Introduction to Health Services Supervision Module 11 Version 2

Learning objectives By the end of this module, learners will be able to: Differentiate between traditional and supportive supervision Define supervision Describe who may be a supervisor and the supervisor’s responsibilities Describe the skills and personal characteristics expected of a supervisor Define desired performance Assess current level of performance

Learning objectives, cont. State the relationship between training and supervision Describe the use of checklists during supervision and assessment for quality improvement (see Appendixes A and D in Community Intermittent Preventive Treatment for Malaria in Pregnancy: Implementation Guide) Describe the process of root cause analysis and selection of problem-solving interventions Develop action plans to address root causes of gaps in performance

Let’s run. Those guys are here again! How do site staff react to the arrival of the “traditional” supervisors? The traditional supervisors Let’s run. Those guys are here again! TS Rural Health Center Traditional supervisors emphasize “inspecting” facilities and “controlling” individual performance. They focus on finding fault or errors and then reprimanding those responsible, or thought to be responsible, for those errors. This type of supervision causes negative feelings and it rarely results in improved health services.

How do staff react to the “supportive” supervisor? TIPTOP Health Center Supportive supervisor Mike, we are glad to see you. Hi, everyone. On the other hand a supportive supervisor focuses on the goal of providing high-quality health services in a facilitative way that promotes mentorship, joint problem-solving, and communication between supervisors and supervisees.

What is supervision? Health services supervision has been defined as: “A process of guiding, helping, training, and encouraging staff to improve their performance in order to provide high-quality health services” Source: Garrison et al. 2004.

Defining supervision A supervisor may: Supervise any number of people, from one to many Work at a small rural health post or a large regional hospital Be a clinician, public health technician, or other health care worker Work at a clinical site and supervise people at that site, or work at a district or regional level and conduct supervision through visits

Defining supervision, cont. Have the word “supervisor” in their job title, or be called a manager, an in-charge, or something other than supervisor Have received some formal training in supervision, or have had no training in how to supervise people

Supportive supervision of community-directed interventions takes place in two locations At the frontline health facility In the community

Who supervises? Supervision is carried out by a person who is responsible for the performance of clinical and nonclinical staff Supervision can be conducted internally by an onsite supervisor or externally by someone who makes periodic supervision visits: The internal, or onsite, supervisor conducts supervisory activities as part of everyday activities Many internal supervisors also provide clinical services at the site

Who supervises? (cont.) External supervisors periodically visit health care delivery sites— where they do not work on a day-to-day basis—to help staff improve and maintain performance and quality A focal person for community-directed intervention at a frontline facility acts as an external supervisor to the CHWs CHWs can supervise themselves and each other by discussing and assessing their performance at their regular meetings. Such CHWs are called peer supervisors.

Supervisor responsibilities Identify standards of good performance and communicate these standards to supervisees Work with staff to assess their performance, periodically, compared to these standards Provide feedback to workers about their performance

Supervisor skills Demonstrate technical competence Facilitate team-building Motivate others Facilitate meetings and discussions Identify strengths of staff members and build on positive aspects Provide constructive, timely, and interactive feedback Communicate effectively with staff and decision-makers Delegate duties to staff

Supervisor personal characteristics Leadership skills and the ability to inspire others A desire to help others achieve their full potential A commitment to the provision of high-quality health services Openness to new and creative ideas

Supervision solves problems Supervisors work with staff and the community to: Identify appropriate interventions that will lead to improved worker performance and delivery of high-quality services Mobilize resources from many different sources to implement interventions Ensure that interventions have had the intended effect

Supervision meetings uncover common problems and seek solutions Photo by Bright Orji, Jhpiego

What is supervision for performance and quality improvement? This type of supervision: Has the goal of providing high-quality health services Uses standardized performance criteria Is a process of continuously improving performance and quality Is a style of encouraging, inclusive, and supportive interaction Involves the people being supervised in identifying their own needs and planning improvements

Performance improvement framework Get and maintain stakeholder agreement Consider institutional context: Mission Goals Strategies Culture Client and community perspectives Find root causes Select interventions Implement Define desired performance Describe actual Monitor and evaluate performance

What is desired performance? To perform well, people must know what they are supposed to do Performance standards need to be set Staff must know not only what their job duties are but also how they are expected to perform them Desired performance should be realistic and based on the: Shared vision of what is to be achieved (often based on national and global standards) Expectations of the community Resources at your site

Assessing performance Your team will need to assess, continually, how team members are performing compared to the desired performance standards Performance can be assessed informally on an ongoing basis or more formally on a periodic basis, by: Observing staff Conducting self-assessments Obtaining feedback from clients Performance assessment is equivalent to post-training evaluation and can lead to diagnosis of new training needs

Relationship: Training and supervision Training objectives and tasks Performance standards

Types of supervisory tools A supervisory tool is often a checklist that guides both the supervisor and the staff as they review the: General environment where services are provided Correctness and completeness of recordkeeping systems Availability of supplies, materials, and equipment Performance of basic service provision skills It helps if multiple copies of checklists or guidelines are available so that everyone can review and mark these together After using the checklists, the supervisor and the supervisee should sit together and discuss the results Facilitator: Pass around copies of tools actually used in your country and talk about them.

