. If any participant
says'building rapport or making friends with staff congratulate
the person. If not tell them it is'RAPPORT BUILDING'. Ask them to
list the ways they think they can show the facility staff that they
want to be a friend to them. Write their answers on the board.
Then with the help of (Slide 68), explain the ways they can build
rapport.
15 minutes
5. Use PPT (Slide 69) to introduce the essential mentoring skills.
Distribute Hand-out 4G1 and discuss each point in detail for the
participants to have an in-depth understanding.
15 minutes ;
Mentoring
skills- essentials
Sukshema Project Volume 1
10 minutes
_______j
Mentoring skills
6. Group Activity:
❖ Divide all participants into 4 groups: A, B, C, & D
❖ Allot the skill sections mentioned in the participants
manual to each of the groups as follows:
Group 1: Attending, Listening & appropriate use of names
Group 2: Speaking, Responding and Exploring skills
Group 3: Giving feedback, summarizing and Evaluation skills
Group 4: Problem sloving and conflict management
120
minutes
❖ Ask the groups to: Read through the notes on mentoring
skills from the participants manual and discuss within the
groups.Then tell them to develop a skit/role play to depict
the skills allotted to the respective groups. Give them 30-45
minutes to plan this.
❖ Allot 10 minutes to each of the groups - 10 minutes for the
skit and 5 minutes for explaining the elements of the skills
enacted in the skit
7. Brainstorm with the entire participant group what they learnt.
Summarize
8. Ask participants to highlight 3 main learnings from the session.
Review the session objectives with the participants.
,, .
5 minutes
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
.ffl"
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Hand-out 14 C.1; Essentials of Mentoring
Knowledge Base
Your job, as a mentor, is to help the staff be the best they can be, professionally and personally.
You are already an expert in your specialty to help patients. Your core knowledge base is at the
center of you being a great mentor.
Relationship
What you do as a mentor is really all about building a relationship. You are creating a special
relationship where you truly care about the mentee. You are fully present, empathetic and finding
the ways to connect truly with another human being. Think about the core values you share with
A commitment to optimal patient care, to lifelong learning, to basic
this human being
human rights and women's rights,
etc
Observation over time
As a mentor, you begin by paying attention. As a mentor you make careful observations about
whatthementee is doing, saying, feeling...etc.These observations when mentoring staff include
history and physical exam skills, diagnostic ability and how appropriate treatment is chosen. For
each staff there are skills to observe. How does the staff educate the patient? How does the
staff help the new patient feel comfortable? There are many such areas to observe. By these
observations you identify not only the weaknesses but also the strengths of the mentee
and therefore be able to encourage, support, or assist the mentee in their professional
development.
Active listening
Beyond our observations we are ACTIVELY Listening. This means we have shown up and are
paying attention and we listen carefully to what is going on.
Interacting
You are a role model, and how you are with patientsand colleagues will be noticed. You may from
moment to moment be teaching, questioning, learning yourself, coaching, supporting, serving as
a sounding board, encouraging, pointing the way in problem solving, be an advocate...etc. You
may be inspired by what you see and/or you may be the inspiration.
In each interaction your relationship and coNurse Mentor unication skills are crucial. These
interactions also include seeking and receiving feedback on the mentoring process.
Continuity
Relationships occur over time. Growth and development occur over time. There should be
continuity in the mentoring process.
£1
Sukshema Project Volume 1
Session 4D: Mentoring Skills - Cultural
Considerations
Materials: Participants manual
Lesson time: 45 minutes
Training methods: Interactive Powerpoint, group work with brainstorming
Session Objectives:
At the end of the session the participants should be able to:
J
Understand the importance of considering cultural influences on mentoring
Identify from experience certain cultural issues that must be considered when
mentoring staff at PHCs
Teaching steps
Introduction
1 forRationale
cultural
considerations in
mentoring
1. Ask any participant to read out the objectives of the session
(Slide 71)
Duration
2 minutes
2. Brainstorm with participants "why is it important to consider
cultural aspects when mentoring?" After the participants have
given answers, discuss with the help of (Slide 72)
❖ Mentoring is about building relationships
❖ This relationship must be respectful, reciprocal and
responsive if it has to be successful
❖ For this it becomes important to consider cultural aspects
of the mentee that might influence the relationship
3. Reinforce that personal growth could be enhanced when the
mentor and mentee are from different cultural backgrounds
1
■
. 4
20 minutes?
