checklist for assessment of iucd

8/16/2019 Checklist for Assessment of IUCD

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Annex -1: Checklist for Assessment of IUCD Provider’s Performance,

Follow -up and On- site Coaching (Skill Assessment)

Name of the Health Facility: ……………………………………….……………………….

District: ……………… Type of Health Facility:………..

Name of Provider: …………………………………, Designation: ………………..

Coached by:……………… Date of Coaching:……/……/…

Key to type of service

for which checklist

criteria apply

A = IUD Counseling

B= IUD Insertion

C = IUD Follow-up

D = IUD Removal

Scoring Key

P (3)

Proficient -- Provider demonstrates ability to perform procedure, executing all

indicated tasks without guidance; does not require further training

C (2)

Competent -- Provider acceptably demonstrates ability to perform procedure, executing

most of the indicated tasks and all of the necessary (highlighted) tasks with little or no

guidance; while sufficiently competent to provide services, the provider would benefit

from continued intermittent oversight to improve confidence and overall ability.

NI (1)

Need Improvement-- Provider does not acceptably demonstrate ability to perform

procedure and does not execute the necessary (highlighted) tasks; provider mustcontinue with training or supervised practice before beginning IUD service delivery

Checklist to assess provider’s skill level relative to performance expectations for IUD service delivery

S e r v i c e

Y o

r N Skills Expectations Demonstrated Ability /

Cases Observed

I II III IV V

PRE-INSERTION (NON-CLINICAL)

A 1. Performs pre‐insertion counseling according protocol

a) Interacts with client in a respectful manner

b)

Asks the

client

questions

to

help

clarify

her

reproductive

health

needs

c) Explains what the IUD (and other methods if client has not already decided to

use IUD) is, how it works, and how it might meet her reproductive health needs

d) Explains possible IUD side effects and reassures client that they are not harmful

and that they usually subside over time

e) Explains potential complications involved with IUD use and reassures client that

she is unlikely to experience any problems, especially if she has the IUD inserted

by a skilled provider who knows how to minimize risks

f) Explains eligibility criteria and procedures for assessing client eligibility

g) Explains insertion procedures

h) Checks to make sure that client understands key messages conveyed

i) Answers any questions the client has

)

Assists client

in

making

a decision

about

using

the

IUD

(or

another

method

if

appropriate)

k) Respects client's choice of family planning methods and does not try to

convince her to use one method over another

A 2. Performs non‐clinical aspects of pre‐insertion screening according to protocol

a) Determines that client is not pregnant (acts accordingly if she is)

b) Takes client's medical history


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S e r v i c e

Y o


Cases Observed

I II III IV V

PRE-INSERTION (CLINICAL)

A 3. Performs pre‐insertion counseling according protocol

a) Reviews client's reproductive health history to ensure that client meets initial

criteria for IUD. If client does not, appropriate steps are taken. If client does

meet criteria, provider proceeds with clinical screening.

b)

Instructs client

to

empty

her

bladder

if necessary

c) Has HLD instrument pan, supplies, and light source available

d) Helps client onto exam table

e) Washes hands with soap and water

f) Tells the client what is going to be done and answers any questions she may

have

g) Checks for signs of severe anemia

h) Performs abdominal exam ‐‐ palpates abdomen and checks for suprapubic or

pelvic tenderness and adnexal abnormalities

i) Drapes client for vaginal exam

) Puts new exam (disposable) or HLD or sterile (reusable) gloves on both hands

k)

Performs

vaginal

exam ‐‐

checking

for

ulcers,

lesions,

sores,

or

discharge l) If no problems found, proceeds to bimanual exam. If problems found, performs

speculum exam next.

m) Performs bimanual exam checking for cervical, adnexal, or uterine

abnormalities that would preclude insertion

n) Uncovers instruments for speculum exam

o) Assembles HLD (or sterile) speculum

p) Inserts speculum

q) Performs speculum exam, locates cervix checking for any signs of cervical or

vaginal problems that might preclude insertion at this time

r) Makes appropriate findings based decision on whether or not to proceed with

insertion and explains decision to client

s)

If

decision

is

to

NOT

insert

the

IUD

at

this

time,

then

terminates

exam

and explains reasons to client and makes recommendations for other method and

for any necessary treatment needed.

