Supportive Supervision Plan & Checklists

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SUPPORTIVE SUPERVISION PLAN & CHECKLISTS
2013
Maternal Health Division Ministry of Health & Family Welfare Government of India
Contents
List of Contributors................................................................................................................................. 4 Plan of Field Visits for Monitoring.......................................................................................................... 5 Household Visit Checklist (Families with 0-6 Years Children).......................................................................................................7-9 Sub Centre Level Monitoring Checklist. ................................................................................................ 12 PHC/CHC (NON FRU) Level Monitoring Checklist ............................................................................................................ 19-20 FRU Level Monitoring Checklist ..................................................................................................................... 27-28 DH Level Monitoring Checklist ..................................................................................................................... 37-38
Supportive Supervision Plan & Checklists 3
List of Contributors
1. 2. 3. 4. 5. 6. 7. 8. 9. Ms Anuradha Gupta AS&MD (NHM), MoHFW Dr Rakesh Kumar JS, RCH, MoHFW Dr Himanshu Bhushan DC (I/c MH), MoHFW Dr Manisha Malhotra DC (MH), MoHFW Dr Dinesh Baswal DC (MH), MoHFW Dr S.K. Sikdar DC ( I/c FP), MoHFW Dr Haldar, DC (Immunisation), MoHFW Dr P.K. Prabhakar DC (CH), MoHFW Dr Sila Deb, DC (CH), MoHFW
10. Dr Ravinder Kaur, Senior Consultant, MH, MoHFW 11. Dr Pushkar Kumar, Lead Consultant, MH, MoHFW 12. Dr Rajeev Agarwal, Senior Consultant, MH, MoHFW 13. Mr Vipin Garg, Consultant JSY division, MoHFW 14. Dr Rajesh Narwal, NHSRC 15. Dr Rajesh Singh, MCHIP
Supportive Supervision Plan & Checklists
Plan of Field Visits for Monitoring

Level PHC Person responsible LHV Minimum frequency of field visit At least 3 days/week, to one SC per visit Every SC will be covered twice a month At least 1 VHND/ Week Medical Officer PHC At least twice a month to 2 weak performing SCs/ANMs and 2 VHNDs/ Month Block MO-I/C At least twice a month to 2 weak performing PHCs and 2 week performing SCs Block Programme At least twice a week i.e. 8 times in a month Manager 2 SCs /Outreach and household assessment per visit OR Public Health Nurse 1 PHC and 1 SC/outreach and household assessment per visit At least twice a week i.e. 8 times in a month 1 PHC and 1 SC per visit OR CMO District Programme Manager 2 SCs, 1 outreach and household assessment per visit At least twice a month to any weak performing facility and outreach At least once a week i.e. 4 times in a month 1 CHC and 1 SC per visit OR 2 PHCs and 1 SC per visit OR RCHO/ADHO/ACMO and other technical officers 1 PHC, 1 SC, 1 outreach and household At least once a week i.e. 4 times in a month 1 CHC and 1 SC per visit OR 2 PHCs and 1 SC per visit OR 1 PHC, 1 SC , 1 outreach and household At least once a week i.e. 4 times in a month to different districts by rotation 2 CHC- FRUs/ SDH per visit OR 1 CHC FRU/SDH and 1 PHC per visit OR State 1 PHC, 2 SCs / outreach and household Mission Director At least twice a month to one poor performing district per visit, Ideally 1SC, 1PHC and 1 CHC/DH to be visited per visit State Programme At least twice a month to one poor performing district per visit. Manager Ideally 1SC, 1PHC and 1 CHC/DH to be visited per visit Senior Officer of State At least twice a month to one poor performing district per visit. Directorate/ State Ideally 1SC, 1PHC and 1 CHC/DH to be visited per visit Technical Programme Officer
CHC
District
Divisional
Regional Programme Manager/Divisional Programme Manager
Based on the observations during field visits, plan of action to be made Action Points with timelines and officials responsible for action points to be uploaded on the State NRHM Website Supportive Supervision Plan & Checklists 5
HOUSEHOLD VISIT Checklist
Household Visit
(Families with 0-6 years Children)
8
Households
Indicators
(Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N)
Knowledge and Awareness
Total (Y)
Supportive Supervision Plan & Checklists
Is the mother aware that Breast feeding (BF) must be initiated within one hour after birth? Did the mother Initiate BF within one hour of birth? Is the mother aware that Exclusive Breast feeding should be done for Six months and continued till child attains age of 2 years? Has the mother Exclusively Breast fed her youngest child for Six months and continued BF till 2 years? 2. Complementary Is she aware about initiating Feeding Practices Complementary Feeding (CF) from 6 months onwards? Has she adhered to initiating CF from 6 months onwards? 3. Diarrhoea Does the mother know that ORS+ Zinc needs to be given to child with diarrhoea? As per mother, is ORS+ Zinc available with ASHAs? 4. Pneumonia Can mother tell at least two danger signs of pneumonia? Is she aware whom to approach on recognizing the danger signs?
1. Breast Feeding
Key Questions
Households
Total (Y)
Household Visit
(Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) (Y/N)
Is the MCP card being regularly filled? * Is the quality of ANC and regularity of ANCs adequate? * Is the pregnant woman aware about birth preparedness? Does the pregnant woman have knowledge of JSY and JSSK? Whether the pregnant woman has received safe motherhood booklet? Does the pregnant woman have the telephone number of call center for referral transport/ other available referral transport? Does the pregnant woman have telephone numbers of ASHA/ ANM? Is guidance and referral provided along with birth preparedness in case of high risk pregnant woman ?
(Pregnant Woman/ High Risk Pregnant Women)
*(Probe by questions and verify through filled up MCP card)
Sub Centre
Monitoring Checklist
Sub Centre Level Monitoring Checklist

