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  • Concept and objectives of supervision

    Content

    Concept of Supervision

    • Supervision is a systematic, ongoing process for increasing the efficiency of health personnel by developing their knowledge, perfecting their skills, improving their attitudes towards their work and increasing their motivation.
    • It is one of the most important management functions in an organisation.
    • Supervision is also defined as an act of a superior person overseeing the work of the personnel working under him or her. This overseeing means directing, investigating, guiding, helping and advising the subordinates in their performance with the purpose of achieving the established objectives.
    • Therefore, it is an extension of training which provides constant observation, monitoring, evaluation and guidance to workers, with the aim of enabling them to perform their activities effectively and efficiently while maintaining the required standards.

     

    Basic Tenets of a Good Supportive Supervisory Process

    • Supervision is carried out in direct contact with health personnel.
    • It is a two-way communication between supervisors and those being supervised.
    • Supervisors are always accountable for the performance of the subordinates under her/his span of control.
    • It should not be a fault-finding exercise but a collaborative effort to identify problems and find solutions. Supervisors are to help the workers improve, develop and reinforce knowledge and skills according to their individual learning needs.
    • Supportive supervision is provided to health personnel at all levels since they need ongoing support for solving problems and to overcome difficulties.
    • Health personnel also need constructive feedback on their performance and continuous encouragement in their work.
    • Supportive supervision assists workers to perform in the best possible way to yield the best results in terms of realisation of the organisational goals.

    Supportive supervision ensures smooth implementation and continuous programme improvement.

     

    Objectives of Supervision

    • To ensure equitable provision of high-quality healthcare services to all sections of society.
    • To build capacity of the health staff to implement programme procedures correctly.
    • To increase the involvement and commitment of staff at different levels, and to help staff develop their highest potential.
    • To plan services cooperatively and to develop coordination to avoid overlapping.
    • To develop standards of service and methods of evaluation of personnel and services.
    • To assist in problem-solving of the matters concerning personnel, administrative and operational services.
    • To provide timely and actionable feedback.
    • To assess human resources and their training needs.
    • To ensure logistic management as per guidelines.
    • To ensure accurate and valid data recording and reporting in Nikshay and other recording systems.
    • To interpret policies, objectives and needs of the organisation and to suggest ways and means to improve them.

     

    Resources

     

    Assessment

     

    Question​

    Answer 1​

    Answer 2​

    Answer 3​

    Answer 4​

    Correct answer​

    Correct explanation​

    Page id​

    Part of Pre-test​

    Part of Post-test​

    Which of the following are the basic principles of supervision?

    It is an ongoing process.

    It involves a co-ownership between supervisors and those supervised.

    It is a fault-finding exercise designed to point out the weaknesses in healthcare personnel.

    Options 1 and 2

    4

    Supervision is an ongoing, two-way communication between supervisors and those being supervised. It should not be a fault-finding exercise but a collaborative effort to identify problems and find solutions.

    ​

    		 Yes yes

     

     

  • Supervision by STS

    Content

    The Senior Treatment Supervisor (STS) is a part of the Tuberculosis Unit (TU) team at the sub-district level in the National TB Elimination Programme (NTEP).

    The STS is responsible for supervising the treatment of the patients and works closely with treatment supporters and Primary Health Care system.

    The objective of these supervisory visits is to supervise patients' treatment and to monitor the programme at the TU level. They also support the treatment supporters to carry out their role efficiently and troubleshoot the issue that they might face.

    The visits by STS are conducted on a systematic basis and the protocol to be followed during these visits is shown in the figure below.