4; Inform participants that if as a mentor they are sensitive to the
cultural values of the society, they would be more accepted.
A simple example it is expected that all women who are married
dress in a particular manner.
5. Individual Activity (Reflection): ask participants to complete this
statement thinking of what a woman can or cannot do during
pregnancy, child birth or child rearing."In my culture, the women
must . After 2 minutes ask volunteers to come out with
statements that they had written. Write the main points in the flip
chart/board for all to see.
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
6. Brainstorm: "what factors do you think can influence how you
||| develop your relationship with the mentee?"
; ’ ■ :J. " 1' 1
Reflection on
challenges
mentors
Illi
wJfSili
. Cemetroma^ntp^e
c
:i
llliiiiii
❖ Might be from a different religion, language hav.
accent, may use different words with entirely different
meaningt
7. Reinforce that being aware of these challenges is the first step
processofdevelopingamutualrelatlonshipof
in the mentoring process
of d(
trust
; i88
I
i
Summarize
9. Summarize with the key messages. Clarify any doubts
Sukshema Project Volume 1
5 minutes
Session 5A: Managing a Mentoring Visit Using A.M.M.A Approach at facility Level
Materials: Colour markers, chart paper, LCD, Power point presentation
Session time: 3 Hours 30 minutes
Training methods: Group activity, discussion and PPT.
Session Objectives:
At the end of the session the participant will be able to:
Get familiar with the schedule and outline of mentors'visits to designated Facilities.
Understand the broad stages in the process of mentoring visits.
Learn and practice the importance of the'Pre - Meeting'.
Z
Learn and practice how to introduce Quality Improvement principles to the facility
staff.
Learn and Practice facilitating Quality Improvement exercise using 'self-Assessment
guides'.
Learn and Practice developing an effective Action plan.
Teaching steps
Introduction
Duration
1. Ask any participant to read out the objectives of the session
(Slide 74)
2. Explain to the participants with the help (Slide 75) the goal of
mentoring at the facility level.
Schedule and
3. Explain to the that the facility visit consists of three steps that
include:
outline of
Mentors'visits to
a. Pre Visit / Meeting Plans (Slide 76)
the designated
u.
Ib. Managing the first and subsequent visit meetings
PHCs
..
r Idpntifvinn
the Site
CJita rn-nrdinafrnr
c.
Identifying the
Co-ordinator
_____
d. Debriefing after completing the visit
2 minutes
8 minutes
•
__________
__ L- —
—_____________ 1
Broad stages in 4. Ask them to list why Pre Meeting preparation is required. Then ask
one of the participants to read from the manual the'Pre Meeting'.
the process of
Explain and check if they have any questions.
mentoring visits
15 minutes
41
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
■■
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
5. Explain to the participants that when they start their visit at the
Introduce
PHC it is important to:
Quality
Improvement to a. Introduce themselves and explain how often they will visit; for
the PHC staff
how long; what they are going to do while in the facility and that
they will interact together and individually with all staff during
the visit
b. Introduce the concept of QI; three QI principles and what is the
impact of good and poor quality within the facility.
c. Lead the facility staff in a self-assessment exercise using certain
tools from which the staff will identify areas that are working well
and areas that they can improve.
d. The mentor will facilitate a process of analysis for cause and
solution for each area to be improved and fix responsibility and
their timelines covering system areas including supply chain
management Infection control and referrals.
e. Identify an active facility staff to measure if the solutions are
implemented as per schedule.
f.
The mentor will work alongside the staff and use every
opportunity to role model and influence clinical practice that is in
accordance with National/UP state guidelines.
6. Inform the participants that they will go through each of these
steps by reading the manual to understand how they will actually
implement these activities.
7. Divide them into four groups and ask them to read from the
beginning of chapter 5 to the end of the Pre-Meeting section.
