File 177

Integrated Supportive Supervision

Federal Democratic Republic of Ethiopia

Ministry of Health

Guideline for

Integrated Supportive SupervisionNovember 2008

Addis AbabaFederal Democratic Republic of Ethiopia

Ministry of Health

Guideline

forIntegrated Supportive SupervisionNovember 2008

Addis Ababa

Table of Contents1Table of Contents

4Introduction

6Definition of terms

8Purpose

9Scope

10Procedures

10Integrated Supportive Supervision to Regional Health Bureaus

10Federal ISS Indicative Core and Comprehensive Plan Preparation

12Preparations for Conducting Supervision

12Conducting the Supervision

13Introduction in the Process of Supervision Visit

13Interview Appropriate Staff at RHB

13RHB Performance Review

14Administration Review

14Discussions and Problem Solving

14Conduct Visits to Selected Health Facilities

15Constructive Feedback

15Recording and Reporting supervisory findings

15Job and Structure for Integrated supportive supervision

16Supervisory Authority and Accountability

16The Role of Supervisors

17Supervisory Team make-up

18Integrated Supportive Supervision to Woreda Health Office

18RHB ISS Core and Comprehensive Plan Preparation




21Interview Appropriate Staff at WoHO

21WoHO Performance Review


22Community Involvement Review

22On-site Update/Training


23Conduct Visits to Selected Health Facilities






25Supervisory Competence

26Integrated Supportive Supervision to H. Centers and H. Posts

26Woreda ISS Indicative Core and Comprehensive Plan Preparation


291.Integrated Supportive Supervision to Health Centers



30Interview Appropriate Staff at Health Centers

30Quality of Clinical Care review

31Performance Review

32Referral System Review



33On-site Training Role of ISS




35Job and Structure for Health Center ISS




382. Integrated Supportive Supervision to Health Posts



39Structured discussions with Health Extension Workers

39Quality of Service Review













46Integrated Supportive Supervision to Hospitals

46Hospital Comprehensive Plan Preparation




49Interview Appropriate Staff

49Quality of Clinical Care Review








54Job and Structure for Hospital ISS




IntroductionIntegrated supportive supervision (ISS) is a process of managing human functions and motivation to enhance the personal and professional capabilities of staff intended to promote the achievement of institutional goals for ultimate client/ patient satisfaction. Supervision is not new to Ethiopian health care system. However, it was not process focused aimed at problem solving and improving the quality of service delivery conducted irregularly without meaningful structure. ISS is one of the approaches used in the general framework of improving quality of health care and services. To address the weakness and problems of traditional supervision, a new approach to supervision is desirable. Ideally, supportive supervision is a process of guiding, helping/supporting, training, and encouraging staff to perform their duties and improve performance in order to provide high-quality healthcare services with those being supervised as well as those supervising to solve problems jointly arising in the health service primarily at the local level.

Supportive supervision emphasizes mentoring, team-building and joint problem solving through a two-way communication with the aim of continuous improvement in the quality of health care delivery. Supportive supervision affords an opportunity to increase ownership and accountability helping health workers at the operational level to follow through progresses and challenges in their work.

Definition of terms

Annual Plan: a document that contains operational targets and objectives prepared every year and aligned to the strategic plan.

Checklist: This is a tool to ensure consistency and completeness in carrying out a task. Effectiveness: The ability to achieve a desired effect or an outcome under everyday or typical conditions

Facilitator: someone who helps a group of people understands their common objectives and assists them to plan to achieve them without taking a particular position in the discussion.

Facility: A Public institution in which health service is provided which includes health post, health center, and hospital.

Feedback: is a circular causal process whereby some proportion of a system's output is returned (fed back) to the input.

Integrated Supportive Supervision: a process of guiding, helping, training, and encouraging staff to improve their performance in order to provide high quality health services through the use of integrated tools for all priority programs and empowering the motivation of health service providers at all levels.Input: organizational units, people, money, and other resources actually devoted to the particular program or activity.

Mentorship : a developmental relationship between a more experienced person to help a less experienced person referred to as , apprentice, mentee, or (person) being mentored develop in a specified capacity.

Monitoring: is a process by which priority data and/or information is routinely collected analyzed, used and disseminated to track progress towards the achievement of planned targets and take timely corrective actions to improve performance.

Outcome: a description of the intended result, effect, or consequence that will occur from carrying out a program or activity [the medium term result of set of activities]

Output: data, information resulting from the operation of the activities [the immediate product of an activity]

Quality improvement: a modality by which health facilities use the opportunity of using locally available data generated during their provision of health service to improve quality of health care through a continuous process of measurement and improvement.

Quality management: is a method for ensuring that all the activities necessary to design, develop and implement a product or service are effective and efficient with respect to the system and its performance.

Supervisor: is somebody whose job is to oversee and guide the work or activities of a group of other people

Target: this is the specific level of the indicator which will be achieved by a certain data.

Purpose

The process of ISS: 1) Sets expectations and health service delivery standards against which performances and results can be measured 2) Provides a continuous monitoring and performance improvement through different modalities3) Identifies problems/gaps between the set expectations and attained results and4) Takes appropriate corrective action primarily locally.Higher level structures in the supervisory system play roles of marshalling the required resources, motivating health workers, and soliciting the support of service providers. In general, supportive supervision is a process that promotes quality at all levels of health system by strengthening relationships within the system, focusing on the identification and resolutions of problems and helping to optimize the allocation and use of health resources.

The fundamental principle for introducing ISS includes creating opportunities for health workers and their supervisors to form and work as a team for participatory problem identification and solving. Supervisors act as facilitators, trainers, mentors and coaches. This helps to build partnerships with health workers at the levels being supervised to maximize quality of services. Basic skills and the techniques of two-way communication or participatory decision making are mandatory for ISS supervisors. They should also have good understanding of the steps, and standard problem-solving techniques including: defining the priority problem, analyzing its possible causes, identifying possible solutions, developing an action plan to implement these solutions, and evaluating the results are a requirement. Supervisors must know the broad array of services that are available at a site, as well as what the national standards and guidelines call for in terms of the quality of those services. The following are necessary requirements for having effective supervisory system:

An integrated annual plan, well thought through visitation schedules

Advance communication to the supervisee levels

A thorough preparations by ISS supervisors

Initiation of participatory assessment and problem solving with the development of an agreed upon action plan

The willingness to provide adequate and transparent feedback to those supervised.

Adequate time for the supervisory process.

Scope

The Integrated Supportive Supervision manual will address all levels within the health sector.

Procedures Integrated Supportive Supervision to Regional Health Bureaus

Federal Ministry of Health is responsible to supervise and support Regional Health Bureaus (RHB) and Federal Hospitals. A supervision session to RHB will include review of priority program implementation at bureau level and site visits to selected health facilities (one hospital, one health center and one health post). The supervision sessions will target to assess and provide support on the major components of the health system in a structured manner.

Frequency of Integrated Supportive Supervision will be once every three months to Federal Hospitals and Once every six months to Regional Health Bureaus. In this section emphasis will be given the supervisory support to RHBs. ISS to hospitals, health centers and health posts will be addressed in subsequent sections. Visits to health facilities outside the jurisdiction of FMOH should be coordinated with supervisory visits of the RHB. Federal ISS Indicative Core and Comprehensive Plan Preparation

Supervision plans should be integrated in the annual work plan at every level of the health care system. This process should be the outcome of appropriate consultation with all health institutions administrative offices that have stakes in supervisory system.