t) If decision is to go ahead with insertion, then the provider obtains informed

consent appropriate to the setting and proceeds with the procedures that

follow

Insertion

B 4. Performs pre‐insertion task according protocol

a) Loads the IUD inside the sterile package according to package

instructions/protocols

b) Swabs cervix and vagina with antiseptic

c) Gently grasps cervix with tenaculum or Vulsellum Forceps

d)

Sounds the

uterus

to

check

positioning

of

uterus

e) Sets depth gauge on the loaded IUD inserter to the depth of the sound

f) Inserts the IUD using the withdrawal technique

g) Cuts strings and gently removes tenaculum

5. Performs post ‐insertion tasks according to protocol

a) Processes instruments and consumables (places used instruments in chlorine

solution for decontamination, disposes of waste materials properly, removes

reusable gloves and places them in chlorine solution)


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S e r v i c e

Y o


Cases Observed

I II III IV V

b) Washes hands with soap and water

c) Schedules a follow‐up appointment with client for 3‐6 weeks after insertion

d) Gives client a referral card for follow‐up if does not provide follow‐up care

e) Records insertion according to record keeping protocols

f) Reviews key messages for women who have just had an IUD inserted (refer to

table in

protocols

section

6.4)

g) Assesses client to make sure that she feels well and observes her for 15 minutes

before sending her home

FOLLOW-UP

C 6. Conducts client assessment according to protocol

a) Assesses client’s satisfaction with IUD

b) Assesses for common side effects

c) Screens for warning signs (PAINS)

d) Addresses any questions or concerns the client may have

e) Reviews key IUD messages (see textbox 2.2.1) with client

C 7. Performs physical exam where indicated (for first routine checkups and where

infection may

be

suspected

for

other

return

visits)

a) Explains to client why and how she will do the pelvic exam

b) Prepares the client while ensuring dignity and privacy

c) Performs a speculum exam and checks to make sure the string is visible and that

there is no partial or complete expulsion

d) Explains findings and reassures the client

e) Appropriately manages any side effects or complications that the client is

experiencing (according to procedures outlined in Table 3, section 7.3)

REMOVAL

D 8. Conducts pre‐removal counseling

a) Asks the client her reason for removal and answers any questions she may have

b)

Reviews the

client's

present

reproductive

goals

c) Describes the removal procedure and what to expect

D 9. Removes IUD according to protocol

a) Washes hands thoroughly with soap and water

b) Puts new exam (disposable) or HLD or sterile (reusable) gloves on both hands

c) Inserts HLD or sterile speculum and looks at length and position of strings

d) Swabs cervix and vagina with antiseptic

e) Grasps strings close to the cervix and pulls gently but firmly to remove the IUD

f) Shows client the IUD and places it in chlorine solution for decontamination

10. Performs post ‐removal tasks according to protocol

a) Places used instruments in chlorine solution for decontamination

b)

Disposes of

waste

materials

according

to

guidelines

c) Removes reusable gloves and places them in chlorine solution or disposes of

disposable gloves

d) Washes hands thoroughly with soap and water

e) Records IUD removal according to PSI record keeping protocol

f) Assists client in selecting and obtaining new contraceptive method if desired

g) Keeps client at clinic for 15 minutes for observation to make sure she feels fine

before leaving


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S e r v i c e

Y o


Cases Observed

I II III IV V

INFECTION PREVENTION

B

,

C

,D

11. Practices proper infection prevention procedures before, during, and after the

procedure according to protocol

a) Instruments and supplies are ready and available for use at time of procedure

for which they are needed

b) IUD package is not opened until after it is loaded and at time of procedure

c) Procedures for hand washing and use of exam gloves are followed

d) Proper client cleansing procedures are followed

e) “No touch” technique is used when inserting the IUD

f) Instruments, gloves, and other items are processed and stored according to

protocol

Score Calculation:

1. Insertion Score:

Score of (1-5) and 11

------------------------------- x 100% = ------------------- = ---------%

Total Score (Total 159)

2.

Follow up Score:


------------------------------ x 100% = ------------------- = ---------%


3. Removal Score:


------------------------------ x 100% = ------------------- = ---------%


Index Score:

Proficient = >90%

Competent = 69-89%

Need Improvement =


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Overall Impression to Skill Level of Service Provider:

Total Score Percent and Category = ……………………………………………

Impression……………………………………………………………………….

Recommendation:

1.

………………………………………………………….………………….

2. ……………………………………………………………………………..

3. ……………………………………………………………………………..

