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Existing Tools for Supervision

The following list includes a sampling of tools that currently exist for various types of supervision. Note that this list is not exhaustive.

Kenya-Specific Tools

• Training Supervision Visit Checklist
  For DTCs
• Support Supervision Summary Skills Report
  For JHPIEGO-supported RH training
• Kakamega District: Rural Health Facility Checklist
  General supervision, includes one short section on MCH/FP
• Facility Improvement Fund (FIF) Supervision Manual for Provincial Medical Officers, District Health Management Boards (DHMBs) and DHMTs
  Intended to improve the collection, management and use of FIF revenues

Other Tools

• National Supervision Guidelines: Quality Assurance Programme, MOH, The Republic of Uganda
  
  These guidelines apply to all levels of the health services delivery chain and will become an effective tool for ensuring adherence to performance standards and improving quality of services provided on a continuous and sustainable basis.
• The Family Planning Supportive Supervision Checklist: National Family Planning Programme, MOH, Tanzania
  
  This tool will help the supervisor and supervisee collect information that can be used to evaluate FP services. By using this checklist, a supervisor will be able to contribute to the content of training programs as well as the quality and utilization of services.

Recommendations for Improving the Performance of the Clinical Supervision System

Informants were asked to specify recommendations for the improvement of the performance of the clinical supervision system. Some of the areas recommended are systemic in nature, but others can be addressed through training (these are highlighted below with an asterisk *). Almost all informants mentioned training as the key to improved performance in supervision.

The recommendations are:

Training

• *Develop a supervision learning package
• *Train supervisors in supervision skills (including DPHC trainers and officers in other departments, DTC trainers, OJT trainers, and supervisors at the facility level)
• *Provide OJT package for supervisors
• *Provide training in financial management
• *Provide training in RH knowledge and skills

Tools and Checklists

• Develop a tool for integrated supervision
• Develop a supervision checklist

 Terms

• Motivate supervisors by providing incentives
• Review DPHNs’ roles and responsibilities, with an eye to reducing their workloads
• *Encourage team supervision among the supervisors
• Involve donors in supervision activities

Resources

• Improve provision of supplies
• Improve provision of transportation
• Increase financial resources

Procedures

• *Carry out supervision more frequently
• Increase supervision time
• *Hold regular meetings to discuss conditions, problems and solutions
• *Develop data computing system
• *Give feedback to the in-charge of the facility and the service provider at the end of the supervision visit

Essential Knowledge and Skills for Effective Reproductive Health Supervision

The following section highlights the findings from two separate but related exercises that were carried out to identify the key areas of knowledge and skills for effective RH supervision. One exercise consisted of a questionnaire administered to supervisors as a part of the performance analysis. The second exercise was a meeting of key stakeholders to identify the key duties of a RH supervisor. The findings or outcomes of these two exercises will help formulate the content of the supervision learning package.

Supervisor Questionnaire

A questionnaire was administered to a sample of RH supervisors from three districts (Kakamega, Siaya and Machakos). This questionnaire was intended to solicit topic ideas (key knowledge and skill areas) for inclusion in the supervision learning package. The sample of 17 respondents included members of the DHMT, the MS and the matron in-charge of MCH at the district hospital as well as representatives from the DTC. (See Appendix for the results of the questionnaire.)

Those who completed the questionnaire supervise the following cadres of health personnel: 8 supervise trainees, 5 supervise physicians, 12 supervise nurse-midwives and COs, 10 supervise auxiliary staff, 5 supervise office staff and 3 supervise CBDs. Twelve respondents provide on-site supervision, 6 provide district level supervision, 2 provide regional and 1 provides central level supervision. All supervise anywhere from 5 to 76 sites.

The findings from this questionnaire are summarized in Table 1. The table lists those topics or skill areas from the questionnaire that a majority of the respondents indicated were essential for effective supervision. It also lists additional topics as suggested by the respondents. The topics in the table are organized according to the duty categories identified during the stakeholders meeting. (See the following section.)