The first step for ISS is to develop a well articulated supervision plan with implementation budget and incorporating it into the Federal annual work plan. When supervisory visits are made frequently and regularly (routinely), supervisors are better able to monitor performance and can identify and address problems before they could negatively impact performance.

Consistent with the annual planning process of top down-bottom up approach, indicative core plan preparation at the Federal level will consider ISS to the Regional level. The core plan for ISS for RHBs will include bi-annual visitation schedules with approximate time frame of two weeks. Suggested scheduling should take into consideration time frames after performance monitoring has been completed at the Federal and Regional level.

It is imperative that the annual supervisory plans at each level be strongly linked with each other to ensure that Federal and Regional supervisory efforts are harmonized. The resource requirement for supervision should be estimated and their availability identified by source and costed. At the end of the annual planning process, the supervisory schedule should be communicated in advance to the RHB and reminded 2-3 weeks ahead of the actual visits.

Preparations for Conducting SupervisionBefore a supervisory visit, a critical review should be performed in regard to program/service targets/coverage and the progress being made in the implementation of programs by the Regional Health Bureau.Adequate time should be allocated prior to the visit for preparation. Preparation includes but is not limited to:

1. Review reports of prior visits and any agreed follow up Action Plans, 2. Review of HMIS reports with determination of performance gaps (or areas of concern based on previous visits), 3. Review with programs and relevant expert areas that need follow up.

4. Clear objectives for each visit should be presented to RHB management along with a supervisory checklist for approval.

5. Every supervisory visit should be well planned and communicated in advance (2-3 weeks) to assure the availability of responsible health personalities so that it could be possible to spend sufficient time for support.

6. To address the needs of other development partners and stakeholders, the schedule should be communicated so that they can participate during supervisory visits.Clear objectives for each visit should be presented to FMOH management along with a supervisory checklist for approval. To address the needs of other development partners and stakeholders, the schedule should be communicated so that they can participate during supervisory visits.

Conducting the SupervisionISS will be conducted by holding detailed discussions and interview with program/administrative managers and record reviews supplemented by observation of selected health facilities. Health facility visits will be coordinated with the RHB.How the health facilities will be selected?

Based on their pervious performance [best and worst performance]

Based on their geographical accessibility [far and near]

Based on their current condition [health facilities which need attention]

Introduction in the Process of Supervision Visit The supervision process starts with delineating the objectives of the visit. Both the FMOH team and RHB management should discuss and agree on where and how to proceed with the supervisory process. The FMOH team should have a checklist that should be shared at this point and additional elements may be added as suggested by RHB management. This will ensure that the supportive supervision is a two way dialogue and not something imposed by the FMOH team. The time requirement for interviews, relevant record review and action planning should be agreed upon at this stage. Both parties should briefly review actions taken after the previous visit and should reflect on the progresses that have been made based on the reports, completed checklists and action plan developed, review the RHBs latest self-assessment report and agree on the specific program areas that might be focused on during the current visit.Interview Appropriate Staff at RHBHolding discussions and interviewing case-teams and other RHB staff requires an allocation of several hours. This process may be conducted with the FMOH team with individual RHB case teams, Individual FMOH team members with individual RHB case teams or any way that is appropriate depending on the recognized strength and weaknesses of either team.

This process includes mainly the completion of integrated supervisory checklists. Both teams should have a checklist in hand so that all can follow the progress of supervision and should complete the checklist and take note of the major issues of concern. All agreed upon elements are expected to be completed and notes are taken to those comments arising during the process. Supervisors should make verifications to verbal responses through a record review or observation of documents where appropriate.RHB Performance ReviewA functioning information system is essential for the effective management at all levels of the health system and facilitates performance measurement. The FMOH supportive supervision team plays a very important role in ensuring the accuracy and validity of the information system. The FMOH team will concentrate on review of the quarterly reports, the use of data for health service planning, monitoring and evaluation. In the process, the supervisory team will conduct in-depth interviews about focus and priority health areas like maternal health, child health, TB/HIV and Malaria or additional elements like construction, budget utilization etc. Administration ReviewThe FMOH support and supervision activities will include reviewing aspects of administrative issues at the RHB. The supervision process should address administrative matters including:

1) Budget allocation and resource utilization, 2) Budget utilization versus liquidation3) Reprogramming of left over budget4) Audit reports and recommendations and5) Construction and infrastructure of health facilities and administrative offices, equipment, supplies and various legal issues. Discussions and Problem Solving Prompt problem solving at the level of supervisee is an integral part of the supervisory process. Many problems can be dealt with on the spot whilst others will have to be taken to the FMOH management. A note will be made of problems requiring solutions at a higher level and actions taken will be reviewed at the subsequent supervisory visit. In the course of problem solving, full participation of RHB team and their inputs are indispensable. At this stage, Both FMOH and RHB teams should identify problems, listen, discuss, give feedback, and solve problems together Identify areas of weakness and strength or best practices Prioritize problems Share responsibilities of solving problem among the two levels and analyze through discussions the underlying causes for the identified problem/s. Set target for improvement. Identify appropriate strategy to solve the identified problems according to their priorities. Draw upon identified local strengths to set practical solution. Draw an agreed upon follow up mechanism and an action plan. Prepare an agreed upon action plan.Conduct Visits to Selected Health Facilities

After conducting the supervision steps described earlier, the ISS team should arrange site visit to a hospital, a health center and a health post. The supervision process owner at the RHB should schedule the site visit prior to the supervision session. And the visit should follow the regular ISS procedures to the specific health facility levels which will be discussed later in this document.Constructive FeedbackIt is always important to discuss the findings from the visit and the recommendations forwarded by the FMOH team. Providing feedback to the RHB team is an important step in effective supervisory process. At the end of the visit, a wrap up meeting will be held with the RHB leaders (political and or administrative). This debriefing meeting is chaired by the head of the RHB with the FMOH as secretary and will involve all core process owners. The secretary will present/report on the major findings and possible suggested recommendations. The ensuing discussion and agreed upon plan is recorded in the minutes and circulated.

The report should be action-oriented to increase commitment towards the implementation of the agreed actions and address the interview, observations, record review and problem analysis and be able to create an opportunity for sharing and learning for both teams.Recording and Reporting supervisory findingsSupportive supervision will not be able to accomplish its intended objectives unless there is a mechanism that would allow routine follow up. Follow up involves monitoring of implementation of activities that were agreed upon during any supervision visits. The FMOH team will produce report on findings and share such reports with the FMOH management team within a week of completing the visit. The report will include findings, action recommended or taken or those issues which require a decision. The report should also highlight any special achievements and/or problems seen and should be accompanied with a copy of an agreed upon follow-up action plan.

Actions expected from the FMOH management team are decision about issues for follow up before a subsequent visit can be initiated. A decision on the frequency of follow-up and the next visit should be decided at this time. Generally, it may be helpful to consider that lesser performing RHBs may need to receive more frequent support and follow-up visits. Job and Structure for Integrated supportive supervision

Supervisory hierarchy takes into account the relationship, administrative and technical responsibilities of the supervisor and supervisee. In order to provide an adequate supervisory input into public health practices that are characterized by delegation of responsibilities, integration of program and services, continuous learning, interdisciplinary teamwork, inter-sectoral collaboration, community involvement, partner involvement and participatory planning and implementation, supervision has to evolve as an integrated tasks that should be managed by qualified professionals.

