Mentoring Activities to Improve Nursing Service Quality

MENTORING ACTIVITIES TO IMPROVE SERVICES QUALITY OF NURSING

A substantial amount of the mentors' time will be spent at the main CHC facility in the block. The main purpose of being in health facilities is to ensure the quality of services that encompasses both system-level issues and individual provider-level issues.

At healthcare facilities, mentors should use the PDCA approach at two levels First at the health facility level mentors will help staff to improve service delivery by helping the health facility team to solve problems related to facility systems that hamper day to day functioning of the facility. 

The mentor will encourage providers to understand that when they work together their collective strength helps to resolve certain problems. Second, at an individual provider level, the mentor's focus should be to improve clinical competencies. 

This chapter describes how the mentors can use the PDCA approach and specific tools at the first of these levels - service quality issues. The following chapter describes how mentor can use the same approach to improve provider clinical skills.

In order to effectively do this, the mentor needs to undertake 4 key steps when at a facility, either the one where based most of the time (usually a CHC) or when out in the community visiting PHCs or SCs:

• Make pre-meeting/visit plans
• Manage the first meeting
• Facilitate the QI exercises using the QI tools
• Facilitate the follow-up action planning meeting

Make pre-meeting/visit plans

The mentors' preparation starts well before the site visit and includes 4 important steps.

Step one -  If it is the first visit, the mentor should review the data of the health facility that can be obtained from the health management information system (HMIS/ UPHMIS) to develop a facility profile. 

This will help the mentor to become familiar with staffing, existing systems, delivery volumes, etc. If it is a subsequent visit, the action plan that has been developed during the previous visit should be reviewed beforehand.

Step 2 - Inform the health facility in-charge ahead of time that you would like to visit the health facility. In consultation with the M.O. choose two days for your visit that will least disrupt services (e.g. not on an antenatal day).

Step 3 - Discuss with the in-charge that you would like to meet with all clinical and support staff who are involved in some way in provision of maternal and newborn services at the health facility. 

This would usually include all nurses, lady health visitors, pharmacists, record keepers, ancillary cleaning staff and the medical officers (M.O), also ANMs if they are available.

Step 4 - be prepared. Know your tools and think about how you can be facilitative during the meetings. Review in your mind how you need to facilitate meetings. 

As mentoring date draws nearer, remind the facility that you are coming. Have enough copies of the self-assessment guides, pens or pencils, flipchart paper and pens for action plan. Prepare flipcharts required for writing the action plans.

Manage the first meeting

It is important to understand that sometimes you are entering the health facility and meeting the staff for the first time. You require time to get to know the staff and make friends with the team. 

Use the first visit to develop rapport with the staff and implement some of the self-assessment tools. Remember some of the rapport-building skills already discussed. At subsequent visits, you can spend more time on self-assessment exercises and teaching.

This section describes what you should do during a mentoring visit though not all should necessarily be done each time:

1. Meet with the health facility in charge and introduce yourself, the purpose of your visit and that you are visiting the health facility to work with the in charge to assist the staff in improving the quality of care and service delivery. The confidence of the leader in you is very important and this can facilitate a good working relationship with others.

2. Hold a staff meeting at which you should:

Introduce yourself and others and the purpose of the mentoring- 

• Have introductions and ensure staff inclusiveness and comfort.

• Start the meeting by asking if everyone has come for the meeting. Reiterate that you would like as many health facility team members as possible to come, including providers, paramedics as well as support staff.

• Ensure seating arrangements that are comfortable for all. If possible sit in a circle so that everyone feels equal.

• Throughout the day, the mentors should try to help the support staff feel included, and try not to let senior staff dominate the discussion.

• Introduce yourself and explain what you are there for, how often you will.

• visit and what you want to achieve Give a clear introduction about yourself, your background, the purpose of your visit, frequency of visits and the process of working with the facility staff.

• Gaining the confidence of the staff and having their acceptance of the the process is dependent on your ability to communicate clearly.