Name of District: ................................ Name of Block:................................ Name of SC:................................ Catchment Population: .......................... Total Villages: .......................... .Distance from PHC: .......................... Date of last supervisory visit:.............................................................. Date of visit: ............................... Name & designation of monitor:................................................................. Names of staff posted and available on the day of visit: ................................................................................. Names of staff not available on the day of visit and reason for absence : ........................................................
Section I: Physical Infrastructure:

S.No. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 Infrastructure Subcentre located near a main habitation Functioning in Govt building Building in good condition Electricity with functional power back up Running 24*7 water supply ANM quarter available ANM residing at SC Functional labour room Functional and clean toilet attached to labour room Functional New Born Care Corner (functional radiant warmer with neo-natal ambu bag) General cleanliness in the facility Availability of complaint/ suggestion box Availability of deep burial pit for waste management / any other mechanism Yes Y Y Y Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N N Remarks
Section II: Human Resource:

S.No. Human resource 2.1 2.2 2.3 2.4 ANM 2nd ANM MPW - Male Others, specify Numbers Specify the Training received Remarks
12 Supportive Supervision Plan & Checklists
Section III: Equipment

Mark () in appropriate column S.No. Equipment 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 Equipment for Hemoglobin Estimation Blood sugar testing kits BP Instrument and Stethoscope Delivery equipment Neonatal ambu bag Adult weighing machine Infant/New born weighing machine Needle &Hub Cutter Color coded bins RBSK pictorial tool kit Available and Available but Not Functional non-functional Available Remarks
Section IV: Essential Drugs

S.No. Availability of at least 2 month stock of essential Drugs 4.1 IFA tablets 4.2 IFA syrup with dispenser 4.3 Vit A syrup 4.4 ORS packets 4.5 Zinc tablets 4.6 Inj Magnesium Sulphate 4.7 Inj Oxytocin 4.8 Misoprostol tablets 4.9 Antibiotics, if any, pls specify 4.10 Availability of drugs for common ailments e.g PCM, anti-allergic drugs etc. Yes Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N Remarks
Section V: Essential Supplies

S.No. 5.1 5.2 5.3 5.4 5.5 5.6 Essential Medical Supplies Pregnancy testing Kits Urine albumin and sugar testing kit OCPs EC pills IUCDs Sanitary napkins Yes Y Y Y Y Y Y No N N N N N N Remarks
Section VI: Service Delivery in the last two quarters:

S.No. 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Service Utilization Parameter Number of estimated pregnancies Percentage of women registered in the first trimester Percentage of ANC3 out of total registered Percentage of ANC4 out of total registered No. of pregnant women given IFA Number of deliveries conducted at SC Number of deliveries conducted at home No. of neonates initiated breast feeding within one hour 6.9 Number of children screened for defects at birth under RBSK 6.10 No. of sick children referred 6.11 No. of pregnant women referred 6.12 No. of IUCD insertions 6.13 No. of children fully immunized 6.13 a Measles coverage 6.15 No. of children given ORS + Zinc 6.16 No. of children given Vitamin A 6.17 No. of children given IFA Syrup 6.18 No. of Maternal deaths recorded , if any 6.19 No. of still birth recorded, if any 6.20 Neonatal deaths recorded, if any 6.21 Number of VHNDs attended 6.22 Number of VHNSC meeting attended 6.23 Service delivery data submitted for MCTS updation Q1 Q2 Remarks
Section VII: Quality parameters of the facility:

Through probing questions and demonstrations assess does the ANM know how to S.No. 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 Essential Skill Set Knowledge Correctly measure BP Y N Correctly measure hemoglobin Y N Correctly measure urine albumin and protein Y N Identify high risk pregnancy Y N Awareness on mechanisms for referral to PHC Y N and FRU Correct use of partograph Y N Provide essential newborn care Y N (thermoregulation, breastfeeding and asepsis) Correctly insert IUCD Y N Skill Y Y Y Y Y Y Y Y N N N N N N N N Remarks
S.No. 7.9 7.10 7.11 7.12 7.13 7.14 7.15
Essential Skill Set Correctly administer vaccine Adherence to IMEP protocols Segregation of waste in colour coded bins Guidance/ Support for breast feeding method Correctly identifies signs of Pneumonia and dehydration Awareness on Immunization Schedule Awareness on site of administration of vaccine
Knowledge Y N Y N Y N Y N Y N Y Y N N
Skill Y Y Y Y Y Y Y N N N N N N N
Remarks
Section VIII: Record Maintenance:

