Annex1: Checklist for Assessment of IUCD Providers Performance,

FollowupandOnsiteCoaching(SkillAssessment)

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
Proficient -- Provider demonstrates ability to perform procedure, executing all
indicated tasks without guidance; does not require further training
P (3)
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
C (2)
guidance; while sufficiently competent to provide services, the provider would benefit
from continued intermittent oversight to improve confidence and overall ability.
Need Improvement-- Provider does not acceptably demonstrate ability to perform
procedure and does not execute the necessary (highlighted) tasks; provider must
NI (1)
continue with training or supervised practice before beginning IUD service delivery

Y or N

Service

Checklist to assess providers skill level relative to performance expectations for IUD service delivery

Skills Expectations

Demonstrated Ability /
Cases Observed
I
II
III
IV V

PRE-INSERTION (NON-CLINICAL)
1.
a)
b)
c)

d)
e)

f)
g)
h)
i)
j)
k)

2.

Performspreinsertioncounselingaccordingprotocol
Interactswithclientinarespectfulmanner
Askstheclientquestionstohelpclarifyherreproductivehealthneeds
ExplainswhattheIUD(andothermethodsifclienthasnotalreadydecidedto
useIUD)is,howitworks,andhowitmightmeetherreproductivehealthneeds
ExplainspossibleIUDsideeffectsandreassuresclientthattheyarenotharmful
andthattheyusuallysubsideovertime
ExplainspotentialcomplicationsinvolvedwithIUDuseandreassuresclientthat
sheisunlikelytoexperienceanyproblems,especiallyifshehastheIUDinserted
byaskilledproviderwhoknowshowtominimizerisks
Explainseligibilitycriteriaandproceduresforassessingclienteligibility
Explainsinsertionprocedures
Checkstomakesurethatclientunderstandskeymessagesconveyed
Answersanyquestionstheclienthas
Assists client in making a decision about using the IUD (or another method if
appropriate)
Respects client's choice of family planning methods and does not try to
convincehertouseonemethodoveranother
Performsnonclinicalaspectsofpreinsertionscreeningaccordingtoprotocol

a)Determinesthatclientisnotpregnant(actsaccordinglyifsheis)
b)Takesclient'smedicalhistory

Y or N

Service

Skills Expectations

Demonstrated Ability /
Cases Observed
I
II
III
IV V

PRE-INSERTION (CLINICAL)
3. Performspreinsertioncounselingaccordingprotocol
a) Reviews client's reproductive health history to ensure that client meets initial
criteria for IUD. If clientdoes not, appropriate stepsare taken. Ifclientdoes
meetcriteria,providerproceedswithclinicalscreening.
b) Instructsclienttoemptyherbladderifnecessary
c) HasHLDinstrumentpan,supplies,andlightsourceavailable
d) Helpsclientontoexamtable
e) Washeshandswithsoapandwater
f) Tells the client what is going to be done and answers any questions she may
have
g) Checksforsignsofsevereanemia
h) Performs abdominal exam palpates abdomen and checks for suprapubic or
pelvictendernessandadnexalabnormalities
i) Drapesclientforvaginalexam
j) Putsnewexam(disposable)orHLDorsterile(reusable)glovesonbothhands
k) Performsvaginalexamcheckingforulcers,lesions,sores,ordischarge
l) Ifnoproblemsfound,proceedstobimanualexam.Ifproblemsfound,performs
speculumexamnext.
m) Performs bimanual exam checking for cervical, adnexal, or uterine
abnormalitiesthatwouldprecludeinsertion
n) Uncoversinstrumentsforspeculumexam
o) AssemblesHLD(orsterile)speculum
p) Insertsspeculum
q) Performs speculum exam, locates cervix checking for any signs of cervical or
vaginalproblemsthatmightprecludeinsertionatthistime
r) Makesappropriatefindingsbaseddecisiononwhetherornottoproceedwith
insertionandexplainsdecisiontoclient
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
foranynecessarytreatmentneeded.
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
4. Performspreinsertiontaskaccordingprotocol
a) Loads the IUD inside the sterile package according to package
instructions/protocols
b) Swabscervixandvaginawithantiseptic
c) GentlygraspscervixwithtenaculumorVulsellumForceps
d) Soundstheuterustocheckpositioningofuterus
e) SetsdepthgaugeontheloadedIUDinsertertothedepthofthesound
f) InsertstheIUDusingthewithdrawaltechnique
g) Cutsstringsandgentlyremovestenaculum
5. Performspostinsertiontasksaccordingtoprotocol
a) Processes instruments and consumables (places used instruments in chlorine
solution for decontamination, disposes of waste materials properly, removes
reusableglovesandplacestheminchlorinesolution)