Check if they have any questions and then ask them to read
subsequent sections as given below stopping to ask a volunteer
in each group to role play that section and members can take
turns to be the mentor. Encourage the rest to observe and provide
positive feedback and areas for improvement:
a. Till the next section till 'Talk about poor quality'.
b. Till the end of'Introduce the A.M.M.A approach'.
c. Till the end of Case sheet review.
d. Till the before 'Facilitate the collective action planning meeting'
e. Till the end of the chapter.
Sukshema Project Volume 1
45 minutes
Quality
Improvement
exercise
8. Explain to them that they now look at how as mentors they could
Assess and Diagnose (A.M.M.A. approach) PHC level gaps using
three self-assessment guides. Ask them to recall about SelfAssessment and then explain for better comprehending.
9. Distribute the'Self-Assessment Guides'and ask the participants
to read the first guide, and then tell them to explain how this will
improve the quality of the services in the PHC. Continue this for
each of the guides till all are completed.
10. Now distribute the Client interview and Record reviews formats
and ask the participants to identify what are the gaps that staff
will be able to identify by using these two guides.
11. Explain what is'root cause analyses'to participants.
90 minutes
12. Group Activity:
❖
Divide them into 3 groups
❖ Ask them to analyse the causes of two or three scenarios in
5 minutes to discuss
❖ Call a representative to present their points in 3 minutes.
❖ Summarize importance of'multiple WHY'to identify the
root cause and other causes.
13. Explain how staff will develop and finalize an Action plan to
address gaps identified.
T
14. Ask them to read subsequent sections as given below stopping
to ask a volunteer in each group to role play that section and
members can take turns to be the mentor. Encourage the
rest to observe and provide positive feedback and areas for
Improvement:
'
■
■
■
■
■
■
■
I
45 minutes i
J
a. Till the before 'Facilitate the collective action planning
meeting'
'ij
■
b. Till the end of the chapter.
Summarize
________ _____________
15. Ask any one to summarize what they understood on applying the
A.M.M.A approach to improve quality at the facility level.
........
..
.
. .1. .
-J j
5 minutes
43
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
<
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 5B: Managing a Mentoring Visit - Using
A.M.M.A Approach at Individual Clinical Level
Material: Chart paper strips, cello tape (1 inch), colour markers, chart paper, LCD, Power point presentation
Session time: 1 hour 50 minutes
Training methods: Group activity, discussion and PPT.
Session Objectives:
At the end of the session the participant will be able to:
Learn the activities for preparing for the visit.
Understand how to identify staff clinical mentoring needs in the facility.
Classify learning objectives into appropriate domains
Select appropriate Teaching-Learning methods for each domain
Understand and practice one to one mentoring.
Z
Understand and practice immediate responsive methods.
Understand and practice delayed reinforcement methods.
Understand and practice distance mentoring
Duration
Teaching steps
Introduction
Preparation and
site visit
1. Ask any participant to read out the objectives of the session from
(slide 78)_______________________________________ __
2. Review with participants how they should prepare for a site visit
❖
Review site details and on subsequent visits review the
clinical topics covered including topics for this visit.
❖ Communicate the purpose, schedule, arrangements and
the monitoring checklist.
..................................................................................... ...
Sources of
On-site
staff clinical
mentoring
needs
2 minutes
,
,
............................................................ ■
.
...
„
............................ ;
Sminutes
I
'
........................... ........................
3. Discuss with the participants 'Mentor Visit Checklist in participant
manual annexure.
4. Brainstorm:"How would you be able to identify what the
mentoring needs of a particular facility would be?"Waitfor
responses.
5. Highlight the sources of individual clinical mentoring i.e. how they
can identify mentoring needs.
❖ Self-Assessment guides
❖ Auditing Case sheets
❖ Observation of staff practices
6. Reinforce that this is'assess" part of a Nurse Mentor approach.
Sukshema Project Volume 1
ft
8 minutes
Specific learning 7. Explain the meaning of specific learning objectives, its importance
and the difference between 'knowledge', 'Practice' and 'Affective'
objectives into
(Slide 79).
domains
8. Interactive discussion: (Hand-out 5 B.1)
10 minutes
❖ Ask the participants to individually read through all the
listed Learning Objectives and share what they think is the
predominate domain.