Supervisory Authority and Accountability

The FMOH supervisory teams first duty is to be fully conversant on the objectives and values of the FMOH and to assume a duty that demands to adequately represent it. The FMOH supervisory team is a delegated middleman and a buffer between the RHB and the FMOH management team and hence responsible for follow-up of all activities related to the RHB and ensure that support is provided in a consistent manner. Furthermore, supervisory teams need a firm authority that is necessary to take actions on the spot to enhance acceptability and credibility and accorded a clearly delineated line of responsibility from the FMOH management backed by appropriate authority and accountability.The Role of Supervisors

It is the supervisory teams job to help the RHB, envisage the future needs and to ensure that the performance goals are met. To ensure this is accomplished, the FMOH team should make certain that RHBs have the tools and material that they need to carry out their duties.More power should be placed in the hands of the FMOH supervisory team to make changes and improve services. The team should be seen as catalysts for change. They can do this by creating an environment of teamwork in which change and improvements can flourish.

The FMOH supervisory teams are expected to be knowledgeable about standard problem-solving steps which involves among others, problem definition, analyzing possible causes, identifying possible solutions, developing an action plan to implement solutions, and evaluating the results.Supervisory Team make-up

To ensure provision of support with adequate expertise, supervision to RHBs will be conducted by teams of supervisors. Experts from different case teams under the Ministry will be scheduled to provide ISS to the RHBs and Federal Hospitals. FMOH supervisory team make-up should be decided during the annual planning season. All Federal level management team members should participate in and lead the supervisory process. Considering the time required per visit and the diversity of expertise, the number of supervisors for each RHB will be four. These experts will be from different case teams of the FMOH led by a FMOH senior management team member. Supervisors should be equipped with basic skills and the techniques of two-way communication or participatory decision making. They should also have good understanding of the steps, and standard problem-solving techniques including: defining the priority problem, analyzing its possible causes, identifying possible solutions, developing an action plan to implement these solutions, and evaluating the results are a requirement.

Supervisors must have solid technical knowledge for the duties they are to perform and must know how and where to gain access for additional support. Supervisors must know the broad array of services that are available at a site, as well as what the national standards and guidelines call for in terms of the quality of those services.Integrated Supportive Supervision to Woreda Health Office

Regional Health Bureaus and delegated Zonal Health Departments are responsible to supervise and support Woreda Health Offices (WoHO) and Regional Hospitals. An integrated supportive supervision session to a WoHO will include review of priority program implementation at Woreda level and site visits to selected health facilities (primary hospital, health centers and health posts). The supervision sessions will target to assess and provide support on the major components of the health system in a structured manner.

Frequency of Integrated Supportive Supervision will be once every three months to Regional Hospitals and Woreda Health Offices. In this section emphasis will be given to the supervisory support to WoHOs and are applicable to both RHB and Zone Health Departments (ZHD). ISS to WoHOs may be delegated to ZHDs. ISS to hospitals will be addressed in subsequent sections.

RHB ISS Core and Comprehensive Plan Preparation

Consistent with the annual planning process of top down-bottom up approach, indicative core plan for supervision time will be negotiated with the FMOH and in turn an indicative plan will be submitted to the WoHO to establish a fixed date for supervision.The core plan for ISS for RHBs will include quarterly visitation schedules with approximate time frame of 5 days. Scheduling should take into consideration time frames after performance monitoring has been completed at facilities and Woreda level.

The core plan developed will have a well articulated supervision plan with implementation budget and incorporating it into the institutional annual work plan. The resource requirement for supervision should be estimated and their availability identified by source and costed. At the end of the annual planning process, the supervisory schedule should be communicated in advance to the levels where supervisions are going to take place. Moreover, the supervisees should be reminded 2-3 weeks ahead of the actual supervision visits.

Preparations for Conducting Supervision

Before a supervisory visit, a critical review should be performed in regard to program/service targets/coverage and the progress being made in the implementation of programs by the WoHO.

Adequate time should be allocated prior to the visit for preparation. Preparation includes but is not limited to: 1. Review reports of prior visits and any agreed follow up Action Plans, 2. Review of HMIS reports with determination of performance gaps (or areas of concern based on previous visits), 3. Review with programs and relevant expert areas that need follow up. 4. Clear objectives for each visit should be presented to RHB management along with a supervisory checklist for approval. 5. Every supervisory visit should be well planned and communicated in advance (2-3 weeks) to assure the availability of responsible health personalities so that it could be possible to spend sufficient time for support.6. To address the needs of other development partners and stakeholders, the schedule should be communicated so that they can participate during supervisory visitsConducting the Supervision

ISS will be conducted by holding detailed discussions and interview with program/administrative managers and record reviews supplemented by observation of selected health centers and health posts.

How the health facilities will be selected?

Based on their pervious performance [best and worst performer]

Based on their geographical accessibility [far and near]

Based on their current condition [health facilities which need attention]Introduction in the Process of Supervision Visit

The supervision process starts with the introduction of the RHB supervisor, their responsibilities and the objectives of the visit. Both the supervisor and WoHO management should briefly discuss and agree on where and how to proceed with the supervisory process. The time requirement for interviews, relevant record review and action planning should be agreed upon at this stage. A brief review of actions taken after the previous visit with emphasis on the progresses that have been made based on the reports, completed checklists and action plan developed, review the RHBs latest self-assessment report and agree on the specific program areas that might be focused on during the current visit.

Interview Appropriate Staff at WoHOInterviewing WoHO staff may require an allocation of several hours to several days. This process includes mainly the completion of integrated supervisory checklists. Both the RHB supervisor and WoHO teams should have a checklist in hand so that all can follow the progress of supervision and should complete the checklist and take note of the major issues of concern. All elements in the checklist are expected to be completed and notes are taken to those comments arising during the process. Supervisors will make verifications to verbal responses through a record review or observation of documents where appropriate.WoHO Performance Review

A functioning information system is essential for the effective management at all levels of the health system and facilitates performance measurement. The supervisor plays a very important role in ensuring the accuracy and validity of the information system. The supervisor concentrates on ensuring the proper use and the correct completion of the quarterly report, the correct graphing of important data and the use of data for health service planning, monitoring and evaluation. In the process, the supervisor will make efforts to conduct in-depth reviews about focus and priority health areas like maternal health, child health, TB/HIV and Malaria, etc. or elements that may arise during the supervision like construction, budget utilization etc.Administration Review

Reviewing aspects of administrative issues at the WoHO is necessary. The support and supervision activities will include reviewing aspects of administrative issues at the WoHO. The supervision process should address administrative matters including:

Budget allocation and resource utilization,

Budget utilization versus liquidation

Reprogramming of left over budget

Audit reports and recommendations and Construction and infrastructure of health facilities and administrative offices, equipment, supplies and various legal issues

Community Involvement Review

During each supervisory visit, supervisors will address issues that are related to community and Woreda Council involvement. Community problems which needed urgent attention (malnutrition, disease outbreaks, campaigns etc) in the prior quarter should be noted and addressed. The planning and execution of events and the satisfaction of the Woreda administration will be assessed and investigated.On-site Update/Training

The supervisor carries a major responsibility to ensure that WoHO staffs are updated, trained and appropriately coached. The Woreda supervisor will conduct educational sessions in relation to program implementation during each visit designed to address specific needs of the WoHO. The supervisor also provides WoHO staff with information on updates of policies or new recommended practices.

Discussions and Problem Solving

Prompt problem solving at the level of supervisee is an integral part of the supervisory process. Many problems can be dealt with on the spot whilst others will have to be taken to the appropriate offices at the higher level. A note will be made of problems requiring solutions at a higher level and actions taken will be reviewed at the subsequent supervisory visit.