Mark () in appropriate column Sl. No Record Available and Available Upto-date and but noncorrectly filled maintained Not Available Remarks
8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17
8.18
Untied funds expenditure (Rs 10,000)Check % expenditure Annual maintenance grant (Rs 10,000-Check % expenditure) Payments under JSY VHND plan VHSNC meeting minutes and action taken Eligible couple register MCH register ( as per GOI) Delivery Register as per GOI format Stock register Due lists MCP cards Village register Referral Registers (In and Out) List of families with 0-6 years children under RBSK Line listing of severely anemic pregnant women Updated Microplan Vaccine supply for each session day (check availability of all vaccines ) Due list and work plan received from MCTS Portal through Mobile/ Physically Supportive Supervision Plan & Checklists 15
Section IX: Referral Linkages in last two quarters:

S.No. Mode of Transport (Specify Govt./ pvt) Home to facility Inter facility Facility to Home (drop back) No. of women No. of sick No. of transported infants children during ANC/ transported 1-6 years INC/PNC Free/Paid
9.1 9.2 9.3
Section X: IEC display:

S.No. 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 10.10 Material Approach roads have directions to the sub centre Citizen Charter Timings of the Sub Centre Visit schedule of ANMs Area distribution of the ANMs/ VHND plan SBA Protocol Posters JSSK entitlements Immunization Schedule JSY entitlements Other related IEC material Yes Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N Remarks
Section XI: Previous supervisory visits:

S.No. Name and Designation of the supervisor 11.1 Place of posting of Supervisor Date of visit
11.2
11.3
11.4
11.5
Note: Ensure that necessary corrective measures are highlighted and if possible, action taken on the spot. The Monthly report of monitoring visits and action points must be submitted to the appropriate authority for uploading on State MoHFW website. _____________________________________________________________________________________ To be filled by monitor(s) at the end of activity Key Findings Actions Taken/Proposed Person(s) Responsible Timeline
PHC/CHC (NON FRU)

PHC/CHC (NON FRU) Level Monitoring Checklist

Name of District:............................ Name of Block:............................. Name of PHC/CHC:............................. Catchment Population:.......................... Total Villages: ............................. Distance from HQ: .......................... Date of last supervisory visit:.............................................................. Date of visit: ............................... Name & designation of monitor:................................................................. Names of staff not available on the day of visit and reason for absence:............................................................
Section I: Physical Infranstructure

S.No. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Infrastructure Health facility easily accessible from nearest road head Functioning in Govt building Building in good condition Habitable Staff Quarters for MOs Habitable Staff Quarters for SNs Habitable Staff Quarters for other categories Electricity with functional power back up Running 24*7 water supply Clean Toilets separate for Male/Female Functional and clean labour Room Functional and clean toilet attached to labour room Functional New born care corner(functional radiant warmer with neo-natal ambu bag) Functional Newborn Stabilization Unit Clean wards Separate Male and Female wards (at least by Partitions) Availability of complaint/suggestion box Availability of mechanisms for waste management Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N N N N N N Remarks
Section II: Human Resource

S.No. 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Category MO SNs/ GNMs ANM LTs Pharmacist LHV/PHN Others Numbers Remarks
Section III: Training Status of HR

S.No. 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 Training BeMOC SBA MTP/MVA NSV IMNCI F- IMNCI NSSK Mini Lap IUD RTI/STI Immunization and cold chain Others No. trained Remarks
Section IV: Equipment

S.No. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 Equipment Functional BP Instrument and Stethoscope Sterilised delivery sets Functional neonatal, Paediatric and Adult Resuscitation kit Functional Weighing Machine (Adult and infant/newborn) Functional Needle Cutter Functional Radiant Warmer Functional Suction apparatus Functional Facility for Oxygen Administration Functional Autoclave Functional ILR Functional Deep Freezer Emergency Tray with emergency injections MVA/ EVA Equipment Laboratory Equipment Functional Microscope Functional Hemoglobinometer Functional Centrifuge, Functional Semi autoanalyzer Reagents and Testing Kits Yes Y Y Y Y Y Y Y Y Y Y Y Y Yes Y Y Y Y Y No N N N N N N N N N N N N No N N N N N Remarks
Remarks
Section V: Essential Drugs and Supplies