Y or N

Service

Skills Expectations

b)
c)
d)
e)
f)
g)

Demonstrated Ability /
Cases Observed
I
II
III
IV V

Washeshandswithsoapandwater
Schedulesafollowupappointmentwithclientfor36weeksafterinsertion
Givesclientareferralcardforfollowupifdoesnotprovidefollowupcare
Recordsinsertionaccordingtorecordkeepingprotocols
ReviewskeymessagesforwomenwhohavejusthadanIUDinserted (referto
tableinprotocolssection6.4)
Assessesclienttomakesurethatshefeelswellandobservesherfor 15minutes
beforesendingherhome

FOLLOW-UP
6.
a)
b)
c)
d)
e)
7.

a)
b)
c)
d)
e)

Conductsclientassessmentaccordingtoprotocol
AssessesclientssatisfactionwithIUD
Assessesforcommonsideeffects
Screensforwarningsigns(PAINS)
Addressesanyquestionsorconcernstheclientmayhave
ReviewskeyIUDmessages(seetextbox2.2.1)withclient
Performsphysicalexamwhereindicated(forfirstroutinecheckupsandwhere
infectionmaybesuspectedforotherreturnvisits)
Explainstoclientwhyandhowshewilldothepelvicexam
Preparestheclientwhileensuringdignityandprivacy
Performsaspeculumexamandcheckstomakesurethestringisvisibleandthat
thereisnopartialorcompleteexpulsion
Explainsfindingsandreassurestheclient
Appropriately manages any side effects or complications that the client is
experiencing(accordingtoproceduresoutlinedinTable3,section7.3)

REMOVAL
8.
a)
b)
c)
9.
a)
b)
c)
d)
e)
f)
10.
a)
b)
c)

Conductspreremovalcounseling
Askstheclientherreasonforremovalandanswersanyquestionsshemayhave
Reviewstheclient'spresentreproductivegoals
Describestheremovalprocedureandwhattoexpect
RemovesIUDaccordingtoprotocol
Washeshandsthoroughlywithsoapandwater
Putsnewexam(disposable)orHLDorsterile(reusable)glovesonbothhands
InsertsHLDorsterilespeculumandlooksatlengthandpositionofstrings
Swabscervixandvaginawithantiseptic
GraspsstringsclosetothecervixandpullsgentlybutfirmlytoremovetheIUD
ShowsclienttheIUDandplacesitinchlorinesolutionfordecontamination
Performspostremovaltasksaccordingtoprotocol
Placesusedinstrumentsinchlorinesolutionfordecontamination
Disposesofwastematerialsaccordingtoguidelines
Removes reusable gloves and places them in chlorine solution or disposes of
disposablegloves
d) Washeshandsthoroughlywithsoapandwater
e) RecordsIUDremovalaccordingtoPSIrecordkeepingprotocol
f) Assistsclientinselectingandobtainingnewcontraceptivemethodifdesired
g) Keepsclientatclinicfor15minutesforobservationtomakesureshefeelsfine
beforeleaving

Y or N

Service

Demonstrated Ability /
Cases Observed
I
II
III
IV V

Skills Expectations

INFECTION PREVENTION
B
,
C
,
D

11. Practicesproperinfectionpreventionproceduresbefore,during,andafterthe
procedureaccordingtoprotocol

a)

Instrumentsandsuppliesarereadyandavailableforuseattimeofprocedure
forwhichtheyareneeded
b) IUDpackageisnotopeneduntilafteritisloadedandattimeofprocedure
c) Proceduresforhandwashinganduseofexamglovesarefollowed
d) Properclientcleansingproceduresarefollowed
e) NotouchtechniqueisusedwheninsertingtheIUD
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:
Score of (6-7) and 11
------------------------------ x 100%
Total Score (Total 48)

= -------------------

= ---------%

= -------------------

= ---------%

= -------------------

= ---------%

3. Removal Score:
Score of (8-10) and 11
------------------------------ x 100%
Total Score (Total 66)

Index Score:

Proficient
= >90%
Competent
= 69-89%
Need Improvement = <69%

Overall Impression to Skill Level of Service Provider:

Total Score Percent and Category =

Impression.
Recommendation:
1. ..
2. ..
3. ..
TotalnumberofIUCDinsertedbytheprovidertilldate:

Coachedby:
Signature:

GuidelinesforfillingAssessmentofIUCDProvidersPerformance,Followupand
OnsiteCoachingForm
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 by
PSI office and handed over to the office on the same day of CSD visit.
Guidelines:

1.
2.