Domain directed 9. Briefly explain how it is important to select teaching learning
methods based on the domain identified.
teaching
learning (T-L)
❖ Group Activity: (Hand-out 5B-2.2) Ask participants to
method
decide, as a mentor how (what method) they would use for
_______ the mentee._____________________________ _______
10. Explain to the participants that Role Play is a method of one to
One to one
one mentoring.
mentoring
11. Role play: Ask participants to demonstrate, using a role play
format, how they would teach on individual observations or
bedside rounds with a single staff who is new to the facility. The
scenario being "The staff has just completed the initial assessment
of a woman who is presenting with labour". After the role play is
over, get a feedback from the participants who acted it out first
and then from the rest of the participants. Discuss, brainstorm and
summarize the sequence of a One on One Mentoring with the
help of (slide 80):
10 minutes
15 minutes
❖ Clinical Work Place attachment
Immediate
response
methods
Delayed
responsive
methods
❖
Observation and Identification of strengths and weakness
(gaps)
❖
Immediate Responsive Methods
❖ Delayed Reinforcement Methods
12. Briefly introduce the meaning of immediate response methods.
Discuss with theparticipants with the help of Hand-out 5B.3, each
listed T-L method to the suitability of the predominant domain
gap in practice.
15 minutes
13. Explain using (Slide 81) different ways delayed response
mentoring could be done:
❖
Case based discussion and the mini-lecture
❖
Case sheet/ register review discussions
❖
Skills demonstrations
❖
Role plays/ video clips
❖
Workplace aids
10 minutes
45
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Modelling
14. Briefly introduce the meaning of modelling
15. Activity: Invite participants to spend a minute or two individually
thinking back on their own past encounters when as students
or when they were first registered. Request a few to share these
instances with the larger group from the past or present where
role models demonstrated positive or negative influenced..
Encourage a discussion to demonstrate whether the participants
have understood the concept.
Distance
mentoring
16. Briefly introduce the meaning of distance mentoring.
leafor a baby who cried soon after birth, but now refusing to feed.
The staff called the mentor. How could the mentor help?
JB
Post visit
10 minutes
T
I W—s
|
18. Explain the activities that they would need to complete after the
mentoring visit that was planned
❖
Documentation: reinforce there will be specific documents
that they would be expected to complete after each visit for
the project.
❖ Action plan: brainstorm how they could develop the action
plan. Reiterate the principle of adult learning and ensure
that the staff at the PHC gets involved in deciding aspects
that are important for them.
❖
10 minutes
Follow up
❖ Thank you
"
19.
Ask
one ^summarize what they understood on applying the
Summarize
1' A.M any
M.A approach to improve quality at the individual facility staff | 5 minute
, 5 m nutes j
level.___
„...... I
PevT
Sukshema Project Volume 1
Hand-out 5B.1
Individually read through all the below listed Learning Objectives and tick the appropriate box to its right
that indicates the predominate domain.
Discuss the same among your group and be prepared to present the same when asked to the entire
audience.
No.
Learning Objective.
At the end of the session, the student
should be able to
i
To diagnose Iron Deficiency Anemia given
relevant blood laboratory reports.
2
To create, implement and interpret a
survey of a sample of a village population's
to determine their health seeking
behaviour for febrile illnesses._____
3
To measure the weight of a newborn given
an electronic weigh scale
4
To pre-test counsel a pregnant woman at
her first ANC visit requiring an HIV Rapid
Screening test
5
To respect the choice of the couple on a FP
method
6
Identify using a light microscope stained
sputum samples of the following three
bacteria: Mycobacterium TB, Hemophilus
influenza and Pneumococcus._________
To detect by palpation of the abdomen a
splenomegaly more than 2 cm in size
7
8
Knowledge
Practical
Affective
(value/ attitude/
interest)
To sensitize the facility staff on the need
to ensure at all times that the rights of the
clients are always safeguarded while they
are at the PHC.
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
iI
1
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Hand-out 5B.2
Individually read through the same listed Learning Objectives which now have the predominate domain
identified. Using the list of potential T-L methods listed above decide how (what method) you intend to use
for your student to learn as a mentor.
Discuss the same among your group and be prepared to present the same when asked to the entire
audience.
No.
Learning Objective.
At the end of the session, the student should be able
1
To diagnose Iron Deficiency Anemia given relevant
blood laboratory reports.