Total number of IUCD inserted by the provider till date:

Coached by:

Signature:


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Guidelines for filling Assessment of IUCD Provider’s Performance, Follow up and

On-site Coaching Form

Objective: The main objective of this checklist is to assess quality of service provider, update about

recent changes and to encourage the providers to apply these in their routine practices.

Responsibility: This checklist is mainly filled by the Coach or Quality Assurance Consultant assigned byPSI office and handed over to the office on the same day of CSD visit.

Guidelines:

1. The first introductory part of checklist, coach should be filled according to the sub-headings

provided at top.

2.

Competency of service provider is divided into 3 category i.e. Proficient (P= score 3), Competent

(C= score 2) and Need Improvement (NI = 1). The broad category of the provider will be provided

in the Index score as percentage.

3. Coach should observe 5 clients receiving services at every section of service provider outlet.

4.

In each cell of the cases observed, Coach should put score 1-3 and put summed score at the top of

each section.

5. For the each type of services e.g. Insertion, Removal or Follow up services, infection prevention

part should be included in each.

6. For overall competency score calculation, coach has to separate the purpose like Insertion, Follow

up or Removal services. In each service, see the score calculation given at the last page.

Competency of each case should calculate and put average score.

7. The average score will put on the total score and mention the category of service provider.

8. Coach should mention the impression of competency of service provider and recommend further

based on the score and competency observed in each client.

9.

The form should be filled and sign on the same day of observation, and handed over to PSI staff.10. Checklists collected from coach should send to MIS section of Head office.

11.

Action plans are made and implemented for every provider by identifying their areas of

improvements to address their needs.

12. This checklist should fill for every provider at service site and follow up coaching for the same

provider after 3 months.


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Annex 2: Knowledge Assessment Test

Name of the Provider:

Date‐

Instructions: Circle the letter that corresponds to the correct answer.

1. Who is the best-qualified person to choose a contraceptive method for a woman in

good health?

a. a trained physician

b. a woman’s mother in law

c. the woman herselfd. the person who counseled her

2. Women who are not in a mutually faithful relationship (i.e., she or her partner

have other sexual partners) may be at increased risk ofa. uterine perforation with IUD insertion

b. Sexually Transmitted Infections (STIs)

c. ovarian cancer

d. all of the above

3. The IUD not only protects a woman from undesired pregnancy, but also from

a. developing fibroids

b. HIV infection

c. anemia

d. all of the above

e. none of the above

4. When an IUD client presents with a late period, you should rule out

a. allergy to copper

b. pregnancy

c. cervical cancer

d. PID

5. Following the insertion of an IUD, you should recommend that the client, even if

she has no problems, have it checked after

a. three days

b. one week

c. six weeks to twelve weeks


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d. three to six weeks

6. The most likely mechanism of action of the IUD is that

a. it interferes with implantation

b. it interferes with fertilization

c. it interferes with ovulationd. it acts as a barrier to prevent sperm from entering uterus

7. The IUD is NOT an appropriate contraceptive method for a woman who

a. is taking rifampin

b. is not sure she wishes to have a tubectomy

c. has unexplained vaginal bleeding

d. gave birth six weeks ago

8. During counseling on the IUD, a client should be informed that common sideeffects of the IUD may include

a. nausea b. headaches

c. mild cramping and light spotting

d. heavy vaginal discharge

9. The IUD is

a. 90 - 95% effective

b. greater than 99% effectivec. 100% effective

d. none of the above

10. Correctly loading the TCu 380A IUD in the sterile package

a. should be done only if sterile gloves are available

b. assures that the IUD will remain sterile until it is removed from the package

c. is not necessary for physicians

d. all of above

11. One of the point is not among the five warning signs in IUCD clients

a. Period late or no period

b. Abdominal pain

c. Infection

d. Not feeling well

e. Ectopic pregnancy


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12. In counseling a woman about the advantages of the TCu 380A IUD, you would