In the course of problem solving, full participation of the WoHO team and their inputs are indispensable. At this stage,

Both RHB supervisors and WoHO teams should identify problems, listen, discuss, give feedback, and solve problems together.

Identify areas of weakness and strength or best practices

Prioritize problems

Share responsibilities of solving problem among the two levels and analyze through discussions the underlying causes for the identified problem/s.

Set target for improvement. Identify appropriate strategy to solve the identified problems according to their priorities. Draw upon identified local strengths to set practical solution. Draw an agreed upon follow up mechanism and an action plan. Prepare an agreed upon action plan.

Conduct Visits to Selected Health Facilities

After conducting the supervision steps described earlier, the supervisor along with the supervisee should arrange site visit to a health center and a health post. Supervisors at the WoHO should schedule the site visit prior to the supervision session. And the visit should follow the regular ISS procedures to the specific health facility levels which will be discussed later in this document.

Constructive Feedback

It is always important to discuss the findings from the visit and the recommendations forwarded by the WoHO team. Providing feedback to the WoHO team is an important step in effective supervisory process.

At the end of the visit, a wrap up meeting will be held with the WoHO leaders (political and administrative). This debriefing meeting is chaired by the head of the WoHO with the supervisor as secretary and will involve all core process owners. The secretary will present/report on the major findings and possible suggested recommendations. The ensuing discussion and agreed upon plan is recorded in the minutes and circulated.

The report should be action-oriented to increase commitment towards the implementation of the agreed actions and address the interview, observations, record review and problem analysis and be able to create an opportunity for sharing and learning for both teams.Recording and Reporting supervisory findings

Supportive supervision will not be able to accomplish its intended objectives unless there is a mechanism that would allow routine follow up. Follow up involves monitoring of implementation of activities that were agreed upon during any supervision visits.

The RHB supervisor will produce report on findings and share such reports with the RHB management team within three weeks of completing the visit. The report will include findings, action recommended or taken or those issues which require a decision. The report should also highlight any special achievements and/or problems seen and should be accompanied with a copy of an agreed upon follow-up action plan.

Actions expected from the RHB management team are decision about issues for follow up before a subsequent visit can be initiated. A decision on the frequency of follow-up and the next visit should be decided at this time. Generally, it may be helpful to consider that lesser performing WoHOs may need to receive more frequent support and follow-up visits.Job and Structure for Integrated supportive supervision

Supervisory hierarchy takes into account the relationship, administrative and technical responsibilities of the supervisor and supervisee. In order to provide an adequate supervisory input into public health practices that are characterized by delegation of responsibilities, integration of program and services, continuous learning, interdisciplinary teamwork, intersectoral collaboration, community involvement, partner involvement and participatory planning and implementation, supervision has to evolve as an integrated tasks that should be managed by qualified professionals.


A RHB supervisor is expected to be accorded distinctly separate sets of responsibilities. The supervisor's first duty is to be fully conversant on the objectives and values of the RHB and to assume a duty that demands to adequately represent it. The Woreda supervisor is a delegated middleman and a buffer between the WoHO and the RHB management and hence responsible for follow-up of all activities and ensure that support is provided in a consistent manner. Furthermore, the supervisor needs a firm authority that is necessary to take actions on the spot to enhance acceptability and credibility and accorded a clearly delineated line of responsibility from the RHB management backed by appropriate authority and accountability.Considering the time required per visit, one supervisor from each RHB will be will oversee 10 WoHO.

The Role of Supervisors

It is the Woreda supervisors job to help the WoHO, envisage the future needs, energize the staff to get their tasks done and support their work in order to ensure that the health service performance goals met. To ensure this is accomplished, the supervisor should make certain that WoHO staffs are equipped with the appropriate tools and backing from the RHB that they need to carry out their duties.The supervisor is a catalyst for performance improvement. More power should be placed in the hands of supervisors to make changes and improve services. Supervisors should be seen as catalysts for change. They can do this by creating an environment of teamwork in which change and improvements in the quality of services can flourish.

Participatory joint problem solving. Supervisors are expected to be knowledgeable about standard problem-solving steps which involves among others, problem definition, analyzing possible causes, identifying possible solutions, developing an action plan to implement solutions, and evaluating the results.

Supervisory Competence

Supervisors should be equipped with basic skills and the techniques of two-way communication or participatory decision making. They should also have good understanding of the steps, and standard problem-solving techniques including: defining the priority problem, analyzing its possible causes, identifying possible solutions, developing an action plan to implement these solutions, and evaluating the results are a requirement.

Supervisors must have solid technical knowledge for the duties they are to perform and must know how and where to gain access for additional support. Supervisors must know the broad array of services that are available at a site, as well as what the national standards and guidelines call for in terms of the quality of those services.Integrated Supportive Supervision to H. Centers and H. PostsWoreda Health Offices are responsible to supervise and support health facilities including Primary Hospitals Health Centers and Health Posts. An integrated supportive supervision session will include review of priority program implementation at health facilities. The supervision sessions will target to assess and provide support on the major components of the health system in a structured manner.

The following are necessary requirements for having effective supervisory system:


Advance communication to the supervisee levels

A thorough preparations by ISS supervisors


The willingness to provide adequate and transparent feedback to those supervised and


Frequency of Integrated Supportive Supervision will be:

1. Once every two months to Primary Hospitals and Health Centers

2. Every month to Health Posts. In this section emphasis will be given the supervisory support to health centers and health posts. ISS to primary hospitals will be addressed in the hospital section.Woreda ISS Indicative Core and Comprehensive Plan Preparation

Consistent with the annual planning process of top down-bottom up approach, core plan preparation at the Woreda level will consider ISS to the health facilities. The core plan for ISS for RHBs will include specific visitation schedules with a definite time line. Suggested scheduling should take into consideration time frames after performance monitoring has been completed at the health facility level.

Annual supervision plans should be integrated in the annual work plan of every health facility and should include an implementation budget. The resource requirement for supervision should be estimated and their availability identified by source and costed The Woreda ISS plan should embrace all health institutions within the respective jurisdiction for supportive supervision.

At the end of the annual planning process, the supervisory schedule should be communicated in advance to the levels where supervisions are going to take place. Moreover, the health facilities should be reminded 2-3 weeks ahead of the actual supervision visits.


Before making a supervisory visit, the supervisor should take the initiative to review records with regard to program/service targets/coverage and the progress being made by health workers in the implementation of the program in comparison with the set targets, previous supervisory reports and the major problems observed in the implementation of programs. The supervisor should critically review the HMIS report of the level being to be supervised as well as the report of the facility level internal quality improvement process.Table 1: Role of supervisor and supervisee on the preparation of ISS

SupervisorSupervisee

The supervisor should make thorough preparation before each visit based upon the supervision plan and schedule.

Review the report of the last supervisory visit and the agreed follow up Action Plan.

Review the HMIS reports of the levels/institutions to be supervised and determine the performance gaps (or areas of concern based on previous visits).

Review with programs and relevant experts program areas that need to be followed up.

Develop clear objectives for each visit.

Collect helpful publications, materials, and supplies for the health facility.

Review the institutions Internal quality management process reports.

Prepare updates and/or refresher training to present during the visit.

Ensure that sufficient copies of the Integrated Supervisory Checklist for health institutions to be visited.

Arrange the necessary transport and logistics for the supervision visit.