     

    Figure: Supervisory Protocols for the STS

     

    Supervisory Checklist for the STS

    A supervisory checklists can be used by the STS to make sure that s/he does not miss any aspect during the visit. In summary, the STS must supervise the following:

    1. Facility assessment:
    • Anti-TB drugs: Assess for storage conditions (including if First-Expired, First-Out (FEFO) is followed), stock availability and stock-outs.
    • Infrastructure: Presence and condition of physical spaces (including cleanliness) for patient consultation and waiting areas, availability of functional X-ray units (in case of X-ray centres) and weighing scales.
    • Supplies: Assess the quantity of supplies such as sputum containers, forms, and treatment cards.
    1. Case detection and diagnosis: Check if all suspects identified were referred for diagnosis, check referral in Nikshay and specimen processed, check for any losses, check if all specimen collected reached laboratory and examined. Check if all diagnosed are tacked correctly.

     

    1. Treatment: This includes monitoring for:
    • Early treatment initiation, entry in Nikshay (Notification), and allocation of treatment supporter. 
    • Appropriate medicine dosage by weight and type.
    • Alternative resources mobilised for treatment observation.
    • DOT for every dose in the Intensive Phase (IP) of treatment.
    • Universal Drug Susceptibility Testing  
    • Prompt follow up sputum examinations 
    • Acceptability of the treatment supporter to the patient
    • Prompt treatment tectorial efforts for interrupting patients

     

    1. Recording and Reporting: This includes:
    • Ensuring all patients are correctly registered in Nikshay 
    • Proper updation of treatment schedules and doses, including retrival actions in Nikshay by the treatment supporter
    • All treatment supporters are given Nikshay credentials, their Direct Benefit Transfer (DBT) entered in the Nikshay properly
    • DBT of the patients correctly recorded in the nikshay portal
    • DBT of the private providers are recorded correctly in the Nikshay portal

     

         5. Patient interviews: The STS should check the following:

    • TB knowledge: If the patient knows about TB, its symptoms, drugs prescribed, duration of treatment, consequences of irregular/ incomplete treatment, frequency and importance of follow up tests, and importance of examining symptomatic close contacts.
    • Monitoring: If they are receiving DOTS as prescribed, if the Peripheral Health Worker (PHW) knows their home, frequency of home visits during IP/ Continuation Phase (CP)/ missed doses, and if help from family members/ others was ever enlisted.

         6. Supportive supervision with on job capacity building:

    • The STS is expected to build the capacity of treatment supporter during the field visit. Build their capacity by 
      • Demonstrating Nikshay portal entry 
      • Imparting skills on the patient support system (guiding, counselling, contact tracing, treatment retrieval, Adverse Drug Reaction management, DBT and other social schemes etc)

     

    Resources

     

    Assessment

    Question​

    Answer 1​

    Answer 2​

    Answer 3​

    Answer 4​

    Correct answer​

    Correct explanation​

    Page id​

    Part of Pre-test​

    Part of Post-test​

    How often should an STS visit a PHI in their area?

    Once a month

    Twice a month

    Every quarter

    Every day

    3

    Senior Treatment Supervisors (STS) should cover all PHIs/ treatment observation centres every quarter.

    		   Yes Yes

    The STS can involve themselves in role plays to communicate key health messages.

    TRUE

    FALSE

     

     

    1

    Senior treatment supervisors can involve themselves in role plays with MPWs/ DOTS providers to communicate key health messages.

     

    Yes

    Yes

     

  • Role of STS at a DMC

    Content

    At a DMC, the STS primarily ensures that 

    1. All patient services from enrolment to outcomes for a TB patient are completed optimally. This is done by monitoring information submitted by the DMC such as referral for testing, no of people tested, no of people diagnosed with TB, initiated on treatment. 

    2. All the patients started on treatment are tested promptly using the appropriate follow-up testing schedule( i.e. at the end of IP and CP). 

    3. Maintain profile of the DMC in the Nikshay such as tagging the PHI as DMC, name of contact person and other particulars

    4. Ensure data quality in the various records, both in physical and electronic records. This includes patient data, referral data and testing data.

  • Supervisory checklist at TU level

    Content

    At the Tuberculosis Unit (TU), the presiding supervisory team uses a standardized checklist mandated by the National TB Elimination Programme (NTEP) during their periodic supervisory visits. The report and copies of the checklist may be shared with appropriate authorities within 1 week of completing the supervisory visit.