S.No. 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 S.No 5.17 5.18 5.19 5.20 5.21 5.22 S.No 5.23 Essential Medical Supplies EDL available and displayed Computerised inventory management IFA tablets IFA tablets (blue) IFA syrup with dispenser Vit A syrup ORS packets Zinc tablets Inj Magnesium Sulphate Inj Oxytocin Misoprostol tablets Mifepristone tablets Antibiotics Labelled emergency tray Drugs for hypertension, Diabetes, common ailments e.g PCM, anti-allergic drugs etc. Vaccine Stock available Supplies Pregnancy testing kits Urine albumin and sugar testing kit OCPs EC pills IUCDs Sanitary napkins Essential Consumables Gloves, Mckintosh, Pads, bandages, and gauze etc. Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Yes Y Y Y Y Y Y Yes Y No N N N N N N N N N N N N N N N N No N N N N N N No N Remarks
Remarks
Remarks
Note: For all drugs and consumables, availability of at least 2 month stock to be observed and noted
Section VI: Other Services

S.No. 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Lab tests being conducted for Haemoglobin CBC Urine albumin and Sugar Serum Bilirubin test Blood Sugar RPR (Rapid Plasma Reagin) test Malaria (PS or RDT) T.B (Sputum for AFB) Yes Y Y Y Y Y Y Y Y No N N N N N N N N Remarks
S.No. Lab tests being conducted for 6.9 HIV (RDT) 6.10 Others
Yes Y Y
No N N
Remarks
Section VII: Service Delivery in last two quarters

S.No. 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 7.22 7.23 7.24 7.25 7.26 7.27 7.28 7.29 Service Utilization Parameter OPD IPD Expected number of pregnancies Percentage of women registered in the first trimester Percentage of women registered in the first trimester Percentage of ANC3 out of total registered Percentage of ANC4 out of total registered Total deliveries conducted Number of obstetric complications managed, pls specify type No. of neonates initiated breast feeding within one hour Number of children screened for Defects at birth under RBSK RTI/STI Treated No of admissions in NBSUs, if available No. of sick children referred No. of pregnant women referred No. of IUCD Insertions No. of Tubectomy No. of Vasectomy No. of Minilap No. of children fully immunized Measles coverage No. of children given ORS + Zinc No. of children given Vitamin A No. of women who accepted post partum FP services No. of MTPs conducted Maternal deaths, if any Still births, if any Neonatal deaths, if any Infant deaths, if any Q1 Q2 Remarks
Section VII a: Service delivery in post natal wards

S.No. Parameters 7.1a All mothers initiated breast feeding within one hr of normal delivery 7.2a Zero dose BCG, Hepatitis B and OPV given 7.3a Counseling on IYCF done 7.4a Counseling on Family Planning done 7.5a Mothers asked to stay for 48 hrs 7.6a JSY payment being given before discharge 7.7a Mode of JSY payment (Cash/ bearer cheque/Account payee cheque/Account Transfer) 7.8a Any expenditure incurred by Mothers on travel, drugs or diagnostics(Please give details) 7.9a Diet being provided free of charge Yes Y Y Y Y Y Y No N N N N N N Remarks
Y Y
N N
Section VIII: Quality parameter of the facility

Through probing questions and demonstrations assess does the staff nurses and ANMs know how to S.No. Essential Skill Set 8.1 Manage high risk pregnancy 8.2 Provide essential newborn care (thermoregulation, breastfeeding and asepsis) 8.3 Manage sick neonates and infants 8.4 Correctly uses partograph 8.5 Correctly insert IUCD 8.6 Correctly administer vaccines 8.7 Alternate Vaccine Delivery (AVD) system functional 8.7 Segregate waste in colour coded bins 8.8 Adherence to IMEP protocols Knowledge Y N Y N Y Y Y Y Y Y Y N N N N N N N Skill Y Y Y Y Y Y Y Y Y N N N N N N N N N Remarks
Section IX: Record Maintenance

Sl. No Record Available, Available Updated and but Not correctly filled maintained Not Available Remarks/Timeline for completion
9.1 9.2 9.3 9.4 9.5 9.6
OPD Register IPD Register ANC Register PNC Register Indoor bed head ticket Line listing of severely anaemic pregnant women
Sl. No Record
Available, Available Updated and but Not correctly filled maintained
Not Available
Remarks/Timeline for completion
9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18
Labour room register Partographs OT Register FP Register Immunisation Register Updated Microplan Drug Stock Register Referral Registers (In and Out) Payments under JSY Untied funds expenditure (Check % expenditure) AMG expenditure (Check % expenditure) RKS expenditure (Check % expenditure)
Section X: Referral linkages in last two quarters

10.1 10.2 10.3
Section XI: IEC display

S.No. Material 11.1 Approach roads have directions to the health facility 11.2 Citizen Charter 11.3 Timings of the Health Facility 11.4 List of services available 11.5 Essential Drug List 11.6 Protocol Posters 11.7 JSSK entitlements 11.8 Immunization Schedule 11.9 JSY entitlements 11.10 Other related IEC material Yes Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N Remarks
Section XII: Additional/Support Services

S.No. 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Material Regular sterilisation of Labour room (Check Records) Functional laundry/washing services Availability of dietary services Appropriate drug storage facilities Equipment maintenance and repair mechanism Grievance redressal mechanisms Tally software implemented Yes Y Y Y Y Y Y Y No N N N N N N N Remarks
Section XIII: Previous supervisory visits