• It is important to spend adequate time in this initial briefing to ensure that each person is clear about your role and purpose.

Talk about quality improvement

Discuss what we mean by a quality service - what should clients have a right to expect and what do health facility providers have a right to expect in order to meet clients' rights? What really is good quality service? If this is the first visit, complete the exercise below. 

If this is not your first meeting at the facility and you have done the exercise before, just have a quick reminder of quality issues.

The "what is quality" exercise

1. Hand out two cards to each of the staff present. Ask them to write down on one card 2 things that women have a right to expect from the health facility when they come for antenatal care, or when in labour or in the postpartum period. 

Ask them to think about what they would want, what their sisters would want, and what they would think are the components of quality service. Give them five minutes to discuss this and to write down their ideas. Help the people who are not literate or who want to discuss with you. Collect the cards.

2. Read out what is on the client rights cards, and sort them into different ideas - you should have ideas about all the components of the guides. If you are missing any of the key issues, ask them to think of anything to add, and formulate questions to solicit more ideas. 

For example, if they do not mention timely referral to an FRU, you could ask "what about when a woman has a complication that you cannot manage here, what do you think she would hope for?" Likewise, if they do not mention confidentiality, you could ask "how would you feel if the doctor talked about your bleeding problem in a loud voice in the ward? 

What would you hope for, expect? For each thing mentioned, ask them to give examples of how these quality issues might be addressed (examples are shown in Table 5). Hand out the client right and provider rights handout.

3. Now request them to look at what they need to provide these services (what are their rights?) and list ideas on the other card. Then collect them and read out the provider rights cards and sort them into different themes. If you are missing any of the key issues, ask them to think of anything to add, and formulate questions to solicit more ideas. For example, if they do not mention good supervision, ask "how about if you don't know what the government standards of care are, what do you need? Likewise if they do not mention a clean environment ask, "How d you feel as health workers if the compound is dirty, or the walls are not painted, what do you need?" Examples are shown in Table 6

Talk about poor quality

Ask the health facility provider, "What is the cost of poor quality?" What are some of the potential consequences when a health facility does not provide good quality services? 

Some answers might be:

• When women in labour are diagnosed with eclampsia and having convulsions; if the health facility does not have MgSO4 then the women may develop serious complications. Thus the women and babies might be lost due to lack of a drug at the health facility.

• Infections can spread to women and babies during delivery due to the lack of good infection prevention practices such as cleaning the labour table with 0.5% chlorine between deliveries.

• Women do not get treatment on time due to lack of drugs or absence of trained staff to handle complications.

• Families do not know how to care for the mother and baby after discharge. This could be due to the fact that the staff did not educate or counsel the woman or family on care at home.

• Babies might not be fed properly. This might be due to the fact that the mother is inexperienced and does not know how to breastfeed her baby. The mother might not have been counseled and supervised by the staff nurse while breastfeeding during the first 48hrs post delivery.

• Women and/or babies get sick or even die, due to poor post-delivery monitoring. This could result in not recognizing danger signs and initial management. This could lead to complications and increased chances of death.

Talk about responsibility for the quality

Then ask "who is responsible for the quality of services"? The answer is that quality is everyone's business, from the sweeper outside (she is part of the team and contributes when she knows where to send a woman in an emergency) to the pharmacist (who may understand the importance of keeping adequate stocks of magnesium sulphate) to the record keeper (who helps the nurses fill in the registers properly) to the ANMs (who tells a woman about danger signs) to an ASHA (who knows how to advise a woman about feeding) to a staff nurse (who manages properly a woman with sepsis) to the doctor (who shares new knowledge with his/her team members, helps with difficult cases, or orders case sheets from the district HQ). Quality improvement is not the responsibility of outside quality assurance people; it is the health facility team's responsibility.

Explain that as quality is everyone's responsibility, all health facility staff have been invited to the meeting and as far as possible, will participate in working together as a team, to look at quality issues in this health facility.