Communicate with supervisee on the actual date of supervision visit. The supervisee level should prepare for the supervisory visit Review the previous supervisory report and associated action plan developed during the last supervision

Review the HMIS and performance monitoring reports for the previous months to ensure that they can report on any special actions they have taken to address any problems that have arisen;

Review the progress in implementing the plan;

Conduct monthly self-assessment, identify any problems and determine actions that need to be taken to address these problems.

Make sure that all key officers are present for the supervisory visit.

1. Integrated Supportive Supervision to Health CentersConducting the Supervision

ISS will be conducted in several ways including interviewing service providers and clients, record reviews, health facility observation, meeting with the health workers to discuss and assess performance and quality goals, meeting with community members and hold discussions with program/administrative managers. During the supervision process, the critical factor is the amount of time spent in a given health center. Therefore, every supervisory visit should be well planned and communicated in advance to assure the availability of the responsible health personalities so that it could be possible for the supervisor to spend sufficient time (from several hours, to a full day or more) to go through each step stated.

Introduction in the Process of Supervision Visit

The supervision process starts with the introduction of the supervisor and the performance improvement team, their responsibilities and the objectives of the visit. Both the supervisor and health center management should briefly discuss and agree on where and how to proceed with the supervisory process. The time requirement for interviews, relevant record review, quality assessment and action planning should be agreed upon at this stage. A brief review of actions taken after the previous supervisory visit and reflection on the progresses that have been made based on the reports, completed checklists and action plan developed during previous supervisions, review the sites latest self-assessment report and agree on the specific program areas that might be focused on during the current supervisory visit. The supervisor should complete all activities/tasks before providing feedback.

Interview Appropriate Staff at Health CentersInterviewing and observation of appropriate staff might require an allocation of several hours. This process includes mainly the completion of integrated supervisory checklists. Both the supervisor and health center case teams should have a checklist in hand so that all can follow the progress of supervision and should complete the checklist and take note of the major issues of concern. All elements in the checklist are expected to be completed and notes are taken to those comments arising during the process. Supervisors should make verifications to verbal responses through a record review or observation of documents where appropriate.

Quality of Clinical Care reviewCorrect application of service delivery standard, protocols of treatment, guidelines of operation and use of the approved list of essential drugs is of great importance to ensure high quality care. Qualities of clinical care or preventive services are reviewed by making observations of how services are provided and by comparing such service delivery against the agreed standards, protocol and guidelines. Hence, supervisory visits should be arranged when supervisors can observe health services being provided and interview clients on the services they received.

The supervisor should review the health center quality improvement cycle and assess the teams activities and plans to address specific quality shortcomings.

Generally, the client and provider interactions, process of diagnosis, treatment and counseling is observed to confirm that these are being done in line with service delivery standards. Additional questions may be asked by the supervisor to gather all relevant information about the area under review and to understand whether certain activities are done correctly. For those observed problems that are amenable to be dealt with immediately, the necessary guidance are offered to fix the problem.

Providing appropriate feedback and planning for further capacity building of the providers is part of the observational and quality assessment process in supportive supervision. Helpful behaviors in gaining the commitment of those being supervised include:

Building the feedback upon positive findings or things that are done correctly. Praise for the work well done before raising problems.

If you see a problem, check to see if the supervisee sees the same problem. If not, this gives the supervisor a clue as to what is causing the poor performance.

Analyze the problem with the supervisee to gain a good understanding of what has been causing the problem. This process is linked to as feasible to the internal quality improvement program Once the causes of a problem have been identified, try to get the supervisee to suggest possible solutions. A person is always more likely to follow ideas that they have thought of themselves.

Observe patient flow in the health facility, and other client related issues.

Observe the sanitation and hygiene practices/injection safety, waste disposal, etc.Performance Review

A functioning information system is essential for the effective management at all levels of the health system and facilitates performance measurement for quality improvement. The supervisor plays a very important role in ensuring the accuracy and validity of the information system. The supervisor concentrates on:

1. Ensuring the proper use of the registers, 2. The correct completion of the monthly report, 3. The correct and up to date graphing of data and 4. The use of data for health service planning, monitoring and evaluation. In the process, the supervisor should make efforts to conduct in-depth reviews about focus and priority health programs, especially maternal health, child health, TB/HIV, Malaria, etc. and identify areas of performance gaps that need to be addressed.Referral System Review

Dealing with referral problems is an important element of the supervisory visit. Any problems with referrals, both in terms of patient movement as well problems related to communication between the levels (i.e. health centers to hospitals, health posts to health centers) needs to be clearly investigated and prompt actions taken. Supervisors should check and ensure that appropriate feedback is received and or sent to the respective health institution.

Administration Review

Reviewing aspects of administrative issues at the health center is necessary. The support and supervision activities will include reviewing aspects of administrative issues at the WoHO. The supervision process should address administrative matters including:

Staff matters, relationship between the management and staff (degree of transparency), Staff training and the level of their use and assignment, the practice of sharing of information by the one trained to the remaining colleagues, Budget allocation and resource utilization,



Audit reports and recommendations and

Infrastructure of health facilities and administrative offices, equipment, supplies


During each supervisory visit, supervisors should take the initiative to enquire about issues that are related to community involvement. When feasible, community assembly should be encouraged and any community problems which need urgent attention (malnutrition, disease outbreaks, etc) should be noted and addressed. The supervisor should also encourage health facility staff to plan and conduct specific community activities on a regular basis.

On-site Training Role of ISS

The supervisor carries a major responsibility to ensure that health workers are updated, trained and appropriately coached. The technical supervisor will conduct educational sessions during each visit designed to address specific needs of the health facility staff. Training activities mainly concentrate on skill building of facility staff targeted by identified performance gaps. The supervisor also provides health staff with information on updates of policies or new recommended practices.


Prompt problem solving at the level of supervisee is an integral part of the supervisory process. Many problems can be dealt with on the spot whilst others will have to be taken to the appropriate offices at the higher level. A note will be made of problems requiring solutions at a higher level and actions taken will be reviewed at the subsequent supervisory visit.

In the course of problem solving, full participation of supervisee team and their inputs are indispensable. At this stage,

Both the supervisor and health center staff should identify problems, listen, discuss, give feedback, and solve problems together.

Staff should identify areas of strength and weakness. A supervisor can serve as a facilitator and help the staff develop strategies for solving problems.

Prioritize problems by urgency to solve/local concern and resource availability

Analyze through discussions the underlying causes for the identified problem/s.

Look for strength or best practices. Praise health workers in public for good performance and for practices that meet quality standards. Correct performance only in private.

Set target for improvement. Identify appropriate strategy to solve the identified problems according to their priorities. Draw upon identified local strengths to set practical solution. Share responsibilities of solving problem among the two levels (supervisory and supervisee)

Draw an agreed upon follow up mechanism and an action plan. Prepare two copies of the agreed action plan. Both copies should be signed by the respective teams and each group should keep a copy.


It is always important to discuss the findings from the supervision visit and the recommendations forwarded by the supervisor with the health facility team. Providing feedback to the health center team is an important step in effective supervisory process. Feedback is provided in variety of forms:

On site verbal feedback: Interview, observations, record review, problem analysis and action planning provide a huge opportunity for sharing and learning for both the supervisor and the health center team if adequate time is given to supervision, full participation of staff allowed and trust is built. The final feedback may be provided to wider audiences or to all relevant staff at the health center. This provides opportunity to staff who were not involved in the supervisory process in a way heightening their awareness and commitment for implementation of agreed actions.

On site written feedback: The health center should have a supervision visitors book for documentation of the supervisory findings and recommendations. The supervisor documents key findings (strengths and gaps), agreed actions in supervisory visitors book at the health center. A copy of agreed action plan can be attached onto the supervisory report book. This also provides access to all staff of the health center to the supervisory findings and agreed action plan.