S.No. Name and Designation of the supervisor 13.1 13.2 13.3 13.4 13.5 Place of posting of Supervisor Date of visit
Note: Ensure that necessary corrective measures are highlighted and if possible, action taken on the spot. The Monthly report of monitoring visits and action points must be submitted to the appropriate authority for uploading on State MoHFW website _____________________________________________________________________________________ To be filled by monitor(s) at the end of activity Key Findings Actions Taken/Proposed Person(s) Responsible Timeline
FRU
FRU Level Monitoring Checklist

Name of District:............................. Name of Block:................................ Name of FRU:................................. Catchment Population:........................ Total Villages: ........................... Distance from Dist HQ: ....................... Date of last supervisory visit:.............................................................. Date of visit: ............................... Name & designation of monitor:................................................................. Names of staff not available on the day of visit and reason for absence:............................................................

S.No. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 Infrastructure Health facility easily accessible from nearest road head Functioning in Govt building Building in good condition Habitable Staff Quarters for MOs Habitable Staff Quarters for SNs Habitable Staff Quarters for other categories Electricity with power back up Running 24*7 water supply Clean Toilets separate for Male/Female Functional and clean labour Room Functional and clean toilet attached to labour room Functional New born care corner (functional radiant warmer with neo-natal ambu bag) Functional Newborn Stabilization Unit Functional SNCU Clean wards Separate Male and Female wards (at least by partitions) Availability of Nutritional Rehabilitation Centre Functional BB/BSU, specify Separate room for ARSH clinic Availability of complaint/suggestion box Availability of mechanisms for Biomedical waste management (BMW) at facility BMW out sourced Availability of ICTC Centre Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N N N N N N N N N N N N Additional Remarks

S.No. 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 Category OBG Anaesthetist Paediatrician General Surgeon Other Specialists MOs SNs ANMs LTs Pharmacist LHV Radiographer RMNCHA+ counsellors Others Numbers Remarks if any

S.No. 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.16 3.15 Training EmOC LSAS BeMOC SBA MTP/MVA NSV F-IMNCI NSSK Mini Lap-Sterilisations Laproscopy-Sterilisations IUCD PPIUCD Blood storage IMEP Immunization and cold chain Others No. trained Remarks if any

S.No. 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 Equipment Functional BP Instrument and Stethoscope Sterilised delivery sets Functional Neonatal, Paediatric and Adult Resuscitation kit Functional Weighing Machine (Adult and child) Functional Needle Cutter Functional Radiant Warmer Functional Suction apparatus Functional Facility for Oxygen Administration Functional Autoclave Functional ILR and Deep Freezer Emergency Tray with emergency injections MVA/ EVA Equipment Functional phototherapy unit Laboratory Equipment Functional Microscope Functional Hemoglobinometer Functional Centrifuge Functional Semi autoanalyzer Reagents and Testing Kits O.T Equipment O.T Tables Functional O.T Lights, ceiling Functional O.T lights, mobile Functional Anesthesia machines Functional Ventilators Functional Pulse-oximeters Functional Multi-para monitors Functional Surgical Diathermies Functional Laparoscopes Functional C-arm units Functional Autoclaves (H or V) Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Yes Y Y Y Y Y Yes Y Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N N No N N N N N No N N N N N N N N N N N Remarks
Remarks
Remarks

S.No. 5.1 5.2 5.3 Essential Medical Supplies EDL available and displayed Computerised inventory management IFA tablets Yes Y Y Y No N N N Remarks
Essential Medical Supplies IFA tablets (blue) IFA syrup with dispenser Vit A syrup ORS packets Zinc tablets Inj Magnesium Sulphate Inj Oxytocin Misoprostol tablets Mifepristone tablets Availability of antibiotics Labelled emergency tray Drugs for hypertension, Diabetes, common ailments e.g PCM, metronidazole, antiallergic drugs etc. 5.16 Vaccine Stock available S.No. Supplies 5.17 Pregnancy testing kits 5.18 Urine albumin and sugar testing kit 5.19 OCPs 5.20 EC pills 5.21 IUCDs 5.22 Sanitary napkins S.No Essential Consumables 5.23 Gloves, Mckintosh, Pads, bandages, and gauze etc.
S.No. 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15
Yes Y Y Y Y Y Y Y Y Y Y Y Y
No N N N N N N N N N N N N
Remarks
Y Yes Y Y Y Y Y Y Yes Y
N No N N N N N N No N
Remarks
Remarks
Section VI: Other Services:

S.No. 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 Lab tests being conducted for Haemoglobin CBC Urine albumin and sugar Blood sugar RPR (Rapid Plasma Reagin) test Malaria (PS or RDT) T.B (Sputum for AFB) HIV (RDT) Liver function tests(LFT) Others , pls specify Yes Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N Remarks
S.No. Blood bank / Blood Storage Unit 6.11 Functional blood bag refrigerators with chart for temp. recording 6.12 Sufficient no. of blood bags available 6.13 Check register for number of blood bags issued for BT in last quarter
Yes Y Y
No N N
Remarks
Section VII: Service Delivery in last two quarters:

S.No. 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 Service Utilization Parameter OPD IPD Expected number of pregnancies No. of pregnant women given IFA Total deliveries conducted No. of assisted deliveries( Ventouse/ Forceps) No. of C section conducted Number of obstetric complications managed, pls specify type 7.9 No. of neonates initiated breast feeding within one hour 7.10 Number of children screened for Defects at birth under RBSK 7.11 RTI/STI Treated 7.12 No of admissions in NBSUs/ SNCU, whichever available 7.12a Inborn 7.12b Outborn 7.13 No. of children admitted with SAM 7.14 No. of sick children referred 7.15 No. of pregnant women referred 7.16 No. of IUCD Insertions 7.17 No. of Tubectomy 7.18 No. of Vasectomy 7.19 No. of Minilap 7.20 No. of children fully immunized 7.21 Measles coverage 7.22 No. of children given ORS + Zinc 7.23 No. of children given Vitamin A 7.24 No. of women who accepted post-partum FP services 7.25 No. of MTPs conducted in first trimester 7.26 No. of MTPs conducted in second trimester 7.27 Number of Adolescents attending ARSH clinic 32 Supportive Supervision Plan & Checklists Q1 Q2 Remarks
S.No. 7.28 7.29 7.30 7.31
Service Utilization Parameter Maternal deaths, if any Still births, if any Neonatal deaths, if any Infant deaths, if any
Q1
Q2
Remarks
Section VII a: Service delivery in post natal wards:

S.No. Parameters 7.1a All mothers initiated breast feeding within one hr of normal delivery 7.2a Zero dose BCG,Hepatitis B and OPV given 7.3a Counseling on IYCF done 7.4a Counseling on Family Planning done 7.5a Mothers asked to stay for 48 hrs 7.6a JSY payment being given before discharge 7.7a Mode of JSY payment (Cash/ bearer cheque/Account payee cheque/Account Transfer) 7.8a Any expenditure incurred by Mothers on travel, drugs or diagnostics(Please give details) 7.9a Diet being provided free of charge Yes Y Y Y Y Y Y No N N N N N N Remarks
Y Y
N N

Through probing questions and demonstrations assess does the staff know how to S.No. Essential Skill Set 8.1 Manage high risk pregnancy 8.2 Provide essential newborn care (thermoregulation, breastfeeding and asepsis) 8.3 Manage sick neonates and infants 8.4 Correctly uses partograph 8.5 Correctly insert IUCD 8.6 Correctly administer vaccines 8.7 Segregation of waste in colour coded bins 8.8 Adherence to IMEP protocols 8.9 Manage Bio medical waste 8.10 Updated entry in the MCP Cards 8.11 Entry in MCTS 8.12 Corrective action taken on Maternal Death Review finding Yes Y Y Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N Remarks
Section IX: Record Maintenance:

9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19 9.20 9.21 9.22
OPD Register IPD Register ANC Register PNC Register Indoor bed head ticket Line listing of severely anaemic pregnant women Labour room register Partographs FP-Operation Register (OT) OT Register FP Register Immunisation Register Updated Microplan Blood Bank stock register Referral Register (In and Out) MDR Register Infant Death Review and Neonatal Death Review Drug Stock Register Payment under JSY Untied funds expenditure (Check % expenditure) AMG expenditure (Check % expenditure) RKS expenditure (Check % expenditure)
Section X: Referral linkages in last two quarters:

10.1 10.2 10.3
Section XI: IEC display:

S.No. 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 11.10 Material Approach roads have directions to the health facility Citizen Charter Timings of the health facility List of services available Essential Drug List Protocol Posters JSSK entitlements (Displayed in ANC Clinics/PNC Clinics) Immunization Schedule JSY entitlements( Displayed in ANC Clinics/PNC Clinics) Other related IEC material Yes Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N Remarks
Section XII: Additional/Support Services:

S.No. 12.1 12.1a 12.2 12.3 12.4 12.5 12.6 12.7 Material Regular sterilisation of LR (Check Records) Regular sterilisation of OT (Check Records) Functional Laundry/washing services Availability of dietary services Appropriate drug storage facilities Equipment maintenance and repair mechanism Grievance Redressal mechanisms Tally software implemented Yes Y Y Y Y Y Y Y Y No N N N N N N N N Remarks

DH
DH Level Monitoring Checklist

Name of District:............................. Name of Block:................................. Name of DH:.................................. Catchment Population:........................ Total Villages: ............................. Date of last supervisory visit:.............................................................. Date of visit: ............................... Name & designation of monitor:................................................................. Names of staff not available on the day of visit and reason for absence:............................................................