Then ask this question, "How we are going to improve quality at this health facility and who is responsible?" Explain that providers sometimes get frustrated with their working conditions and might forget clients rights. Ask the providers to tell you what are some of the things that make staff/providers feel de-motivated to provide good quality?"

Answers might include:

• Poor salary, inequities in pay.
• Long hours, too much work, too many clients.
• Lack of coordination among the health facility team.
• No encouragement was given by supervisors.
• Staff shortage and staff absences.
• No equipment, or supplies.
• Lack of training and updates.
• Poor management and supervision.
• Staff/providers blame each other.
• People in the community do not come to use the services.
• The remoteness of the health facility and poor transport connectivity.

Explain that sometimes staff/providers blame each other when things go wrong but that does not help providers to be motivated to do better. Ask staff to think about times they have been personally criticized and how that made them feel and react. 

Some may want to give an example. What helps. is an improvement in "systems" - be it training systems, equipment supply systems, or time allocation systems. Explain that sometimes it is difficult to change systems but that we should try to focus on what we can change in the systems, and not blame individuals who are working under the same constraints and have other problems. 

Explain that as quality is everyone's responsibility and that nobody likes or reacts well to personal criticism, the providers will work together to talk about quality, discuss what are some poor quality issues in this health facility, and come up with ideas of what can providers do about them. Providers should remember not to try to suggest solutions that are outside their control, such as pay scales, or that need huge resources such as a new ward, but focus on things they can change.

Explain that you, as the new nurse mentor, will support them to improve quality - you will be here regularly to help them with clinical skills issues and wider quality issues. Tell providers that you will be helping them to assess progress themselves, working to improve clinical skills, and trying to help orient them to new clinical issues.

Explain that they should ask you questions freely and that you are always contactable by phone if they have a question. But say that quality improvement is their responsibility. Ask them if they are ready to do that and be advocates for quality!

Introduce the PDCA Approach

Explain to staff about PDCA and that you will be using it to help them to improve quality at their facility. Using a visual, explain what the acronym means and say that they will learn how to assess and diagnose problems at the facility, how they will learn how to manage those problems, how they will learn to monitor progress and how they will become advocates for quality improvement. You might give an example of an issue that might be identified.

Introduce the self-assessment tools - LaQshya Assessment Checklist

Explain that all providers will now do some work on their own or in teams. Remind of the PDCA and inform them that there are 2 tools that they can use to give them ideas about what can be improved at the facility:

• LaQshya Resource Availability Checklist for each cycle.

• LaQshya Assessment Checklist for Practices for each cycle.

The staff will work on different things, either individually or in teams over the rest of the day. They will sometimes have to consult with other facility staff to help them with the tasks. 

They will need to identify problem areas, but also think about what might be causing those problems. The next day, everyone will come together to present their findings to the group at a meeting where they develop an action plan to address these problems. 

Action planning is a process where the teams do a root cause analysis for each major problem identified so as to arrive at a realistic and effective solution.

Explain how to use the self-assessment exercises

• Self-assessment tools - LaQshya Checklist for each cycle

Explain to staff that the self-assessment guides reflect essential elements for providing a quality service and are organized around the quality of care themes already discussed.

Explain how everything will be managed for the QI exercises. Explain the advantages of a self-assessment process and introduce the self-assessment guides

Inform them that if this is the first visit they will review guides only some of the guides (you might have to decide this on the day depending on time, but usually you should plan do the first and on the second visit they can complete the remaining. 

Staff should be asked to divide the tools between themselves, taking areas in which they are most interested or have expertise - they do not ALL need to work on every tool - they could work in pairs for example; some people can work on more than one tool-it might be a good idea to have a nurse pair up with a non-nurse.

The self-assessment exercise is not a test or exam and nobody will be checking their answers. It is meant as a basis for discussion among staff members. Ask them to look at, and reflect on all the questions together as a team: if a question has several bullets in a list, and they think some aspects are problematic, then "x" those so they know what to discuss in the meeting. Tell staff they can add issues too. The lists are not exhaustive-if staff can think of other problems, they should add them at the end. 