Example of simple checklist on malaria in pregnancy (MiP) services MiP control Task to be observed Verification criterion Observed, satisfactory (2) Observed, unsatisfactory (1) Not observed (0) Comments Provision of intermittent preventive treatment in pregnancy (IPTp) Determine eligibility for an IPTp dose Directly observe the woman swallow dose Counsel on subsequent IPTp Record provision of IPTp Provision of insecticide-treated bed net or long-lasting insecticidal net ITN/LLIN Determine eligibility for ITN/LLIN according to availability and use of ITN/LLIN in the home Provide ITN/LLIN as needed Counsel on ITN/LLIN setup and use Record provision of ITN/LLIN Case management Use appropriate diagnostic tools—blood smear examination in lab or rapid diagnostic test Treat with appropriate antimalarial according to trimester Counsel on adherence/compliance to full course of treatment Give supportive care as needed (e.g., for anemia) Record provision of malaria treatment

Finding root causes of performance gaps A performance gap exists if your team finds that what is actually occurring does not meet the performance standards that have been set If you find that this is the case, then you need to explore carefully with staff why the gap is occurring—what is hindering desired performance Sometimes the reasons for poor performance are not immediately obvious, and it may take some time to find the real cause

Example of performance gap Desired: 80% of pregnant women receive at least three doses of IPTp Gap: 55% of pregnant women did not receive at least three doses of IPTp Actual: 25% of pregnant women received at least three doses of IPTp This slide/overhead shows an example of the PI process in Brazil.

Example of causes of a performance gap Desired: 80% of pregnant women receive at least three doses of IPTp Suggested root causes: Antenatal Care (ANC) staff unaware of policy Pregnant women come to ANC very late (e.g., at 5 months gestation) Frequent stock-outs of sulfadoxine-pyrimethamine (SP) in health facility Unaffordable user fees for SP Fear of adverse effects from SP Gap: 55% of pregnant women did not receive at least three doses of IPTp Actual: 25% of pregnant women received at least three doses of IPTp This slide/overhead shows an example of the PI process in Brazil.

Selecting and implementing interventions Once the causes of the performance gap have been determined, you and your staff will need to identify, put in order of priority, plan, and implement interventions to improve performance These interventions can be directed at improving the knowledge and skills of staff, or they can be directed at improving the environment or support systems that enable staff to perform well

Selecting and implementing interventions, cont. Many different types of interventions can be put in place to improve worker performance To save resources, it is important to select the correct interventions

Exercise: Action planning Intervention assignment: Work in pairs Complete a hypothetical action plan to address the root causes identified for this performance gap Duration: 15 minutes Desired: 80% of pregnant women receive at least three doses of IPTp Suggested root causes: ANC staff unaware of policy Pregnant women come to ANC very late (e.g., at 5 months gestation) Frequent stock-outs of sulfadoxine-pyrimethamine (SP) in health facility Unaffordable user fees for SP Fear of adverse effects from SP Gap: 55% of pregnant women did not receive at least three doses of IPTp Actual: 25% of pregnant women received at least three doses of IPTp This slide/overhead shows an example of the PI process in Brazil.

Sample completed action plan matrix Performance gap and root causes Recommendation Resources needed By whom By when How to verify that the activity was completed 55% of pregnant women do not receive three doses of IPTp ANC staff unaware of policy Pregnant women come to ANC very late (e.g., at 5 months gestation) Frequent stock-outs of SP in health facility Unaffordable user fees for SP Fear of adverse effects from SP Orient ANC staff to the national MiP guidelines including the 2016 World Health Organization recommendations for three doses of IPTp Funds Training materials MiP guidelines Matron Mary Nurse Elizabeth Aug 6, 2018 10 ANC staff oriented to MiP including IPTp Mobilize communities for early ANC booking and benefits of ANC Information, education, and communication/social and behavior change communication materials   John (District Community Mobilization Officer) Nov 15, 2018 Six community mobilization meetings held 200 MiP educational posters in local language printed Advocate to ministry of health for procurement, storage, and distribution of SP to end-user health facilities SP order forms Funds to procure SP Training in logistic management information systems Samuel (Director of Department of Pharmaceutical Services) Anne (Stores Manager) Feb 28, 2019 8 facility staff and 6 district health office staff trained on logistic management information systems 29

Monitoring and evaluating performance Once interventions have been implemented, it is important to determine whether they have had the desired result: Did the intervention cause performance to improve? Did it move staff closer to meeting the established standards? If not, your team will need to reexamine what is hindering performance to make sure the interventions are appropriately targeting the real cause of the performance gap If performance has improved, it is important to continue monitoring to make sure the desired level of performance is maintained

Summary Supervision is a process of guiding, helping, training, and encouraging staff to improve their performance so that they can provide high- quality health services Supervision is not fault- finding and reprimanding

Reference Garrison K, Caiola N, Sullivan R, Lynam P. 2004. Supervising Healthcare Services: Improving the Performance of People. Baltimore, MD: JHPIEGO. https://www.malecircumcision.org/resource/supervising-healthcare-services-improving-performance- people. Accessed October 19, 2018.

Thank you! Any questions or comments?