Immediate verbal feedback to other levels: At the end of a visit, a wrap up meeting may be held with the health center management and staff and a debriefing made on the major findings and recommendations. Minutes of the wrap up meeting taken by the supervisory should be circulated the health center staff. This will help to mobilize support for the health center management and ensures the active participation of all stakeholders.Recording and Reporting supervisory findings

Supportive supervision will not be able to accomplish its intended objectives unless there is a mechanism that would allow routine follow up. Follow up involves monitoring of implementation of activities that were agreed upon during any supervision visits. The supervisor should produce report on supervisory findings and share such reports with an agreed action plan with the management team/ staff at the health center.

A well documented supervision report can provide onsite useful and up-to-date information about progresses and problems on which to offer prompt action or to report to the Woreda for decision making. One of the actions expected from the management team at the Woreda includes decision making about issues for follow up before a subsequent supervision can be initiated. The WoHO should also decide upon the frequency of follow-up between the next supervision visits. Generally, it may be helpful to consider that lesser performing health facilities may need to receive more frequent supervision visits.

The health center management should also share the findings of the supervision visits to its staff and use it for self assessment in order to monitor and improve their own performance. Within a week of completing the supervisory visit, the supervisor should complete a short field supervision report including the findings, action recommended or taken or those issues which require a decision from the higher offices. The report should be action-oriented to increase commitment towards the implementation of the agreed actions. Such report should also highlight any special achievements and/or problems seen and should be accompanied with a copy of an agreed upon follow-up action plan signed by both the supervisor and the health center.

This report should be presented at the next management meeting at the WoHO so that all officers are given feedback on the findings and on the agreed follow-up actions and identify issues for follow up before a subsequent regular supervision.

Job and Structure for Health Center ISSSupervisory hierarchy takes into account the relationship, administrative and technical responsibilities of the supervisor and supervisee. In order to provide an adequate supervisory input into public health practices that are characterized by delegation of responsibilities, integration of program and services, continuous learning, interdisciplinary teamwork, inter-sectoral collaboration, community involvement, partner involvement and participatory planning and implementation, supervision has to evolve as an integrated tasks that should be managed by qualified professionals.


A health center supervisor is expected to be accorded distinctly separate sets of responsibilities. The supervisor's first duty is to be fully conversant on the objectives and values of the WoHO and to assume a duty that demands to adequately represent it.

The supervisor is a delegated middleman and a buffer between the WoHO and the health center management and hence responsible for follow-up of all activities and ensure that support is provided in a consistent manner. Furthermore, the supervisor needs a firm authority that is necessary to take actions on the spot to enhance acceptability and credibility and accorded a clearly delineated line of responsibility from the WoHO management backed by appropriate authority and accountability.Considering the process time required per visit, one supervisor will be will oversee 10 health centers.


It is the supervisors job to help the WoHO, envisage the future needs, energize the staff to get their tasks done and supervise their work in order to ensure that the health service performance goals met. To ensure this is accomplished, the supervisor should make certain that all health center staffs are equipped with the appropriate tools and backing from the WoHO to carry out their duties.

The supervisor is a catalyst for performance improvement. More power should be placed in the hands of supervisors to make changes and improve services. Supervisors should be seen as catalysts for change. They can do this by creating an environment of teamwork in which change and improvements in the quality of services can flourish.

Participatory joint problem solving. Supervisors are expected to be knowledgeable about standard problem-solving steps which involves among others, problem definition, analyzing possible causes, identifying possible solutions, developing an action plan to implement solutions, and evaluating the results.


Supervisors should be equipped with basic skills and the techniques of two-way communication or participatory decision making. They should also have good understanding of the steps, and standard problem-solving techniques including: defining the priority problem, analyzing its possible causes, identifying possible solutions, developing an action plan to implement these solutions, and evaluating the results are a requirement.

Supervisors must have solid technical knowledge for the duties they are to perform and must know how and where to gain access for additional support. Supervisors must know the broad array of services that are available at a site, as well as what the national standards and guidelines call for in terms of the quality of those services.

2. Integrated Supportive Supervision to Health PostsConducting the Supervision

Integrated supportive supervision to health posts will be conducted primarily by meeting with the health extension workers to discuss and assess performance and quality goals. ISS of health extension workers emphasizes extensive visits to households along with health extension workers as well as meeting with community members and hold discussions with administrative managers within the Kebele. This approach to ISS is expected to provide extensive opportunity for mentoring and on-the-job training to HEWs.Introduction in the Process of Supervision Visit

The supervision process starts with the both the supervisor and health extension workers briefly discussing and agreeing on where and how to proceed with the supervisory process. The time requirement for household visits, interviews, relevant record review, quality assessment and action planning should be agreed upon at this stage. Both the supervisor and health extension workers should briefly review actions taken after the previous supervisory visit and should reflect on the progresses that have been made based on the reports, completed checklists and action plan developed during previous supervisions, review the health posts latest self-assessment report and agree on the specific program areas that might be focused on during the current supervisory visit.Structured discussions with Health Extension WorkersInterviewing and holding discussions with HEWs needs to be structured to address all 16 packages supplemented with observation of activities at household level and needs to occur over a period of several days. This process will be guided by the completion of integrated supervisory checklists. Both the health post supervisor and HEWs should have a checklist in hand so that all can follow the progress of supervision and should complete the checklist and take note of the major issues of concern. All elements in the checklist addressing all 16 packages are expected to be completed and notes are taken to those comments arising during the process. Supervisors should make verifications to verbal responses through a record review or observation where appropriate.Quality of Service Review

Correct application of service delivery standard and quality of preventive services is reviewed by making observations of how services are provided and by comparing such service delivery against the agreed standards, protocol and guidelines. Hence, supervisory visits should be arranged when supervisors can observe the HEWs during household visits, and when clinical services are being provided and interview clients on the services they received. Additional questions may be asked by the supervisor to gather all relevant information about the area under review and to understand whether certain activities are done correctly. For those observed problems that are amenable to be dealt with immediately, the necessary guidance are offered to fix the problem. Providing appropriate feedback and planning for further capacity building of the HEWs is part of the observational and quality assessment process in supportive supervision. Helpful behaviors in gaining the commitment of those being supervised include:


Identify problems, check to see if the HEWs identify the same problem. If not, this gives the supervisor a clue as to what is causing the poor performance.

Analyze the problem with the HEWs to gain a good understanding of what has been causing the problem. This process is linked to as feasible to the internal quality improvement program.

Encourage HEWs to come up with possible solutions. Once the causes of a problem have been identified a person is always more likely to follow ideas that they have thought of themselves.Performance Review

A functioning information system is essential for the effective management at all levels of the health system and facilitates performance measurement for quality improvement. The supervisor plays a very important role in ensuring the accuracy and validity of the information system. The supervisor concentrates on ensuring the proper use of the registers, the correct completion of the monthly report, the correct and up to date graphing of data and the use of data for health service planning, monitoring and evaluation.

In the process, the supervisor should make efforts to conduct in-depth reviews about focus and priority health programs, especially maternal health, child health, TB/HIV, Malaria, etc. and identify areas of performance gaps that need to be addressed.