2
To create, implement and interpret a survey of a
sample of a village population's to determine their
health seeking behaviour for febrile illnesses.
3
To measure the weight of a newborn given an
electronic weigh scale
4
To pre-test counsel a pregnant woman at her first ANC
visit requiring an HIV Rapid Screening test
5
To respect the choice of the couple on a FP method
6
Identify using a light microscope stained
sputum samples of the following three bacteria:
Mycobacterium TB, Hemophilus influenza and
Pneumococcus.___________________________
7
To detect by palpation of the abdomen a
splenomegaly more than 2 cm in size
8
To sensitize the facility staff on the need to ensure
at all times that the rights of the clients are always
safeguarded while they are at the PHC.
t .......
Sukshema Project Volume 1
Knowledge/
Practical/
Affective
T-L Method Plan
Hand-out 5B.3
Match each listed teaching-learning method to the predominant domain gap in practice.
Teaching - Learning Method
Gap identified
Incidental Learning
Growth chart incomplete
Modelling
Partograph incomplete
________
Case based Discussion
Iron and Folic acid tablets not prescribed at
exit from ANC
Chart/Register Review
High drop out for post-test (HIV) counselling
,
;
Mini Lecture-Demonstration
Hypothermic neonates during immediate
newborn period
Role Play/Video clips
____ ,
Workplace aids
Child with features of bloody Diarrhoea not
prescribed ORS
'
_____,
______ __________ __ ______ ;
Weights of Mothers not checked periodically
at ANC visits
Irrational Antibiotic usage in the wards for
community acquired pneumonias CAPs
!
Section A: Approaches to Improving Quality of MNCH Services in Primary Health Centres
1
if
> ata: ia
Section B
PHC Systems Strengthening
1
V
■■i
Sukshema Project Volume 1
■ '
J? -i.iMl'l/.'
l.l'I 1 :
Si ■H
ill
Session 1: Infection Control
Materials: Power Point slides, Posters of Standard Precautions and Bio medical waste segregation/
disposal protocols, Videos of Hand washing and PPE use if available, needle hub cutter and needles,
gloves and SBA manual.
Session time: 60 minutes
Training methods: Lecture, Videos, Group discussion
Session Objectives:
By the end of the session participants will be able to:
Comprehend the need for strengthening infection control practices
List the components of effective infection control practices
Appreciate mentor's role in strengthening infection control practices
Teaching steps
Introduction and
Importance of
infection control
Duration
1. Introduce the topic of the session (Slide 1 -2), and then ask the
participants Highlight the sources of infection, and"Why will
infection be prevented?" Explain how (Slide 3-5)
❖ Infection transmission affects maternal and neonatal
outcomes with specific emphasis on postpartum fever/sepsis
and neonatal sepsis.
❖
Standard precautions have been adopted to reduce risk of
infection and that they are based on principles.
10
minutes
2. Ask the participants about personal experiences of needle-stick
injuries, splashes and spills and anecdotes of health providers
getting infected with HIV/HBV
3. Emphasize that simple practices by the health providers can
prevent a majority of these infections and thus save lives
Components of 4. Show standard precautions poster and ask a participant to list the
components. Stress on the importance of following all components
infection control
listed (Slide 6-8).
L
'ii!
■
5. Hand Hygiene (Slide 9-14): Ask a volunteer to come forward and
show a mock demonstration of hand washing. Ask participants to
comment on the technique.
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51
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
❖ Reinforce areas likely missed. Discuss forms of hand hygiene
and the then conduct a Drill on occasions what hand hygiene
would be required:
o Taking blood pressure-Routine
o inserting a ryles tube - Careful
o Monitoring the fetal heart with a fetoscope/stethoscope -Routine
o Giving oral medication-Carefully
o Assisting / conducting a delivery -Surgical
o
Cleaning a newborn soon after birth-Surgical
o
Before and after giving an injection - Hygienic
o Giving a feed to a newborn - Hygienic
o Stitching the perineal tear/episiotomy -Surgical
o
Suctioning the newborn-Surgical
6. PRE (Slide 15-17): Ask the participants about what PPEare available
in their health centre and how they are routinely used. Explain that
PPE use is determined based on risk (involved in being in contact
with infectious body fluids.The risk is higher when there is greater
chance of large areas of the body getting in contact with these
fluids.