Table 1. Summary of Findings from Supervisor Questionnaire

	Very Important (all but 1 or 2 respondents indicated this topic as essential for supervision training)	Moderately Important (at least two thirds of respondents indicated this topic as essential for supervision training)	Suggested by Respondent
Introduction (or Overview)	Understand the roles and responsibilities of a supervisor	na	"Support supervision" "Concept of supervision" "General supervisory methods and tools"
Planning	Plan supervision/ prepare a supervision schedule Coordinate supervision activities	Develop a supervisor’s session plan	"Proposal writing"
Staffing	Manage conflict Set performance objectives	Develop consensus Plan for staffing Deploy staff Develop work teams Improve staff motivation	"Discipline of staff" (3 respondents)
Training	Assess provider clinical and counseling skills Facilitate the transfer of training Provide guidance and training	Assess the clinic facility (physical setting, equipment and supplies) Coach an employee or health provider Prepare for/organize training Manage types of training (group-based, distance, structured OJT) Evaluate/follow up participants Support the transfer of training	"RH and other related issues" "Emergency contraceptive update" "Training needs assessment" "Impact of supervision on quality of services" "Linking trainee supervisor with MTC tutors"
Information	Write reports	Interpret data Use data Share data (up to central level and down to site level)	"Writing reports"
Logistics	Manage supplies and equipment	na	"Management of four M’s"
Problem-Solving	Identify and solve problems	na	na
Communication	Communicate effectively Provide constructive feedback	Conduct presentations Manage a group meeting	"Involving the community in RH" "Basic skills in counseling" "Linking with DHMTs/ DHMBs"
Financial Management	na	na	"Financial management" "Administration as an element of management" "Sustainability of supervision system"

Stakeholders Meeting at the Landmark Hotel

A stakeholders meeting, entitled Supervision for Performance Improvement, was held at the Landmark Hotel in Nairobi, Kenya on 13 August 1999. Twenty key stakeholders who have responsibilities for and experience in clinical supervision attended this meeting. Staff from the MOH/DPHC Training Unit, DON, NCK, DHMTs and nongovernmental organizations (NGOs) (e.g., AVSC, Management Sciences for Health, INTRAH and Family Planning Logistics Management) were represented.

During group work, participants were asked to identify the major duties of a RH on-site supervisor. This activity resulted in the enumeration of 10 duty categories that will form the basis for the chapters and content in the supervision learning package. These duties are: planning, staffing, training (performance improvement and staff development), information, logistics (e.g., physical facility, equipment and supplies), problem-solving, communication and financial management. The workshop participants also developed a list of specific tasks within each of the duty categories. (See Appendix.) An additional chapter entitled "external site supervision" was suggested to address the tasks unique to external supervisors such as DHMTs.

Topics to be Included in the Supervision Learning Package

A number of topics were recommended from the supervisor questionnaire or interviews that were not identified during the stakeholders meeting. These additional topics will be included in the learning package. They are listed below.

Q=Indicated as very important by respondents of the questionnaire

R=Additional suggestions made by respondents of the questionnaire

I=Recommendations by the key informants

• Introduction/Overview
  Understand the roles and responsibilities of a supervisor (Q)
  "Concept of supervision" (R)
  "Definition of support supervision" (R)
  "General supervisory methods and tools" (R)
• Planning
  Plan supervision/prepare a supervision schedule (Q)
  Coordinate supervision activities (Q)
  Encourage team supervision (I)
  Carry out supervision more frequently (I)
  Give feedback to the in-charge and service provider at end of supervision visit (I)
  "Proposal writing" (R)
• Staffing
  Provide guidance (and training) (Q)
  Manage conflict (Q)
  Set performance objectives (Q)
  "Discipline of staff" (R)
• Training
  Facilitate the transfer of training (Q)
  Provide FP/RH updates (Q)
• Information
  Write reports (Q)
• Logistics
  No additional suggestions
• Problem-Solving
  No additional suggestions
• Communication
  "Basic skills in counseling" (R)
• Financial Management
  "Administration as an element of management" (R)
  "Sustainability of supervision system" (R)

By comparing recommendations made by meeting participants, supervisor questionnaire respondents and key informants, the tasks listed in Figure 2 are those determined to be essential for inclusion in the supervision learning package.

Figure 2. Essential Supervisor Tasks

Supervisor Tasks Identified as Essential from Two or Three of the Following:  Stakeholder Workshop, Key Informant Interviews and Supervisor Questionnaire Planning      Evaluates, compiles and gives feedback on site activities Staffing      Implements performance improvement system Training      Conducts site and training needs assessments      Manages various training activities      Provides coaching (guidance)      Identifies strengths and weaknesses of staff clinical skills      Maintains care standards (as an outcome of supervision) Information and Data      Shares information upward and horizontally Logistics      Manages supplies and equipment, in general Problem-Solving      Has problem-solving skills, in general Communication      Provides (constructive) feedback on job performance      Provides linkage between senior supervision staff and other stakeholders      Writes and submits reports      Ensures feedback from community regarding site activities (community involvement in       RH)      Has communication skills, in general      Calls regular staff meetings

Review of Existing Materials That Address Supervision

Family Planning Manager’s Handbook: The Family Planning Manager’s Handbook includes many topics relevant to supervision but does not address some of the topics suggested during this performance analysis. Examples of additional topics not addressed in this handbook are: coaching (both programmatically [facilitation] and clinical), problem-solving (both site-based [e.g., COPE] and system-based plus clinical problem-solving) and communication.

AVSC Facilitative Supervision Document: The emphasis in this document is on the facilitative approach. The document includes very little "how to" information. 

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