There are three levels in EQA Laboratory network under NTEP

1. National Reference Laboratories (NRLs), which are the Central Institutes designated under NTEP. They monitor EQA activities of STDCs/ State labs for the programme. There are six NRLs, viz., National Tuberculosis Institute (NTI) Bengaluru, National Institute for Research in Tuberculosis (NIRT) Chennai, National Institute for Tuberculosis and Respiratory Diseases (NITRD), Bhopal Memorial Hospital and Research Centre (BMHRC) Bhopal, Regional Medical Research Centre (RMRC) Bhubaneshwar and National JALMA Institute for Leprosy and other Mycobacterial Diseases, Agra. Each NRL will eventually monitor 8-12 STDCs/IRLs.
2. STDC Laboratories will work as IRLs in the network. All States should have a State-level reference laboratory for EQA.
3. The Microscopy Centres (MCs)/NAAT sites working for NTEP in the districts will be the Peripheral laboratories.

The three main activities under the NTEP EQA protocol are;

1. On Site Evaluation (OSE): This evaluation is an important activity intended to evaluate whether the programme activities are being carried out i accordance with the recommended guidelines. Guidance is also provided for immediate corrective actions, wherever found necessary. OSE of the STDCs is done at least once a year by NRLs. DTCs (STLS) are evaluated once a year by STDCs and all MCs in the districts at least once a month by respective STLS. Importance will be given for taking action immediately at each level.
2. Panel testing (PT): Panel testing is done mainly to check the staining and smear reading proficiency of LTs of STDCs and STLS of TUs. The Panel testing is not used as a routine for LTs working at TB Diagnostic Centres (TDC). Panel testing of LTs of STDCs and STLS will be conducted once a year under the supervision of the visiting NRL/ STDC team. A set of pre-fixed unstained manufactured slides are used per technician under supervision of the visiting NRL/ STDC supervisor.
3. Blinded Rechecking of slides (RBRC): Blinded rechecking is the most important activity under the EQA programme. It determines the correctness of the smear results of LTs of MCs in an unbiased manner. It is not required for LTs of STDC as STDCs are expected to function at the supervisor level and are not required to perform patient related functions such as diagnosis and follow-up.

Methodology for all the three above mentioned activities is provided in detail in the revised NTEP EQA & DRS Protocols (refer to link)

The EQA for NAAT laboratories are undertaken annually by National Institute.

As an initiative to strengthen STDCs and enable them to perform their functions with better efficiency. The ECHO hubs have been established at STDCs. STDCs need to use these for improvement of programme efficiency and build the workforce capacity. Guidance for STDCs to design their virtual capacity building Programme and effectively utilise virtual knowledge hubs are as follows.

Virtual capacity building programs by STDCs

The knowledge hubs should be widely used by STDCs as a cross learning platform and for mentoring the health workforce at the periphery during the capacity building and programmatic reviews. Following are some of the ways it could be used.

1. Training and Capacity Building: STDC is responsible for ensuring that the entire health system workforce is completely trained in NTEP. The STDCs could use knowledge hubs for training and capacity building in the following ways.

   1. Regular training: STDCs lead the planning and implementation of regular and routine cadre-based training at all levels in the state for all healthcare staff working in the fight against TB in the state. This includes health system (Government or private), partners (NGOs, partner agencies etc) and other sectors. STDCs should effectively utilise Knowledge hubs for delivering the e- training courses for all cadres of including induction/ refresher/ update trainings. They need to prepare an annual training plan and decide which all courses could be scheduled as blended/ e- training through virtual platform. How such trainings could be conducted will be detailed in the training operations guidance under modernized training strategy under NTEP.

      NOTE: Training in only virtual modes should be used only in situations where physical training cannot be conducted.

   2. Thematic Trainings: STDCs shall organize thematic trainings as and when there is a new programme or when there is an update of the guideline/policy or based on the local needs, or as directed by CTD such as PMTPT, PMDT, SNC, Partnership Guidelines, new features in Nikshay. STDCs shall identify the need and decide which all courses could be scheduled as e- training through the virtual platform.
   3. Dissemination of ongoing programme Updates: STDCs could plan regular or need based academic sessions at a fixed frequency for a specific target audience. This could be planned and designed based on local need. All such sessions need to be didactic with active involvement from the spoke institutions. For example, STDCs could plan a one-hour session for all TU level staff on every fourth Friday regarding TB and NTEP updates.
   4. Special advanced courses for building capacity of health workforce/managers/administrators: STDCs could design and implement special courses beyond the routine/ regular training based on felt need of the State, for improving the efficiencies of the health or non-health workforce as an ECHO program. For example, a course on soft skills or communication or leadership or management or operations research or financial management could be imparted to selected cadre of staff virtually.
   5. Continuing Medical Education: STDCs could plan CMEs on TB at fixed frequency for a specific target audience. STDCs could collaborate with State task force (STF) or professional associations for such programmes. For example, session for all post-graduates and interns of medical colleges in collaboration with STF or session for general practitioners in collaboration with professional associations on every second Tuesday. Topics for such sessions could be decided based on local needs.
   6. Case studies / Best Practices/ Cross learning Platforms: STDCs could also arrange a platform for facilitating experience sharing regarding success stories from field. Success stories could be any best practices or local solution to particular problems documented with some learning experiences. For examples DTOs can present about a case study about how they maintained case finding during COVID-19 pandemic period or how they engaged all sectors for TB or how they solved the issue of poor coverage of TB preventive therapy (TPT) among people living with human immunodeficiency virus (PLHIV). Such programmes could be conducted regularly on fixed days (eg. monthly every second Wednesday at 12:00pm).
2. Programmatic Reviews and Supportive supervision: Programmatic reviews directed towards identifying problems and their solutions are an excellent opportunity for mentoring and improving capacity of district level and sub- district level staff. Data available through Nikshay and all other sources may be analyzed as prior preparation for the review and focused problem/ case-based approach may be used. These reviews need to be led and moderated by the STDC under the leadership of the STC.
   1. Periodic Reviews: These include monthly, quarterly, half yearly and annual review for the districts and other sub-levels organized by the STDC in consultation with STC These reviews could be directed internally within the NTEP or could be in collaboration with other programs such as National AIDS Control Organization (NACO) for cross learning and problem-solving activities.
   2. Need-based Thematic reviews: STDCs should conduct thematic reviews on periodically or based local needs. Such reviews will be focusing on one particular theme of the programme and will aim at building capacity of staff at field and solve problems at the field. These include reviews on PMTPT, PMDT, DBT, UDST, Private sector engagement, Pediatric TB Notification, Partnerships for TB Elimination, Finance, ACSM, Contact Tracing and so on.
   3. Virtual Supportive Supervision: STDC may use the virtual interaction platforms to conduct the supportive supervision activities aiming at handholding and mentoring of the staff at periphery in a virtual/ remote fashion. This includes virtual facility visit, physical examination of documents/ registers etc. Note that Periodic visits and regular supervision cannot be entirely replaced by virtual supportive supervisions.
3. Additional need-based capacity building: In order to ensure that complex problems are solved timely, the ad-hoc meetings and reviews play an important role. It ensures timely actions for improving a specific indicator or improvement of programme of a particular district, institutions or staff.

Annual Planning of Virtual activities

Based on the above types of each of the above three types of activities the STDCs may plan an annual calendar of virtual events.