40
minutes
❖ Conduct a drill on determining the PRE that would be
needed for specific procedures:
❖ Starting an IV *- Medium risk (gloves)
❖ Giving an injection - Medium risk (gloves)
❖
Removing a ryle's tube (gloves)
■
❖ Cleaning the baby soon after birth: Medium risk (gloves)
❖
Removing soiled linen - Medium risk (gloves)
❖ Assisting in surgery: high risk (gloves, mask, cap, gowns, eye
wear, foot wear)
❖ Conducting a vaginal examination: medium risk (gloves/
mask optional)
❖ Measuring temperature - low risk (nil)
❖ Assisting in / conducting a delivery: high risk (all)
❖ Checking BP (none)
Sukshema Project Volume 1
❖ Delivering the placenta- high risk (All)
Highlight the "do's and don'ts with regards to PRE.
7. Demonstrate /ask a participant to come forward to show how
gloves; mask will be used and removed.
8. Processing of instruments (Slide 18-24): Discuss the proper
techniques of processing of articles in the hospital, with emphasis
on linen, dressings and instruments.
9; Explain about the
❖ Equipment (autoclave/steam sterilizer) and supplies
(hypochlorite solution, bleach, heavy duty gloves) required
for disinfection of articles and ask about their availability in
the trainees'work places.
❖
Procedures for cleaning and disinfection of surfaces
(including labour room) and handling of spills.
10. Handling of sharps and needles (Slide 25-34): Discuss the do's
and don'ts for handling used needles and other sharps and their
proper disposal. Conduct a drill (Slide 26) on the same. Divide the
participants into four groups and ask them to answer on their note
books "true or fa Ise" as and when the statement is projected
❖ Sharp and needles can be kept with other biological waste
-False
❖ Use a needle cutter or burner can be used to dispose
needles-true
❖ It is safe to reuse disposable needles -False
❖ Sharps/needles can be safely discarded in a card board
box -False
❖ Sharps are best destroyed by incineration -True
❖
Empty sharps containers when full -False (3/4th full)
❖
Passing sharps to another person during suturing can help
prevent sharp injuries - False(greater risk of needle stick
injury.)
❖ Only needles that are used for the HIV infected must be
destroyed carefully -False (we do not know always who has
HIV and who does not have)
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
• •;
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
11. Ask a volunteer to demonstrate the use of a needle hub cutter if
available.
12. Maintain a dean environment (Slide 34-43): Discuss how
surfaces, equipment can be cleaned; preparation of disinfectant,
management of linen and spills on floor.
13. Waste management (Slide 44-61): Provide an overview of the
different categories of waste that are generated in a health centre,
using appropriate pictures.
❖ Emphasize the significance of segregation of wastes at the
source to prevent improper handling and further infection
transmission
■
14. Show pictures of colour-coded bins and asks participants about
their availability in their health centres (inform them the colour
codes might be different compared to what is shown in the picture.
It is important they follow the colour codes according to their
State). Conduct a drill to check the practice of the trainees on
segregation of waste, if time is available
15. Briefly discuss about how the different categories of wastes are
disposed of in the trainees'health centres and reinforce correct
practices._____________
._______________________
16. Discuss the role of a nurse mentor for infection control practices
strengthening in the facility (Slide 62)
Mentor's role in
strengthening
infection control •
practices in the
facility
Assess and diagnose the problems related to infection control
practices
❖ use of self-assessment tools to diagnose issues
❖
•
identify solutions and develop action plan
(M) Manage the problem
❖ sensitization/ onsite orientation on setting up effective
infection control practices
❖ Set up regular meetings to discuss root causes and ways to
solve issues related to infection control practices
•
5 minutes
(M) Measure
❖ Follow up on action plan
❖ Audit infection control practices
Advocate
❖ Champion for the cause
❖
Summarize
Strive for constant refinement
❖ Leverage support from higher level systems for better
_______ infection control practices_________________________
17. Summarise the components of infection control.
18. Clarify any doubts, highlight key points (Slide 63-64) and suggest
the SBA manual and the mentor's manual as a reference.