The supervisor plays a very important role in ensuring the accuracy and validity of the information system. The supervisor concentrates on:

1. Ensuring the proper use of the registers, 2. The correct completion of the monthly report and quarterly compilation 3. The correct graphing and the use of data 4. Perform quality checks for completeness, accuracy and timely submission of reports

5. Assist the HEWs and the Kebele Council with the monthly performance monitoring and quality improvement process

During this process, the supervisor should make efforts to conduct in-depth reviews about focus and priority health programs in line with the 16 packages being implemented.

Referral System Review

Dealing with referral problems is an important element of the supervisory visit. The supervisor should review all referrals made to higher institutions by the health extension workers. This should be considered a mentoring opportunity and all causes for referral, problems with referrals, both in terms of patient movement as well problems related to communication between the HEWs and health centers/hospitals needs to be clearly investigated and prompt actions taken. Supervisors should check and ensure that appropriate feedback is received from the respective institution.Administration Review

Reviewing aspects of administrative issues at the health post is necessary addressing issues that might include relationship between the Kebele management and HEWs (degree of transparency), etc. Besides administrative issues including: HEW training and the level of use, the practice of sharing of information by the one trained, Audit reports and recommendations and Infrastructure of health facilities equipment, supplies


During each supervisory visit, supervisors should take the initiative to enquire about issues that are related to community involvement. When feasible, the supervisor should attend community assemblies and assist the HEW with any community problems which need urgent attention (malnutrition, disease outbreaks, etc).


The supervisor carries a major responsibility to ensure that HEWs are updated, trained and appropriately coached. During all visits, the supervisor will conduct refresher training sessions designed to address specific needs. This will be a planned activity for every quarter with agreed upon schedule between the supervisor and HEWs. The supervisor will also provide HEWs with information on updates or new recommended practices.Discussions and Problem Solving

Prompt problem solving for the HEWs is an integral part of the supervisory process. Many problems can be dealt with on the spot. A note will be made of problems requiring solutions at a Woreda level and actions taken will be reviewed at the subsequent supervisory visit.

In the course of problem solving, full participation of the HEWs and their inputs are indispensable. At this stage,

Both supervisor and HEWs should identify problems, listen, discuss, give feedback, and solve problems together.

HEW should identify areas of strength and weakness. A supervisor can serve as a facilitator and help the HEW develop strategies for solving problems.



Look for strength or best practices. Praise HEWs in public for good performance and for practices that meet quality standards. Correct performance only in private.

Set target for improvement. Identify appropriate strategy to solve the identified problems according to their priorities. Draw upon identified strengths to set practical solution.

Draw an agreed upon follow up mechanism and an action plan. Prepare two copies of the agreed action plan. Both copies should be signed by the supervisor and HEWs and each should keep a copy.


It is always important to discuss the findings from the supervision visit and the recommendations forwarded by the supervisor with the HEWs. Providing feedback to the HEWs is an important step in effective supervisory process. Feedback is provided in variety of forms:

On site verbal feedback: this is an implicit or explicit feedback given to or received from the HEWs in the process of supervisions. Interview, observations, record review, problem analysis and action planning provide a huge opportunity for sharing and learning if adequate time is given to supervision, full participation of HEWs allowed and trust is built. The final feedback may be provided to wider audiences within the Kebele.On site written feedback: HEWs should have a supervisory visitors book for documentation of the supervisory findings and recommendations. Supervisors will write key findings (strengths and gaps), agreed actions in supervisory visitors book. A copy of agreed action plan can be attached onto the supervisory report book.Immediate verbal feedback to other levels: At the end of a visit, a wrap up meeting may be held with Kebele leaders (political and administrative) at least monthly. On such a meeting, debriefing could be made on the major findings and recommendations.Recording and Reporting supervisory findings

Supportive supervision will not be able to accomplish its intended objectives unless there is a mechanism that would allow routine follow up. Follow up involves monitoring of implementation of activities that were agreed upon during any supervision visits. Supervisors should produce report on supervisory findings and share such reports with the Woreda management team/ staff. An agreed action plan between the supervisor and HEWs is one of the important tools to share at this level.

A well documented supervision report can provide onsite useful and up-to-date information about progresses and problems on which to offer prompt action or to report to the Woreda level decision making. One of the actions expected from the Woreda management team includes decision making about issues for follow up before a subsequent supervision can be initiated. The Woreda management should also decide upon the frequency of follow-up between the next supervision visits. Generally, it may be helpful to consider that lesser performing HEWs may need to receive more frequent supervision visits.

Within a week of completing the supervisory visit, the supervisor should complete a short field supervision report including the findings, action recommended or taken or those issues which require a decision from the higher offices. The report should be action-oriented to increase commitment towards the implementation of the agreed actions. Such report should also highlight any special achievements and/or problems seen and should be accompanied with a copy of an agreed upon follow-up action plan signed by both the supervisor and the supervisee.

This report should be presented at the next management meeting at Woreda so that all officers are given feedback on the findings and on the agreed follow-up actions and identify issues for follow up before a subsequent regular supervision.Job and Structure for Integrated supportive supervision

A health post supervisor is expected to be accorded a distinct set of responsibilities. The supervisor's first duty is to be fully conversant on the objectives and values of the Health Extension Program and to assume a duty that demands to adequately represent it.


The health post supervisor is a delegated middleman and a buffer between the HEWs who actually do the job at operational level and the WoHO.Supervisors should have the authority that is necessary to take actions on the spot that will enhance their acceptability and credibility and should be accorded a clearly delineated line of responsibility backed by appropriate authority and accountability from the WoHO.

Considering the process time required per visit, one supervisor will be will oversee 5 health posts.


It is the supervisors job to help the HEWs to get their tasks done and supervise their work in order to ensure that the health service standards are met. To ensure this is accomplished, the supervisor should make certain that HEWs have the appropriate training tools and the material and resources that they need to carry out their duties.

The supervisor is a catalyst for quality improvement. More power should be placed in the hands of supervisors to make changes and improve services. Supervisors should be seen as catalysts for change. They can do this by creating an environment of teamwork in which change and improvements in the quality of services can flourish.

Joint problem solving, with full HEW participation and using simple, practical tools, will foster health care delivery process. Supervisors are expected to be knowledgeable about standard problem-solving steps which involves among others, problem definition, analyzing possible causes, identifying possible solutions, developing an action plan to implement solutions.

Facilitative styles of communication and support are essential. A facilitative style of supervision emphasizes mentoring and coaching of the HEWs. Good communication skills that facilitate dialogue are essential. Supervisors must know how to facilitate discussions, must acquire skills of giving and receiving feedback in an appropriate manner, and must learn how to listen effectively in order to improve communication. An understanding of adult learning processes is also a key to communicating with HEWs.


Supervisors should be equipped with basic skills and the techniques of two-way communication or participatory decision making. They should also have good understanding of the steps, and standard problem-solving techniques including: defining the priority problem, analyzing its possible causes, identifying possible solutions, developing an action plan to implement these solutions, and evaluating the results are a requirement. Supervisors must have solid technical knowledge for the duties they are to perform and must know how and where to gain access for additional support.

Integrated Supportive Supervision to Hospitals

Integrated Supportive supervision to hospitals will target to assess and provide support on the major components of the hospital system in a structured manner with emphasis on the provision of quality services. Federal Hospitals will be supported and supervised by the FMOH while Regional Hospitals will be supported and supervised by RHBs. Primary hospitals will be supported and supervised by either RHB or WoHO.

The following are necessary requirements for having effective supervisory system:


Advance communication to the hospital being supported A thorough preparations by ISS supervisors


The willingness to provide adequate and transparent feedback to those supervised and


Hospital Comprehensive Plan Preparation

Consistent with the annual planning process of top down-bottom up approach, core plan preparation for the hospital will be considered with the FMOH/RHB, depending on the respective jurisdiction. The plan for hospitals will include specific visitation schedules with a definite time line. Suggested scheduling should take into consideration time frames after performance monitoring has been completed at the hospital.