Explain that team members jointly review each of the questions and answer them either (if the practice is good) or X (if there is a problem) through discussion among themselves, with their colleagues or direct observation. If some aspect is truly not applicable, they should write N/A in the column. They should be encouraged to only mark an "x" against issues they think are important and need to be addressed urgently, otherwise they will have too many issues. 

Explain that they can revisit the tools in a few months and identify other issues that become more pressing. In this way it leaves the door open to revisit issues again later in the year.

Case sheet review

It is very important to look critically at the way we manage the cases and how we document our practices in the case sheets that we fill. Case sheets can give us an actual idea of the providers' knowledge and practice related to clinical protocols. One or two staff will be responsible for reviewing the case sheets to understand the current practices and identify areas for improvement.

Tell the providers to examine 10 case sheets and look at all the elements. They should mark each box either with a if something was done, with an X if not done or with a ? if they are not sure. They should make a note of things that are not there for a good reason (e.g. if the baby died you would not check its vital signs on discharge). Then tally the data. 

The providers should come back to the group with a summary sheet, adding up the rows and be prepared to share with the group, identifying areas for improvement. You might have to delay this activity until case sheets have been introduced at the sites.

Organize groups

After you have explained all the tools and depending on how many people are participating, you should divide up the staff into small teams so that some of them work using Tools. Depending on their interest, one or two people can interview clients and one or two people can review case sheets, Teams should consist of a mixed level of staff but should include some clinical providers who will be able to answer the more technical or medical questions. 

Each team will identify a note taker who can present findings to the rest of the group in the form of an action plan. The small groups or the individuals should discuss some of the problems they observe and develop a draft action plan as described below.

Explain root cause analysis

While carrying out the various assessments if something is not being done, or is a problem, team members should discuss why it is not being done, or what is the root cause of the problem? In analyzing root causes, staff should focus on gaps in the systems and processes and not blame individuals. 

What is the root cause of the gap? One of many problem-solving techniques is called the WHY-WHY-WHY analysis to help discern root causes. 

In this technique when presented with a problem you keep asking until there are no more answers. This allows you do "drill down" until you discover the root cause/s the problem and then can focus interventions to address the root cause/s.

In looking for root causes, recognize that there are several factors that affect quality and can lead to performance gaps. Too often people tend to think the root cause of the problem is lack of knowledge and skills and that more training is needed but often, it could be other factors that need to be addressed. Some gaps might have more than one root cause and more than one solution might be needed to address them.

Explain ways to find solutions

Once problems have been identified, then the small groups should brainstorm about possible solutions to address the problems. Groups can also learn from the processes that are working well in other departments within the facility. 

For example, the pharmacy department might not have a supply problem but the lab is often out of reagents. What could lab services learn from the pharmacy department about how to ensure adequate supplies?

Explain the development of an action plan

Initially the smaller groups can brainstorm on the possible solutions before bringing it to the larger group during the action planning meeting where further discussions can take place and more ideas can be gathered to solve problems. Team members must find a solution for each root cause identified and note this all down on an action plan template. 

They should prioritize solutions, taking into consideration such issues as client or provider safety and the ease with which the problem can be solved using local resources or ingenuity. Then the team should then assign someone responsible for implementation and completion dates that reflect the priorities. Discuss and decide on a good time the next day to come back and discuss the results.

Here is an example of an action plan (Table 7).

Facilitate the collective action planning meeting

A moment's reflection

When you come back together at the agreed time, make sure that everyone is there and that all are seated comfortably. To warm up the meeting, ask people to reflect on how they found the experience of doing the exercises did they feel happy, sad, excited, overwhelmed or depressed, bored, energized, hopeless? Be sure to let everyone have the chance to say something and not let the senior staff dominate the discussion.

Guidelines for reporting back

Ask the team spokespersons to report on what they found. Use the A3 size posters of these self-assessment guides for all the staff to see. Reiterate that they need to focus on root causes, not superficial causes so as to not go off in the wrong direction when seeking solutions. They also need to focus on rational, realistic solution, in a realistic timeframe. Advise them not to expect the same person to fix everything.

