STLS: Supportive supervision

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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

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

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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

Role of STLS at a DMC

Content

The Senior TB Laboratory Supervisor (STLS) is the person responsible for monitoring the day-to-day activities of all the microscopy centres and nucleic acid amplification test (NAAT) sites and is thus essential to the success of the National TB Elimination Programme (NTEP). They also ensure the quality of TB diagnostic services.

Roles of STLS at the DMC

Program management

The STLS is responsible for ensuring that microscopy services in the district are well organized and the locations of the designated microscopy centres (DMCs) are known to all the medical officers in all peripheral health institutions (MO-PHI).

The STLS also ensures that there are:

Uninterrupted staffing of DMCs, including coverage for laboratory technicians (LTs) that might be on leave, so that there is regular and uninterrupted availability of smear examination at the DMC.
Uninterrupted supply of reagents and logistics required for the microscopy.
Quality assurance and accuracy guarantee for the microscopic activities carried out.
Regular training and continuing education of LTs.

The STLS reports to the district TB officer (DTO) in collaboration with the senior treatment supervisor (STS) regarding implementation, quality control (QC), supervision and management of laboratory supplies.

Monitor documentation related to microscopy

STLS ensures that all documentation related to sputum smear examinations is accurate and reports of examinations are given to the treating physician promptly. This includes:

Each LT has a TB lab register which is filled completely and accurately.
LTs understand the importance of limiting administrative errors (for example, keeping the sputum specimens with the proper lab forms for sputum examination and slides) and accurately recording the results of sputum smear examinations.
LTs keep examined slides for review and on-site evaluation (OSE) visit by the STLS.
There is an accurate recording of the results of the sputum smear examination.

STLS must explain to LTs that patients are diagnosed and placed on appropriate treatment regimens based on the smear results.

Ensure appropriate number and schedule of sputum examinations

Presumptive TB persons should have their sputum examined the correct number of times for tubercle bacilli, at least 2 sputum samples should be examined.
Follow-up cases should have 2 sputum samples examined and should be done according to the follow-up schedule.

Perform laboratory QC

This is done via OSE visits. The visit includes a comprehensive assessment of the laboratory safety including infection control measures; conditions of the equipment, adequacy of supplies as well as the technical components of acid-fast bacilli (AFB) smear microscopy employing a simple “Yes” and “No” checklist.

The STLS visits every DMC under their supervision at least once every 4 weeks, and more often if possible.
During these visits, at least 5 positive and 5 negative slides must be re-checked by the STLS.
Staff at the DMC is supervised, evaluated and trained during these visits.
The STLS maintains a diary, recording the details of these field visits.

At the end of each QC visit, detailed feedback is given by the STLS for continuous internal quality improvements. The STLS also ensures that centres maintain proper storage and transport of sputum specimens, the safety of lab staff and the maintenance of microscopes.

5. Waste disposal checks: STLS ensures that contaminated material is disposed of safely to ensure infection control. Sputum containers with sputum must either be incinerated, disinfected and autoclaved, or burnt in a pit and the burnt material buried.

6. Maintain an adequate supply of all materials necessary for microscopic examination

The STLS ensures that LTs have an adequate supply of reagents, sputum containers, slides and other materials including boxes for storing slides. This includes:

Calculating the required volume of material (slides, sputum containers, etc.) required.
Ordering supplies during the first week of the quarter to ensure uninterrupted supply at all DMCs.
Distribution of sputum containers to all sputum collection centres/ DMCs in the area.
Estimating and ensuring maintenance of adequate reserve stock at DMCs.

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
What is the role of the STLS in the DMC?	Conduct an on-site evaluation visit.	Make sure that LTs fill the TB lab register properly.	Ensure adequate supply of lab material, like slides, at the DMC.	All of the above	4	The STLS conducts an on-site evaluation visit at the DMC, ensures proper documentation of smear results and ensures an adequate supply of lab materials at the DMC.		Yes	Yes
How often should the STLS visit the DMC?	Every 2 weeks	Every month	Every quarter	Every 6 months	2	The STLS visits every DMC under their supervision at least once every 4 weeks, and more often if possible.		Yes	Yes