Supportive supervision checklist on EPI

Name of the health centre: / Date of supervision:...... /...... /......
Sub-district/municipality/Zone: / Name of Supervisor:
District: / Designation:
1 Health services organisation:
1.1 Is there any available seating area for mother and child? / Yes___ / No___
1.2 Chair and Table for health worker and care taker? / Yes___ / No___
1.3 Up-to-date and complete monitoring chart on the wall? / Yes___ / No___
1.4 Up-to-date cases of target diseases on the wall? / Yes___ / No___
1.5 Vaksin manakah and Vaksin dan cara pemberiannya on wall or desk? / Yes___ / No___
1.6 Contingency Plan for power /supply failures displayed? / Yes___ / No___
1.7 Is a map of local area displayed? / Yes___ / No___
1.8 EPI Local Area Monitoring system displayed? / Yes___ / No___
If any problem is found related to health services organization, what actions are needed to be taken? Develop and ensure support plan also.
Action/s to be taken by supervisee: / Action/s to be taken by supervisor:
2 Clinical Staff Trained on EPI:
Clinical Staff / Available staff at post / #available staff trained in EPI / # staff received refresher training / # staff supported by follow-up after training
2.1 Nurse
2.2 Midwife
3 Quality of EPI case management:
Name of the provider: Designation:
3.1 Consultation observation (observe one patient consultation):
3.1.1 / Did provider show respect to client/s? / Yes__ / No__
3.1.2 / Did provider explain about antigens and diseases with a flip chart? / Yes__ / No__
3.1.3 / Did provider advise on potential side effects? / Yes__ / No__
3.1.4 / Did provider explain when to return for next dose? / Yes__ / No__
3.1.5 / Did provider remind carer to bring LISIO for every visit / Yes__ / No__
3.1.6 / Did provider correctly assess which vaccines infants are eligible for? / Yes__ / No__
3.1.7 / Did provider correctly assess if due for Vitamin A? / Yes__ / No__
3.1.8 / Did provider correctly reconstitute measles and BCG (appropriate diluent and temperature)? / Yes__ / No__
3.1.9 / Did provider correctly administer intra-dermal dose (BCG)? / Yes__ / No__
3.1.10 / Did provider correctly administer intramuscular dose (DTP-HepB and TT)? / Yes__ / No__
3.1.11 / Did provider correctly administer subcutaneous dose (Measles)? / Yes__ / No__
3.1.12 / Did provider correctly administer OPV? / Yes__ / No__
3.1.13 / Did provider have no missed opportunities? / Yes__ / No__
3.1.14 / Did provider load vaccines correctly in refrigerator? / Yes__ / No__
3.1.15 / Did provider not store any vaccines past expiry date? / Yes__ / No__
3.1.16 / Does provider check and use VVM correctly? / Yes__ / No__
3.1.17 / Does provider check expiry dates on vials? / Yes__ / No__
3.1.18 / Does provider dispose of injection supplies correctly? / Yes__ / No__
3.1.19 / Does provider make correct decision on contra-indications? / Yes__ / No__
3.1.20 / Is provider able to identify any RED problem categories based on monitoring chart? / Yes__ / No__
Scoring of skills of provider: give 1 point for each YES answer
Score:
------X 100= ...... %
20
3.2 Cold Chain observation:
3.2.1 / Does provider use ice pack correctly? / Yes__ / No__
3.2.2 / Does provider use vaccine carriers and cold box correctly? / Yes__ / No__
3.2.3 / Does provider implement multi-dose vial policy correctly? / Yes__ / No__
3.2.4 / Does provider discard all antigens used (no MDVP) after mobile / outreach activity? / Yes__ / No__
3.2.5 / Is distance of refrigerator from wall ≥ 10 cm? / Yes__ / No__
3.2.6 / Is freezer ice thickness ≤ 0.5 cm? / Yes__ / No__
3.2.7 / Is fridge seal OK? (Not loose or dirty) / Yes__ / No__
Scoring of cold chain management: give 1 point for each YES answer
Score:
------X 100= ...... %
7
In private, share your findings from observational sessions with provider. Praise for the things done well and discuss on the identified weakness, show how it could be done. Ask provider, does s/he have any problem regarding assessment, vaccination, cold chain, counselling, follow-up etc. If s/he has, try to solve the problem instantly. Note down the decisions which have been taken to improve the skills and continue the practices:
Action/s to be taken by supervisee: / Action/s to be taken by supervisor:
4 Quality of records (Document review):
4.1 Total EPI patient in last month: < 1 year ______≥ 1 year______Total ______Caseload: _____ / provider/ day
4.2 Did they send monthly report of last month? Yes___ No___
4.3 Individual patient register correctly completed? Yes___ No___
4.4 LISIO correctly completed? Yes___ No___
4.5 Records vaccine doses used? Yes___ No___
4.6 Records vaccine doses wasted? Yes___ No___
4.7 Updates temperature twice daily? Yes___ No___
4.8 Vaccine and injection supply needs correctly calculated? Yes___ No___
4.9 Has a session plan for mobile / outreach? Yes___ No___
5  Infection Prevention:
5.1 Did provider always use AD syringe to immunize? / Yes__ / No__
5.2 Did provider avoid recapping needles? / Yes__ / No__
5.3 Did provider dispose of syringe safely? / Yes__ / No__
5.4 Is there soap and/ or disinfectant for washing hands? / Yes__ / No__
5.5 Is there a safe disposal box with cover, not overfilled? / Yes__ / No__
If any problems related to the IMCI corner are found, what actions are needed to be taken? Develop and ensure support plan also.
Action/s to be taken by supervisee:
/ Action/s to be taken by supervisor:
6 Job aid and supplies: ( make a tick mark when correct) /
Logistics
/ Available / Adequate enough in stock for one month / Remark /
LISIO /
Registers /
Tally sheets /
Vaksin manakah and Vaksin dan cara pemberiannya /
Syringe (0.05ml) /
Syringe (0.5ml) /
Syringe (2ml) /
Syringe (5ml) /
Safety Boxes /
BCG /
OPV /
DTP-HepB /
Measles /
TT /
Vitamin A /
If you found any gaps regarding vaccines and supplies, discuss and make an activity and support plan to address the problems /
Action/s to be taken by supervisee: / Action/s to be taken by supervisor:
7 Supervision:
7.1 Did anybody visit this centre for EPI supervision in last three months (quarter)? Yes__ No__
7.2 Ask them to give you the last supervision report / Date ...... /...... /......
Supervisors designation......
7.3 Progress of the last decision/s which was/were taken during last visit?
Signature of Supervisee:______
Date:...... /...... /...... / Signature of Supervisor:______
Date:...... /...... /......
Please leave a copy of signed report to respective facility before leaving and send one copy to district within 7 days of visit

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