Ensure that they can speak without interruption, but do not let them talk for too long stress that they need to make their points quickly and concisely. Ask the rest of their team if they have anything to add. Then invite other people or teams to comment. 

Ask people to rephrase things if the rest of the staff do not agree or have other ideas of what root causes might be, or what potential solutions might be, or of they think other people should be responsible or if the time frame should be changed. Ask all the groups to report back. Where there is overlap, add issues together.

Put the action plan together

Some of your own observations can be included in the follow-up action plan meeting. But remember, the main aim of the exercises is self-assessment, and letting providers find out for themselves what their limitations are, so you should not let your findings (or your recommendations) dominate otherwise staff will feel "inspected" and criticized.

When the action plan is finished, and if there are many items, ask providers If they would like to prioritize and focus on just a few in the next 1-2 months, and leave harder things for later quick results will give impetus the process). Ask staff to commit to following up on the issues they have brought up.

Identify a Site QI Coordinator

Ask them if they would like to nominate someone who can be responsible for checking in with everyone listed as responsible for certain items. This person will measure if the action plan is being implemented as planned and will communicate within the team and with the nurse mentor on successes and difficulties encountered.

During the whole process if you have observed that a particular provider has understood the Ql process well and had good suggestions to contribute, talk to the person and understand his/her role in the center and appreciate his/her effort. 

In the last part of the meeting gently suggest to the team if this person could help coordinate within the facility team. Explain that this person will also be a contact person for you as the RMNCH-A nurse mentor for the facility. Tell the staff that you are available by phone if they want to discuss anything later.

Quality Circle

The Quality Circle (QC), comprising key stakeholders of the facility, will work towards systems strengthening for achieving and sustaining LaQshya standards. As every facility will have different needs so they may have varied mechanisms for sustaining the quality of services, and monitoring and reviewing the service periodically. Empirical evidence suggests that gradually such processes engage the attention of the personnel working in the facility, leading to improvements that are more sustainable.

For institutions such as District Women Hospital / Combined Hospital, the Quality Circles will comprise a team of medical, paramedical, and other support staff such as-

• Chief Medical Superintendent: Chairperson 
• 1/C Operation Theatre/ I/C Anaesthesia 
• 1/C Surgery
• 1/C Obstetrics and Gynaecology 
• Hospital manager/ Program manager
• I/C Nursing
• Nurse Mentor
• I/C Ancillary Services(ward boys) 
• 1/C Stores and Records

At the level of CHC/ BPHC, a smaller committee of 4 to 5 members comprising of the

• Medical Superintendent/ MOIC 
• 1/C Surgery,
• 1/C Obstetrics and Gynecology/ LMO
• 1/C OT and 
• 1/C Nursing.
• Nurse Mentor

The scope of work of this QC will include all the processes involved in the intrapartum and postpartum services being provided at the facility.

Key activities of Quality Circle:

Carry out gap assessment of the facility by the Quality Circle based on the LaQshya checklist of labour room. It should be done once every two month to track the progress 

Prepare an action plan based on the gaps identified by the quality circle with support from the district coaching team based on the gap assessment of the facility

Manage the summary meeting with the staff

This has to be done at the end of the visit before you leave. You will have by now managed some of the self-assessment exercise, had an action planning meeting, and on subsequent visits, will have addressed some provider clinical competency issues (see next chapter).

This meeting will be important to ensure you get an opportunity to:

• Update them on what has taken place during the entire visit.
• Thank them all for all their hard work.

• Compliment them for what they were already doing well at the health facility.

• Compliment the staff on the immediate changes they have made at the health facility. This will give you a chance to appreciate those who have made a special effort to improve the quality of service at the facility like the M.O. purchasing drugs and supplies.

• Highlight the new learnings of how to handle complications the next time they are encountered in the health facility.

• Mention the topics of clinical mentoring that were covered during this mentoring visit.

• Ensure that the staff knows that you are available on the phone should they need your help.