S.No. 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.9 1.10 1.11 1.12 1.13 1.14 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 Infrastructure Health facility easily accessible from nearest road head Functioning in Govt. building Building in good condition Habitable Staff Quarters for MOs Habitable Staff Quarters for SNs Habitable Staff Quarters for other categories Electricity with power back up Running 24*7 water supply Clean Toilets separate for Male/Female Functional and clean labour Room Functional and clean toilet attached to labour room Functional New born care corner(functional radiant warmer with neo-natal ambu bag) Functional Newborn Stabilization Unit Functional SNCU Clean wards Separate Male and Female wards (at least by partitions) Availability of Nutritional Rehabilitation Centre Functional BB/BSU, specify Separate room for ARSH clinic Availability of complaint/suggestion box Availability of mechanisms for Biomedical waste management (BMW)at facility BMW outsourced Availability of ICTC/ PPTCT Centre Availability of functional Help Desk Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N N N N N N N N N N N N N Additional Remarks

S.No. 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14 Category OBG Anaesthetist Paediatrician General Surgeon Other Specialists MOs SNs ANMs LTs Pharmacist LHV Radiographer RMNCHA+ counsellors Others Numbers Remarks if any

S.No. 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.15 3.16 Training EmOC LSAS BeMOC SBA MTP/MVA NSV F-IMNCI NSSK Mini Lap-Sterilisations Laproscopy-Sterilisations IUCD PPIUCD Blood storage IMEP Immunization and cold chain Others No. trained Remarks if any

Equipment Functional BP Instrument and Stethoscope Sterilised delivery sets Functional Neonatal, Paediatric and Adult Resuscitation kit 4.4 Functional Weighing Machine (Adult and child) 4.5 Functional Needle Cutter 4.6 Functional Radiant Warmer 4.7 Functional Suction apparatus 4.8 Functional Facility for Oxygen Administration 4.9 Functional Foetal Doppler/CTG 4.10 Functional Mobile light 4.11 Delivery Tables 4.12 Functional Autoclave 4.13 Functional ILR and Deep Freezer 4.14 Emergency Tray with emergency injections 4.15 MVA/ EVA Equipment 4.16 Functional phototherapy unit S.No. O.T Equipment 4.18 O.T Tables 4.19 Functional O.T Lights, ceiling 4.20 Functional O.T lights, mobile 4.21 Functional Anesthesia machines 4.22 Functional Ventilators 4.23 Functional Pulse-oximeters 4.24 Functional Multi-para monitors 4.25 Functional Surgical Diathermies 4.26 Functional Laparoscopes 4.27 Functional C-arm units 4.28 Functional Autoclaves (H or V) S.No. Laboratory Equipment 4.1a Functional Microscope 4.2a Functional Hemoglobinometer 4.3a Functional Centrifuge 4.4a Functional Semi autoanalyzer 4.5a Reagents and Testing Kits 4.6a Functional Ultrasound Scanners 4.7a Functional C.T Scanner 4.8a Functional X-ray units 4.9a Functional ECG machines 40 Supportive Supervision Plan & Checklists S.No. 4.1 4.2 4.3 Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Yes Y Y Y Y Y Y Y Y Y Y Y Yes Y Y Y Y Y Y Y Y Y No N N N N N N N N N N N N N N N N No N N N N N N N N N N N No N N N N N N N N N Remarks
Remarks
Remarks

S.No. 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 S.No 5.23 Essential Medical Supplies EDL available and displayed Computerised inventory management IFA tablets IFA tablets (blue) IFA syrup with dispenser Vit A syrup ORS packets Zinc tablets Inj Magnesium Sulphate Inj Oxytocin Misoprostol tablets Mifepristone tablets Availability of antibiotics Labelled emergency tray Drugs for hypertension, Diabetes, common ailments e.g PCM, anti-allergic drugs etc. Vaccine Stock available Supplies Pregnancy testing kits Urine albumin and sugar testing kit OCPs EC pills IUCDs Sanitary napkins Essential Consumables Gloves, Mckintosh, Pads, bandages, and gauze etc. Yes Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Yes Y Y Y Y Y Y Yes Y No N N N N N N N N N N N N N N N N No N N N N N N No N Remarks
Remarks
Remarks
Section VI: Other Services :

S.No. 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Lab Services Haemoglobin CBC Urine albumin and sugar Blood sugar RPR (Rapid Plasma Reagin) test Malaria (PS or RDT) T.B (Sputum for AFB) HIV (RDT) Yes Y Y Y Y Y Y Y Y No N N N N N N N N Remarks
S.No. 6.9 6.10 6.11 6.12 6.13 6.14 6.15 S.No. 6.16 6.17 6.18
Lab Services Liver function tests(LFT) Ultrasound scan (Ob.) Ultrasound Scan (General) X-ray ECG Endoscopy Others , pls specify Blood bank / Blood Storage Unit Functional blood bag refrigerators with chart for temp. recording Sufficient no. of blood bags available Check register for number of blood bags issued for BT in last quarter
Yes Y Y Y Y Y Y Y Yes Y Y
No N N N N N N N No N N
Remarks
Remarks
Section VII: Service Delivery in last two quarters:

S.No. 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.11 7.12 7.13 7.14 7.15 7.16 7.17 7.18 7.19 7.20 7.21 Service Utilization Parameter OPD IPD Expected number of pregnancies No. of pregnant women given IFA Total deliveries conducted No. of assisted deliveries( Ventouse/ Forceps) No. of C section conducted Number of obstetric complications managed, pls specify type No. of neonates initiated breast feeding within one hour Number of children screened for Defects at birth under RBSK RTI/STI Treated No of admissions in NBSUs/ SNCU, whichever available No of admissions :Inborn No of admissions :Outborn No. of children admitted with SAM No. of sick children referred No. of pregnant women referred No. of IUCD Insertions No. of Tubectomy No. of Vasectomy No. of Minilap Q1 Q2 Remarks
S.No. 7.22 7.23 7.24 7.25 7.26 7.27 7.28 7.29 7.30 7.31 7.32 7.33
Service Utilization Parameter No. of children fully immunized Measles coverage No. of children given ORS + Zinc No. of children given Vitamin A No. of women who accepted post-partum FP services No. of MTPs conducted in first trimester No. of MTPs conducted in second trimester Number of Adolescents attending ARSH clinic Maternal deaths, if any Still births, if any Neonatal deaths, if any Infant deaths, if any
Q1
Q2
Remarks
Section VII a: Service delivery in post natal wards:

S.No. Parameters 7.1a All mothers initiated breast feeding within one hour of normal delivery 7.2a Zero dose BCG, Hepatitis B and OPV given 7.3a Counseling on IYCF done 7.4a Counseling on Family Planning done 7.5a Mothers asked to stay for 48 hrs 7.6a JSY payment being given before discharge 7.7a Mode of JSY payment (Cash/ bearer cheque/Account payee cheque/Account Transfer) 7.8a Any expenditure incurred by Mothers on travel, drugs or diagnostics(Please give details) 7.9a Diet being provided free of charge Yes Y Y Y Y Y Y No N N N N N N Remarks
Y Y
N N

Through probing questions and demonstrations assess does the staff know how to S.No. Essential Skill Set 8.1 Manage high risk pregnancy 8.2 Provide essential newborn care (thermoregulation, breastfeeding and asepsis) 8.3 Manage sick neonates and infants 8.4 Correctly uses partograph 8.5 Correctly insert IUCD 8.6 Correctly administer vaccines 8.7 Segregation of waste in colour coded bins 8.8 Adherence to IMEP protocols Yes Y Y Y Y Y Y Y Y No N N N N N N N N Remarks
S.No. 8.9 8.10 8.11 8.12
Essential Skill Set Bio medical waste management Updated Entry in the MCP Cards Entry in MCTS Corrective action taken on Maternal Death Review finding
Yes Y Y Y Y
No N N N N
Remarks
Section IX: Record Maintenance:

9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12 9.13 9.14 9.15 9.16 9.17 9.18 9.19 9.20 9.21 9.22
OPD Register IPD Register ANC Register PNC Register Indoor bed head ticket Line listing of severely anaemic pregnant women Labour room register Partographs FP-Operation Register (OT) OT Register FP Register Immunisation Register Updated Microplan Blood Bank stock register Referral Register (In and Out) MDR Register Infant Death Review and Neonatal Death Review Drug Stock Register Payment under JSY Untied funds expenditure (Check % expenditure) AMG expenditure (Check % expenditure) RKS expenditure (Check % expenditure)
Section X: Referral linkages in last two quarters:

S.No. JSSK Mode of Transport (Specify Govt./ pvt) No. of women No. of sick No. of transported infants children during ANC/ transported 1-6 years INC/PNC Free/Paid
10.1 10.2 10.3
Home to facility Inter facility Facility to Home (drop back)
Section XI: IEC display:

S.No. 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 11.10 Material Approach roads have directions to the health facility Citizen Charter Timings of the health facility List of services available Essential Drug List Protocol Posters JSSK entitlements (Displayed in ANC Clinics/PNC Clinics) Immunization Schedule JSY entitlements( Displayed in ANC Clinics/PNC Clinics) Other related IEC material Yes Y Y Y Y Y Y Y Y Y Y No N N N N N N N N N N Remarks
Section XII: Additional/Support Services:

S.No. 12.1 12.1 a 12.2 12.3 12.4 12.5 12.6 12.7 Material Regular Sterilisation Labour Room (Check Records) Regular Sterilisation OT (Check Records) Functional Laundry/washing services Availability of dietary services Appropriate drug storage facilities Equipment maintenance and repair mechanism Grievance Redressal mechanisms Tally software Implemented Yes Y Y Y Y Y Y Y Y No N N N N N N N N Remarks

Maternal Health Division Ministry of Health & Family Welfare Government of India With Support from other RCH Divisions & NHSRC

Supportive Supervision Plan &amp; Checklists

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