Sukshema Project Volume 1
5 minutes
Session 2: Strengthening Referral System
Materials: Power-point slides, participant manual, Hand-outs, Referral form
Session time: 1 Hour
Training methods: Lecture, Group discussion, Review of Referral form and register
Session Objectives: by the end of the session participants will be able to:
Comprehend the need for strengthening referral systems
List the components of effective referral system
Z
Appreciate mentor's role in strengthening the referral systems
Teaching steps
Rationale for
referral systems
strengthening
Duration
1. Introduce the session and objectives (Slide 1 -2)
2. Ask them to go through the Case study (Slide 3) while one
volunteer participant reads aloud the case study
❖
Kala is 20 years old, primi, delivers a live female baby
weighing 2.2 kgs. Post-delivery, she bleeds continuously. The
staff nurse detects low BP and high rising pulse. She gets
nervous and quickly asks the family members to take the
woman to the taluka hospital. In an hour, the woman is taken
to the hospital. The hospital staff do not admit the woman
saying that they do not have blood transfusion facility and so
they refer to a private facility.
5 minutes
3. Elicit responses from the participants to the questions given under
the case study (Slide 4):
❖
If you were the staff nurse at the 24/7 PHC, how would you
have done things differently?
❖
If you detect a complication, what is the first thing that you
have to do?
15
minutes
❖ Whenever you refer any complication, what do you want to
ensure?
❖ What is your major learning from this experience?
❖
How do you want to be prepared to better handle these
situations?
❖ As a mentor, how would you like to support the staff nurse in
this regard?
55
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
I
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
4. Highlight the relevance of establishing a referral system in the
facilities (Slide 5-7):
❖
Continuum of MNCH care
❖
Leading causes of deaths / time of deaths
❖
Introduce the 3 delays framework and explain how timely
identification of complications-common cause of maternal
and neonatal death and referral to higher health facilities
saves lives of mothers and newborns
5. Ask participants to share personal or anecdotal examples where
timely referral resulted in positive outcomes or delays resulted in
adverse outcomes
Components of 6. List and discuss components of referral chain (Slide 8-9)
effective referral • Map MNCH service providers
system
❖ in the PHC area that are the source of referrals
*
Establish a referral directory
❖ Of the referral centers that PHCs have to link up with for
emergency care. Display the contact details.
❖
Update the status of referral centers regularly
Formalize the communication
❖ through frequent interactions and regular coordination
meetings
❖ Call up before you refer to find out availability of beds,
services and supplies
•
Handle emergencies skillfully
20
minutes i
■
❖ Emergency preparedness, complication identification and
pre-referral management
❖
•
Use of case sheets, job-aid and protocol
Document accurately and comprehensively
❖ Case sheets, Referral sheets and register
❖
•
Keep track of logistics and supplies
Follow up on all referrals
❖ Continued follow up to know the final outcome
❖
Keep track of referrals back to the community
❖ Appraise telephonically the front line workers of the cases
discharged from the facility
Sukshema Project Volume 1
Mentor's role in I 7. Explain how the mentor can use the A.M.M.A approach in
strengthening the referral systems in the health facility (Slide 8 -11)
strengthening
referral systems
(A) Assess and diagnose the problems related to referral systems
.
. ..
a. use of self-assessment tools to diagnose issues
sifllHi
b. identify solutions and develop action plan
(M) Manage the problem
•
.
■
.
..
a. sensitization/ onsite orientation on setting up effective
referral system
'■
■
ill
-I
■
■
b. Set up referral directory/ pre-referral management using case
sheets/follow up
■
*
.... .
■
■
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:
’
(M)Measure
15
minutes
if;;
a. Follow up on action plan
b. Audit complication case sheets and referral registers
•
(A) Advocate
a. Championing for the cause
■
Summarize
b.
strive for constant refinement
, c.