3.
4.
5.
6.

7.
8.
9.
10.
11.
12.

The first introductory part of checklist, coach should be filled according to the sub-headings
provided at top.
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.
Coach should observe 5 clients receiving services at every section of service provider outlet.
In each cell of the cases observed, Coach should put score 1-3 and put summed score at the top of
each section.
For the each type of services e.g. Insertion, Removal or Follow up services, infection prevention
part should be included in each.
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.
The average score will put on the total score and mention the category of service provider.
Coach should mention the impression of competency of service provider and recommend further
based on the score and competency observed in each client.
The form should be filled and sign on the same day of observation, and handed over to PSI staff.
Checklists collected from coach should send to MIS section of Head office.
Action plans are made and implemented for every provider by identifying their areas of
improvements to address their needs.
This checklist should fill for every provider at service site and follow up coaching for the same
provider after 3 months.


Annex2:KnowledgeAssessmentTest

NameoftheProvider:
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 womans mother in law
c. the woman herself
d. 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 of
a. 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 ovulation
d. 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 side
effects 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% effective
c. 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
8

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
9

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.

TotalScore:
Percentage:

10

GuidelinesforfillingKnowledgeAssessmentTest
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. EveryserviceproviderisgiventheknowledgeassessmenttestduringtheQualityAssurance
visittoselfassessherknowledge.
2. Theserviceproviderisgiven20setsofquestionstoanswerandattheendofthetesther
marksisusedtoassessherknowledgeaboutIUDs.
3. Incaseshehasgivenanyincorrectanswerstothequestionthecoachcorrectsherto
ensurethattheproviderhascorrectinformationsonIUDs.

11


Annex3:QualityAssuranceChecklist

Sector ID:

Date:

District ID:
Name of health facility:
Channel:
Health Facility Code:
Name of the service provider:
Name of the coach:

HealthFacilityassessmentYes/No

Adequatespaceforservicedelivery?

Isprivacymaintained?

Servicedeliveryformsavailable?

Registration/Counseling
CounselingAidsavailable?

Individualcounselingdone?

InformedChoiceofFamilyplanning?

Isconsenttakenbeforeservicedelivery?

Medicalscreening
Historyoftheclienttakenproperly?

Vitalsrecorded?

CorrectBimanual/pelvicexaminationfindings?

Checklistforscreeningfollowed?

Servicedelivery
LoadingofIUCDdonebynontouchtechnique?

12

HighfundalplacementofIUCD

5. Post counseling

Clientsexplainedaboutthepossiblesideeffectof

LTM?

Clientsexplainedaboutthefollowup?

Clientsexplainedaboutdesignatedpointofcontactin

caseofanyAEandcomplication?

Clientsexplainedaboutthewarningsigns?

6. Infection prevention
Instrumentsopenedinvirex?

Alltheinstrumentssterilizedproperly?

Wastematerialsdisposedproperly?

Summary
Qualityofservice=Totalno.ofYESX100=
20
IndexScore:

Morethan90%=Qualitystandardmet(Good)
Lessthan90%=Qualitynotmet(Bad)
Impression:
Recommendations:

1.

2.

3.

Visitedby:

Signature:

13

GuidelinesforfillingQualityAssuranceChecklist
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:ThisChecklistisfilledbytheQualityAssuranceConsultantassignedbythePSIofficeand
handedovertotheofficeonthesamedayofQualityVisit.
Guidelines:
1.Thereare6setsofquestionsthataremadeaccordingtotheIUCDservicedeliveryprotocol.
2.Thereare20questionsregardinghealthfacility,counseling,medicalscreening,servicedelivery,post
counselingandinfectionpreventionservicesavailableattheclinicsupportday.
3.Iftheindexscoreismorethan90%itrefersthatthequalitystandardshasbeenmetattheclinic
supportdaysandifthescoreislessthan90%thenthequalitystandardislow.
4.RecommendationsaregivenbytheQualityAssuranceConsultanttoimprovethequalityofservice
delivery.
5.WhenthefinalprocessiscompletedonlinereportingisdoneintheMISsystem.
6.AnactionplanismadeandimplementedtoaddresstheissuesoftheQualityAssurancevisitssothat
thequalitystandardsaremet.

14