19.4 Tools for supervision

Supervisory checklists are to be used to review and identify the administrative and technical issues methodically (Annex 3). Checklist should be systematically filled in, calculating all indicators and answering all questions along with the relevant health worker. The checklist should be completed by the end of the supervisory visit. The checklist provides a broad guideline, but the supervisory visit should not be confined only to the checklist and there is ample scope to look at other issues that are locally relevant.

General

• Availability of the National Guidelines and Operational Manual for TB; other NTP guidelines and SOPs including laboratory manual
• Availability of all updated recording and reporting formats
• Availability of all standard ACSM/IEC/BCC materials for TB
• Human resources: staff status (post sanctioned and vacant), availability of job description; availability of the individual work plan, training status of staff; knowledge, skills and attitude of relevant staff; job satisfaction.

Identification of presumptive TB cases and laboratory diagnosis

• Trends of presumptive cases: number of Presumptive TB cases per month; presumptive TB notification rate (Presumptive TB cases detected during a defined period in a defined geographic area /total population of that area x 100,000)
• Review data outliers and unusual scenarios and provide feedback; e.g., number of sputum samples examined per presumptive TB case (if there are multiple instances of single sample examination, this usually indicates poor patient counselling and / or incorrect identification of presumptive TB.
• Review the source of referral of presumptive cases
• Triangulation: check that all patients who are diagnosed as per the TB Laboratory Register (TB 04) have been started on treatment [treatment card (TB 01) available] and are registered in the TB register (TB 04). Cross check the consistency of data recorded in these 3 records.
• Check that clinically diagnosed presumptive TB cases (smear negative) are referred to a qualified physician for further investigations according to TB diagnostic algorithm
• Calculate sputum positivity rates among both, presumptive TB cases as well as during follow up examinations. Conduct in depth review to find out possible causes for very low or very high sputum positivity rates and suggest remedial measures.
• Quality of sputum samples; quality and quantity
• Check the quality of smears (size, shape, thickness, evenness, staining)
• Review reporting turnaround times and discuss issues identified if any.
• Check the upkeep and maintenance status of microscope, Xpert, functional module/s of Xpert, and other equipment and logistics
• Check whether there is adequate supply of laboratory consumables for at least one month
• Check for Infection control measures (patients waiting area, sputum collected outside, availability and use of mask, etc.).