    These appropriate authorities include the Central TB Division, Ministry of Health and Family Welfare (MoHFW) and respective district and state authorities, who will in turn initiate remedial measures in a timely and appropriate manner.

    The TB Unit/ Designated Microscopy Centre (DMC)/ Peripheral Health Institute (PHI) Health Facility Checklist is shown in the table below.

    Table: Checklist for Supportive Supervisory and Monitoring Visits under NTEP for TB Unit/ DMC/ PHI - Health Facilities

    Name of the TB Unit/ DMC/ PHI:

    Name of District and State:

    Date of Visit:

    Facilities Visited:
    1 Interact with the Medical Officer (MO) to know their involvement in TB case detection. Look at the Outpatient Department (OPD) register to know what % of adult OPD patients are being referred for sputum microscopy. %
    2 % of MOs trained in NTEP on the management of TB cases. (Assess their knowledge on NTEP, Cartridge-based Nucleic Acid Amplification Test (CBNAAT)/ Truenat services, newer Drug-resistant TB (DR-TB) drug regimen, Nikshay Poshan Yojana, etc.)   %
    3 Is the MO regularly undertaking supervisory visits? (Observe the field visits undertaken by the MOs in the supervisory register) Y/N
    4 Information, Education and Communication (IEC)/ Advocacy, Communication and Social Mobilisation (ACSM) activities undertaken by the MO? (Enquire about the ACSM activities like school health programs, village health sanitation and nutrition meetings, community orientation meetings etc. undertaken, and observe for visible IEC wallpapers/ banners etc. in the PHI and its vicinity) Adequate/ Not adequate
    Designated Microscopy Centres
    5 Are the sputum samples being tested as soon as they are received? (Observe for the presence of Laboratory Technician (LT) availability on all days, availability of Binocular/ Fluorescence Microscope(BM/ FM), the average time taken from the time of sample receipt to smear result reported (lab turnaround time) Y/N
    6 Is the LT trained in performing smear microscopy? (Assess their knowledge of the smear microscopy procedure) Y/N
    7 Lab turnaround time - Average time taken from the time of sample receipt to smear result reported (in days)
    8 Are chest symptomatics offered chest X-ray? (either directly or linked with an X-ray centre - % of chest symptomatic offered) Y/N
    9 Is there provision for collection and transport of samples of key populations/ TB notified patients to the CBNAAT/ Truenat lab available? (Review the transport mechanism available) Y/N
    10 Are presumptive TB patients offered HIV testing? (% offered HIV testing – Check in the Lab register) Y/N
    11 Are there adequate supplies of reagents, slides and other consumables for the next month? (Check for the reagents availability, quantity and labelling of expiry date) Y/N
    12 Does the DMC have continuous water and electricity supply? Y/N
    Treatment Services
    13 Are all diagnosed patients notified in the TB notification register? (Cross check the lab register with the TB notification register and look for the Nikshay id) Y/N
    14 Are all notified patients initiated on treatment? (Including those referred/ transferred out) Y/N
    15 Average time taken for treatment initiation from the time of diagnosis? (Calculate for 30 recent patients including those transferred/ referred out) (in days)
    16 Are TB-notified patients offered HIV testing? (% offered HIV testing – Check in the TB notification register/ Nikshay) Y/N
    17 Are TB-notified patients offered Diabetes Mellitus (DM) testing? (% offered DM testing – Check in the TB notification register/ Nikshay) Y/N
    18 Are TB notified patients screened for Tobacco usage? (% screened for tobacco usage – Check in the TB notification register/ Nikshay) Y/N
    19 Nikshay Poshan Yojana - % of TB notified patients who have been offered Nikshay Poshan Yojana (Patients currently in the PHI for the last 1 year may be taken) %
    Treatment Supporters
    20 Does the treatment supporter require training/ sensitisation? (Assess knowledge in Directly Observed Therapy Short-course (DOTS), treatment card maintenance, patient services, Nikshay Poshan Yojana) Y/N
    21 Is the treatment supporter monitoring daily drug intake by the patient (either directly/ digital adherence)? (Check the treatment card – cross-match with drugs issued and pills taken) Y/N
    22 % of honorarium received? (Ask whether the treatment supporter has received the honorarium for all eligible patients who have completed their treatment) %
    Field Supervisors (Senior Treatment Supervisor (STS)/ TB Health Visitor (TBHV)/ General Health System (GHS) Staff)
    23 Is an individual vehicle available for field visits? Y/N
    24 % of TB notified patients currently on treatment in whom home visits have been undertaken? (Cross check with the treatment card/ Lat. long. coordinates captured in Nikshay/ patient interaction) %
    25 % of TB notified patients currently on treatment linked to a treatment supporter? %
    26 % of children identified in whom chemoprophylaxis with Isoniazid has been given? %
    27 Has the staff received the salary & POL to date? If No, record the issues therein? Y/N
    28 % of private notified patients in whom public health actions have been provided? %
    Senior TB Lab Supervisors (STLS)/ GHS staff
    29 Is the STLS reviewing slides preserved by the LT during the On-site Evaluation (OSE)? Y/N
    30 Are the reports of TU-OSE done by the STLS available in the DMC? (Check for the copy of at least the last month) Y/N
    31 Is corrective action as suggested in the TU-OSE report being carried out by the DMC? (Current status may be used as an assessment of the corrective actions taken) Y/N
    32 Assess 2 slides to check if they match with the OSE report? Matches/ Does Not match
    Drug Store
    33 Is the stock register maintained as per guidelines? Y/N
    34 Are the drug stocks adequate as per the suggested norms? Adequate/ inadequate
    35 Are the stocks matching with Nikshay Aushadhi? Y/N
    36 Is bio-medical waste from the DMC disposed of as per Bio-Medical Waste (management and handling) Rules 2016  
    Comments and Recommendations: (Use an extra sheet, if required)
    1    
    2    
    3    
    4    
    Name and signature of the visiting team members with their designation:

     

    Resources

     

    Assessment

     

    Question​

    Answer 1​

    Answer 2​

    Answer 3​

    Answer 4​

    Correct answer​

    Correct explanation​

    Page id​

    Part of Pre-test​

    Part of Post-test​

    The TB Unit/ Designated Microscopy Centre (DMC)/ Peripheral Health Institute (PHI) Health Facility Checklist covers which of the following thematic areas?

    Advocacy, Communication and Social Mobilisation

    Direct Benefit Transfer

    Stock availability

    All of the above

    4

    The TU level checklist covers ACSM, DBT and stock availability as well as other parameters at the TU level.

    ​

    		 Yes Yes

     

     

     

  • Supervision by MO-TC at TU level

    Content

    The Medical Officer-TB Control (MO-TC) at the TB Unit (TU) has the overall responsibility for the management of the National TB Elimination Programme (NTEP) at the sub-district level and is assisted by the Senior Treatment Supervisor (STS) and the Senior TB Lab Supervisor (STLS).

    The MO-TC is responsible for supervising the work of the TU and of the STS and STLS, in addition to his/her other responsibilities. These visits are conducted on a systematic basis and the protocol to be followed during these visits is shown in the figure below.

    Figure: Supervisory Protocols for the MO-TC 

    Abbr: NGO: Non-government Organisation

     

    Checklist for the MO-TC at the TU

     