Annual supervision plans should be integrated in the annual work plan of the supervisory body and should include an implementation budget. The resource requirement for supervision should be estimated and their availability identified by source and costed.At the end of the annual planning process, the supervisory schedule should be communicated in advance to the hospitals. Moreover, the hospitals should be reminded 2-3 weeks ahead of the actual supervision visits.


Before making a supervisory visit, the supervisor should take the initiative to review records with regard to program/service targets/coverage and the progress being made by the hospital in the implementation of the program in comparison with the set targets, previous supervisory reports and the major problems observed in the implementation of programs and provision of services. The supervisor should critically review the HMIS report of the hospital to be supervised as well as the report of the internal quality improvement process.

SupervisorSupervisee

The supervisor should make thorough preparation before each visit based upon the supervision plan and schedule.

Review the report of the last supervisory visit and the agreed follow up Action Plan.

Review the HMIS reports of the levels/institutions to be supervised and determine the performance gaps (or areas of concern based on previous visits).

Review with programs and relevant experts program areas that need to be followed up.

Develop clear objectives for each visit.

Collect helpful publications, materials, and supplies for the health facility.

Review the institutions Internal quality management process reports.

Prepare updates and/or refresher training to present during the visit.

Ensure that sufficient copies of the Integrated Supervisory Checklist for health institutions to be visited.

Arrange the necessary transport and logistics for the supervision visit.

Communicate with supervisee on the actual date of supervision visit.The supervisee level should prepare for the supervisory visit Review the previous supervisory report and associated action plan developed during the last supervision

Review the HMIS and performance monitoring reports for the previous months to ensure that they can report on any special actions they have taken to address any problems that have arisen;

Review the progress in implementing the plan;

Conduct monthly self-assessment, identify any problems and determine actions that need to be taken to address these problems.

Make sure that all key officers are present for the supervisory visit.

Conducting the Supervision

ISS at hospitals will be conducted in several ways including interviewing service providers and clients, record reviews, health facility observation, meeting with the health workers to discuss and assess performance and quality goals, meeting with community members and hold discussions with program/administrative managers. The supervisor is expected to provide on-the-job skill building training.

Every supervisory visit should be well planned and communicated in advance to assure the availability of the responsible health personalities so that it could be possible for the supervisor to spend sufficient time (from several hours, to several days) to go through each step stated.

Introduction in the Process of Supervision Visit

The supervision process starts with setting of the objectives for the visit. Both the supervisor and hospital management should briefly discuss and agree on where and how to proceed with the supervisory process. The time requirement for interviews, relevant record review, quality assessment and action planning should be agreed upon at this stage. A brief review of actions taken after the previous supervisory visit and should be reflected upon the progresses that have been made based on the reports, completed checklists and action plan developed during previous supervisions, review the sites latest self-assessment report and agree on the specific program areas that might be focused on during the current supervisory visit.

Interview Appropriate Staff

Interviewing and observation of appropriate staff might require an allocation of several hours to days. This process includes mainly the completion of integrated supervisory checklists. Both the supervisor and hospital case teams should have a checklist in hand so that all can follow the progress of supervision and should complete the checklist and take note of the major issues of concern. All elements in the checklist are expected to be completed and notes are taken to those comments arising during the process. Supervisors should make verifications to verbal responses through a record review or observation of documents where appropriate.Quality of Clinical Care Review

At the hospital level correct application of service delivery standard, protocols of treatment, guidelines of operation and use of the approved list of essential drugs is of great importance to ensure high quality care. Qualities of clinical care or preventive services are reviewed by making observations of how services are provided and by comparing such service delivery against the agreed standards, protocol and guidelines. Hence, supervisory visits should be arranged when supervisors can observe health services being provided and interview clients on the services they received.

Generally, the client and provider interactions, process of diagnosis, treatment and counseling is observed to confirm that these are being done in line with service delivery standards. Additional questions may be asked by the supervisor to gather all relevant information about the area under review and to understand whether certain activities are done correctly. For those observed problems that are amenable to be dealt with immediately, the necessary guidance are offered to fix the problem.

The supervisor should assess and review the hospitals quality improvement cycle and assess the activities and plans to address specific quality shortcomings. The quality improvement process should be assessed for every case team and if possible the supervisor should sit in on a quality management team meeting. Activities and plans for the case teams and their follow up should also be assessed.

Providing appropriate feedback and planning for further capacity building of the providers is part of the observational and quality assessment process in supportive supervision. Helpful behaviors in gaining the commitment of those being supervised include:


If you see a problem, check to see if the supervisee sees the same problem. If not, this gives the supervisor a clue as to what is causing the poor performance.

Analyze the problem with the supervisee to gain a good understanding of what has been causing the problem. This process is linked to as feasible to the internal quality improvement program

Once the causes of a problem have been identified, try to get the supervisee to suggest possible solutions. A person is always more likely to follow ideas that they have thought of themselves.

Observe patient flow in the health facility, and other client related issues.

Observe the sanitation and hygiene practices/injection safety, waste disposal, etc.

Performance Review

A functioning information system is essential for the effective management at all levels of the health system and facilitates performance measurement for quality improvement. The supervisor plays a very important role in ensuring the accuracy and validity of the information system. The supervisor concentrates on:

1. Ensuring the proper use of the registers, 2. The correct completion of the monthly report, 3. The correct graphing of important data and 4. The use of data for health service planning, monitoring and evaluation.In the process, the supervisor should make efforts to conduct in-depth reviews about focus and priority health program and areas specific for hospitals will include mortality reports, infection prevention, length of stay and bed utilization rates.Referral System Review

Dealing with referral problems is an important element of the supervisory visit. Any problems with referrals, both in terms of patient movement as well problems related to communication between the hospital being supervised and other health institutions needs to be clearly investigated and prompt actions taken. Supervisors should check and ensure that appropriate feedback is received and sent to the respective level.

Administration Review

Reviewing aspects of administrative issues at the health center is necessary. The support and supervision activities will include reviewing aspects of administrative issues at the WoHO. The supervision process should address administrative matters including:

Staff matters, relationship between the management and staff (degree of transparency),

Staff training and the level of their use and assignment, the practice of sharing of information by the one trained to the remaining colleagues,

Budget allocation and resource utilization,



Audit reports and recommendations and

Infrastructure of health facilities and administrative offices,

Logistics and supply management.


The supervisor carries a major responsibility to ensure that health workers are updated, trained and appropriately coached. The hospital supervisor will conduct or coordinate educational sessions during each visit designed to address specific needs of the health facility staff. Training activities mainly concentrate on skill building of facility staff targeted by identified performance gaps. The supervisor also provides health staff with information on updates of policies or new recommended practices.


Prompt problem solving at the hospital is an integral part of the supervisory process. Many problems can be dealt with on the spot whilst others will have to be taken to the appropriate offices at the higher level. A note will be made of problems requiring solutions at a higher level and actions taken will be reviewed at the subsequent supervisory visit.

In the course of problem solving, full participation of supervisee team and their inputs are indispensable. At this stage,

Both the supervisor and hospital staff should identify problems, listen, discuss, give feedback, and solve problems together.

Staff should identify areas of strength and weakness. A supervisor can serve as a facilitator and help the staff develop strategies for solving problems.



Look for strength or

Documents

File 177