inform her that the IUD

a. is permanent b. is less effective

c. has few side effects for most women

d. interferes with sexual intercourse

e. is effective in preventing anemia

13. Which of the following conditions are precautions which influence the suitability

of IUD for a particular woman?a. pregnancy

b. three or more children

c. not at risk for STIs

d. history of candidiasis

e. retroverted uterus

14. Prior to IUD insertion, a pelvic exam is performed to

a. determine uterine position and size

b. rule out ante-flexion

c. rule out retro-version

d. rule out presence of ectopic pregnancy

15. Physical examination of a prospective IUCD client must include at least:

a. abdominal and bimanual exams

b. abdominal and pelvic (speculum and bimanual) exams

c. breast, abdominal and pelvic (speculum and bimanual) exams

d. general, breast, abdominal and pelvic (speculum and bimanual) exams

16. After an IUD insertion all metal instruments used should be

a. decontaminated with soap and water

b. decontaminated in 0.5% chlorine solution for 10 minutes

c. cleaned with formaldehyde and water

d. high level disinfected by autoclaving (unwrapped) for 20 minutes at 106 kPa pressure

at 1210 degrees

17. Key infection prevention activities for IUD insertion include

a. washing hands carefully

b. cleaning the cervix and vagina with an antiseptic solution

c. decontaminating, cleaning, and high-level disinfecting, or sterilizing all instruments


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d. proper contaminated waste disposal

e. all of the above

18. Reasons for follow up visits after an IUD insertion can include

a. first check up one week after insertion b. first check up three to six weeks after insertion

c. first check up 6 months after IUCD insertion

d. removal when the IUD has been in place for one year

19. The following is warning sign that you should explain to an IUD client, which

indicate that she may be having a problem with her IUD and should seek medical

attention:

a. cramping with menses

b. increased length of menstrual cycle

c. Mild vaginal discharge

d. string is longer than usual/Missing string

20. IUD clients should be counseled

a. before the insertion

b. after insertion

c. during each follow up visit

d. all of the above.

Total Score:

Percentage:


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Guidelines for filling Knowledge Assessment Test

Objectives: The main objective of this test is to assess the knowledge of the service provider during

Quality Assurance visit

Responsibility: This test is mainly filled by the service provider herself and checked by the Quality

Assurance Consultant to assess the knowledge of provider.

Guidelines:

1. Every service provider is given the knowledge assessment test during the Quality Assurance

visit to self assess her knowledge.

2.

The service provider is given 20 sets of questions to answer and at the end of the test her

marks is used to assess her knowledge about IUDs.

3. In case she has given any incorrect answers to the question the coach corrects her to

ensure that the provider has correct informations on IUDs.


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Annex 3: Quality Assurance Checklist

Sector ID: Date:

District ID:

Name of health facility:

Channel:

Health Facility Code:

Name of the service provider:

Name of the coach:

Health Facility assessment Yes/No

Registration/Counseling

Counseling Aids available?

Individual counseling done?

Informed Choice of Family planning?

Is consent taken before service delivery?

Medical screening

History of the client taken properly?

Vitals recorded?

Correct Bimanual/pelvic

examination

findings?

Checklist for screening followed?

Service delivery

Loading of IUCD done by non‐touch technique?

Adequate space for service delivery?

Is privacy maintained?

Service delivery forms available?


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High fundal placement of IUCD

5. Post counseling

6. Infection prevention

Instruments opened in virex?

All the instruments sterilized properly?

Waste materials disposed properly?

Summary

Quality of service= Total no. of YES X 100 =

20

Index Score:

More than

90%

= Quality

standard

met

(Good)

Less than 90% = Quality not met (Bad)

Impression:

Recommendations:

1…………………………………………………………………………………….

2…………………………………………………………………………………….

3…………………………………………………………………………………….

Visited by:

Signature:

Clients explained about the possible side effect of

LTM?

Clients explained about the follow up?

Clients explained about designated point of contact in

case of any AE and complication?

Clients explained about the warning signs?


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Guidelines for filling Quality Assurance Checklist

Objective: The main objective of this checklist is to assure the quality of service provided at

service site, performance skills and knowledge of provider.

Responsibility: This Checklist is filled by the Quality Assurance Consultant assigned by the PSI office and

handed over to the office on the same day of Quality Visit.

Guidelines:

1. There are 6 sets of questions that are made according to the IUCD service deliver y protocol.

2. There are 20 questions regarding health facility, counseling, medical screening, service delivery, post

counseling and infection prevention services available at the clinic support day.

3. If the index score is more than 90% it refers that the quality standards has been met at the clinic

support days and if the score is less than 90% then the quality standard is low.

4. Recommendations

are

given

by

the

Quality

Assurance

Consultant

to

improve

the

quality

of

service

delivery.

5. When the final process is completed online reporting is done in the MIS system.

6. An action plan is made and implemented to address the issues of the Quality Assurance visits so that

the quality standards are met.

checklist for assessment of iucd

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