    • Ensure that all private-sector patients are captured in the Nikshay portal by notification and that public health actions are taken on all TB patients notified irrespective of private or public.
    • Ensure that the treatment supporters are adequately trained and updated on the latest guidelines. 
    • Ensure that the treatment supporters and the private providers are allotted proper Nikshay credentials and that the troubleshooting mechanism works promptly.
    • Organise sputum smear examination at all DMCs of the sub-district.
    • Ensure proper treatment categorisation of diagnosed patients by supporting other MOs of the sub-district. 
    • Ensure that Directly Observed Treatment (DOT) is taking place as per guidelines at all treatment observation centres.
    • Ensure a regular supply of drugs and other logistics and ensure their uninterrupted availability in all Peripheral Health Institutes (PHIs) in the sub-district.
    • Ensure periodic updating of treatment by the corresponding treatment provider/ supporter.
    • Ensure that all the reports pertaining to programme management from the TU are submitted to the district on time.
    • Ensure that all beneficiaries are given Direct Benefit Transfer (DBT) as per the guidelines.
    • Ensure that the External Quality Assurance (EQA) of the DMCs under the TU is properly conducted every month.
    • Ensure that the STS and the STLS do proper field visits, carry out the supervision and monitoring as per the checklist and give feedback on a periodical basis.

     

    Resources 

     

     

    Assessment 

    Question​ 

    Answer 1​ 

    Answer 2​ 

    Answer 3​ 

    Answer 4​ 

    Correct answer​ 

    Correct explanation​ 

    Page id​ 

    Part of Pre-test​ 

    Part of Post-test​ 

    How often should an MO-TC visit a DMC in their area? 

    Every month 

    Twice a month 

    Every quarter 

    Every day 

    1 

    The Medical Officer-TB Control (MO-TC) should cover all Designated Microscopy Centres (DMCs) every month.

     

    Yes

    Yes

  • Supervision by DTO at TU level

    Content

    The District TB Officer (DTO) at the District TB Centre (DTC) has the overall responsibility for the physical and financial management of the National TB Elimination Programme (NTEP) at the district level as per the guidelines.

    The DTO is also responsible for the involvement of other sectors in NTEP to ensure better compliance and is assisted by a Medical Officer (MO), statistical assistant and other paramedical staff. For each district, there should be a full-time DTO, who is trained in NTEP.

    The Senior Treatment Supervisor (STS) and Senior TB Lab Supervisor (STLS) at the Tuberculosis Unit (TU) level are under the administrative supervision of the DTO/ Medical Officer -TB Control (MO-TC).

    The DTO conducts supervisory visits by himself/ herself, or in a team of MO-TC/ STLS/ STS. These visits are conducted on a systematic basis and the protocol to be followed during these visits is shown in the figure below.

     

    Figure: Supervisory Protocols for the DTO

    Abbr: NTEP: National TB Elimination Programme; NGO: Non-government Organisation

     

    The following are the major points to be covered by the DTO under supervision:

     

    • All the MO-TCs, the NTEP staff (STS, STLS, TB Health Volunteers (TBHVs), DR-TB-HIV coordinators, PPM coordinators, etc.) are conducting supervisory visits and giving proper feedback on a periodical basis.
    • Early diagnosis and treatment initiation are being carried out in the district by all stakeholders.
    • Private Practitioners are sensitised adequately and they are notifying all cases of TB in Nikshay.
    • Treatment provided by the Public provider is as per the program guidelines and Private practitioners are as per the standards for TB care in India. 
    • Public health actions are undertaken in all TB cases notified in Nikshay.
    • Direct Benefit Transfer (DBT) is being provided to all beneficiaries as prescribed under NTEP.
    • Nikshay recordings are updated and factual.
    • External quality assurance is being carried out as per the NTEP protocol.
    • Drugs and supplies are supplied uninterruptedly and as per the stocking norms at various levels.
    • Microscopes and the other diagnostic equipment including the Nucleic Acid Amplification Test (NAAT) devices are adequately calibrated, and the annual maintenance is being carried out as per protocol.
    • All MOs and the staff carrying out TB services in the district are adequately trained. 

     

    Resources  

     

     

    Assessment  

    Question​  

    Answer 1​  

    Answer 2​  

    Answer 3​  

    Answer 4​  

    Correct answer​  

    Correct explanation​  

    Page id​  

    Part of Pre-test​  

    Part of Post-test​  

    How often should a DTO visit a TB unit in their area?  

    Every month  

    Twice a month  

    Every quarter  

    Every day  

    1  

    The District TB Officer (DTO) should cover all TB units every month. 

      

      Yes

      Yes