1. Introduction to Health Services Supervision
Module 11
Version 2

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

3. 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

4. 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.

5. 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.

6. 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

7. 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

8. 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

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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. Relationship: Training and supervision
Training objectives and tasks
Performance standards

22. 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.

23. 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

24. 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

25. 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.

26. 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.

27. 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

28. 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

29. 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.

30. 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

31. 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

32. 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

33. Reference
Garrison K, Caiola N, Sullivan R, Lynam P Supervising Healthcare Services: Improving the Performance of People. Baltimore, MD: JHPIEGO. people. Accessed October 19, 2018.

34. Thank you!
Any questions or comments?