____
______________
________
Leverage
support from higher
level systems
8. Review the objectives once again and invite any questions/
clarifications
5 minutes
57
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
i
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Session 3: Supply chain management
Materials: Powerpoint slides, participant manual, case study
Session time: 60 minutes
Training methods: Lecture, Group discussion, case study review
Session Objectives:
By the end of the session participants will be able to:
J
Comprehend the need for strengthening supply chain systems
List the components of effective supply chain system
Appreciate Mentor's role in strengthening the supply chain systems
Teaching steps
Introduction
Case study
1. Review with participants what they mean by supply chain. Ask
them "what are some examples of supplies they come across
daily". Review the objectives of the session. (Slide 1-2).
Duration
5 minutes
2. Ask them to go through the Case study (Slide 3) while one
volunteer participant reads aloud the case study
❖ On the night of 1 st of August 2012 at 8:00 pm, Belagola
PHC receives a woman with history of labor pain. The staff
nurse on duty during the initial assessment finds out high
BP (150/100 mm of Hg) and proteinurea (2+). She decides
to refer the woman to an higher facility and attempts
the pre-referral management. She runs to the pharmacy
and finds out that Inj. Hydralazine is not found. Later she
remembers pharmacist mentioning that Hydralazine has
been in nil stock since a week. She panics and now tries to
find Tab. Nifedepine which is an alternative. She does find
few boxes of Nifedepine, but discovers that the entire batch
had expired almost two months ago. By now, the woman's
BP shoots further up and develops convulsions. The staff
nurse quickly administers 10 gm of Inj Magnesium Sulfate
and refers urgently to the higher facility.
1
15 minutes J
3. Elicit responses from the participants to the questions given
under the case study (Slide 4):
❖
Did the woman receive good quality service in this PHC?
■
❖ What could have contributed to nil stock situation of Inj.
Hydralazine?
£1_______
Sukshema Project Volume 1
❖ How could we have prevented this?
t
❖ What contributed to expiry date situation of Tab.
Nifedipine?
❖
How does a staff nurse get prepared to avoid getting into
this situation?
❖
How do you think this instance will impact on the mindsets
of family / community?
4. Highlight the relevance of maintaining supplies in the PHC at all
times (Slide 5 - 6).
Supply chain
management
components
5. List an discuss the components of supply chain management
components (Slide 7-17)
Mentor's role in
strengthening
supply chain
7. Explain how the mentor can use the A.M.M.A approach in
strengthening the supply chain in the health facility (Slide 18-19)
6. Have an open discussion with them to understand what they are
practicing in the setting they have come from. Reaffirm them for
their contribution. Clarify any wrong practices.
•
20 minutes
(A) Assess and diagnose the problems related to supplies
a. use of self-assessment tools to diagnose issues
b. identify solutions and develop action plan
•
(M) Manage the problem by implementing the action plan
a. sensitization/ onsite orientation on setting up effective
supply system
b. Clarify roles
c. Share essential drug list/ use of case sheets / checking stocks
regularly / indenting timely to avoid stock out
15 minutes j
(M) Measure
a.
Follow up on action plan
b. Audit complication case sheets, assess stocks and registers
(M) Advocate
Summarize
8.
a.
Championing for the cause
b.
strive for constant refinement
c.
Leverage support from higher level systems
Review the objectives once again and invite any questions/
clarifications
5 minutes
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Section B: Approaches to Improving Quality of MNCH Services in Primary Health Centres
Workshop Evaluation
Nurse Mentor Training Program
Session Feedback From
Name of Session:
Date:
1. What did you find to be most helpful in the session?
2. What did you find to be least helpful in this session?
3. How could we improve the session?
4. Please rate the following
1
2
3
3
I
1
|
2z_____
2
2
,|
~
1
|
2
Effectiveness of facilitator
I__
Training room/area
Materials
Content
f >
'
2
Exercises and activity
I Session overall
Comments:
Sukshema Project Volume 1
Excellent
Average
Poor
J
3
3
|
4
4
4
|
5
5
,
5
3
4
5
5
3
4
______ 2______J
5
1
i
________
sukshema
Improved Maternal, Newborn & Child Health
Global Public Health
- ------ --------- o----------------- University of Manitoba
University
A'l
• •••
t
A™
of Manitoba
r ^BECAVSEOfME
IntraHealth
INTERNATIONAL
Because Health Workers Save Lives.
St John's National Academy of
Health Sciences
Q3J1L»
)<aruna tru^t
20 years of Integrated Rural Development
- Media
15497.pdf
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