Effective Supportive Supervision

Dr. Henock A. M. Ngonyani MD, MPH

Public Health Specialist
 Learning Session Objectives- #1
At the end of this session students will be able to:
 Define supervision, supportive supervision (SS),
coaching and mentoring

 Explain why SS?

 Describe SS as an opportunity

 Mention the characteristics of SS

 Compare SS with Traditional Supervision

 Explain the pre-requisite for SS

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 Learning Session Objectives- # 2
 Describe SS process and its types

 Mention the qualities of a supportive supervisor

 Outline the areas to be supervised, duration and

frequency.

 Explain the barriers to effective SS

 Mention the challenges in SS implementation; and

 Explain the lessons from SS implementation

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 Definition of Supervision
 Supervision refers to management function
planned and carried out in order to guide,
support and assist health providers in
carrying out their assigned tasks.

 It involves on job transfer of knowledge and

skills between the supervisor and the one
being supervised through opening of
administrative and technical communication
channel.
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 Definition of Supportive Supervision # 1

 Supportive supervision is a process which

promotes quality outcomes by strengthening
communication, identifying and solving problem,
facilitating team work, and providing leadership
and support to empower health providers to
monitor and improve their own performance.

 It expands the scope of supervision method by

incorporating self assessment, peer assessment
as well as community input.
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Definition of Supportive Supervision # 2

 Supportive supervision is a process that

promotes quality at all levels of the health system
by:
 Strengthening relationships within the system;
 Focusing on the identification and resolution of
problems; and
 Helping to optimize the allocation of resources.

 Supportive supervision promotes continuous

improvements in the quality of care by:
 Providing the necessary leadership and support for
quality improvement processes;
 Promoting high standards, teamwork; and
 Promoting a better two way communication. 6
 Why Supportive Supervision? - #1

 To help staff to identify and solve problems

 To motivate the staff.

 To improve the skills of the staff

 To find out what is being done well

 To make sure that operational objectives are

appropriate.
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 Why Supportive Supervision? - #2
 The issues of Client Rights and Staff Needs
 The supportive supervisor focuses on the needs
and expectations of both the client and health
care staff.
 Clients have rights to:
 Information
 Access to service
 Informed choice
 Safe services
 Privacy and confidentiality
 Dignity, comfort, and expression of opinion
 Continuity of care 8
 Why Supportive Supervision? - #3

 Health-care staff have the following needs;

Support from supervisors, management and
clients
Information, training, and career development
Supplies, equipment, and infrastructure
 The supportive supervisor keeps in mind
these rights and needs when assessing
quality, identifying problems/constraints and
finding solutions.
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The Concept of Supportive Supervision

WORK SUPPORTIVE SUPERVISION

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 The goal of Supportive Supervision

In supervision the goal is:

To building health workers (in all service

areas) capacity and commitment to carry
out their duties in providing quality
healthcare services, by enabling each
individual to perform at her/his personal
best, through coaching, mentoring and
performance management.
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 ‘SS’ is an Opportunity FOR:- #1

 Helping service providers to achieve work

objectives by improving their performance.

 Ensuring uniformity to set standards.

 Identifying problems and solving them at

appropriate time.

 Helping other people to take responsibility

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 ‘SS’ is an Opportunity FOR:- #2

 Making follow up on decision reached during last

supervision visit.
 Identification of the staffing needs e.g. training
needs.
 Providing opportunities for personal
development
 Maintaining and reinforcing the administrative
and technical link between high and lower levels

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 Characteristics of Supportive
Supervision

 Focus on problem solving to assure quality and

meet client needs
 Responsibility of entire team(supervisor -
supervisees) to ensure quality
 Empowerment of health providers to monitor and
improve their performance
 Supervisor acts as facilitator, trainer and coach
 Supervisees participate in supervising
themselves and each other
 Decision - making is participatory.
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 Comparison of Traditional and
Supportive Supervision
Parameters Traditional supervision Supportive supervision
Who performs External supervisors External Supervisor,
supervision colleagues, staff
themselves, community
Frequency of Periodic visits: Continuously: routine
supervision monthly/quarterly work, team meetings +
periodic visits
How Inspection, review of Observation, dialogue,
supervision is records, decision by diagnosis, feedback,
conducted supervisor discussions, on-site
training
After No or irregular follow- Recording, monitoring
supervision up and follow-up
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Pre-requisite for Supportive Supervision
- #1
 A functional and accessible health care delivery
system

 Competent human resources both for delivery of

health care and for carrying out supervision

 Team spirit between supervisors and health

personnel to be supervised

 Supervision tools with key information on

various technical programmes included in the
health care delivery package
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 Pre-requisite for Supportive Supervision - #2

 Well prepared supervision plan with

schedule of supervision

 A reliable Health Management Information

System (HMIS)

 Availability of logistics and financial

resources.
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 The Process of Supportive Supervision

The steps: SET EXPECTATIONS

Job Description / Standards

TAKE ACTION
help marshalling resources MONITOR AND ASSESS
necessary (human, financial, PERFORMANCE
material, political, institutional) Performance Gaps /
Best Practices

IDENTIFY PROBLEMS AND

OPPORTUNITIES
Facilitate open communication
and teamwork
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 Stages of Supportive Supervision

 Stage I: Planning and preparation

 Stage II: Actual supervision

 Stage III: Immediate Feedback

 Stage IV: Final feedback & Follow up

action.

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 Stage I: Planning and preparation

 Review records such as progress reports or previous

supportive supervision reports and/or data
 from the HMIS.
 Identify specific supportive supervision needs from the
respective facilities.
 Set clearly defined objectives and standards.
 Prepare logistics, teams and other resources.
 Prepare supervisory tools.
 Schedule and communicate to the supervisee,
administrative authorities and community where
 appropriate
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 Stage II: Actual supervision – 1/2

 Get to the facility on time

 Pay courtesy call to the relevant authorities (introduce
yourself and your team, objectives, sites to be visited
and de-briefing date)
 Introduce oneself and team, purpose of the visit and
agree on how the supportive supervision will proceed
 Review previous supportive supervision report, assess
level of implementation of agreed tasks
 Provide feedback in relation to the previous tasks if any
 Establish if there is any alarming problem that needs
immediate attention and agree on corrective measures
to be taken 21
 Stage II: Actual supervision – 2/2

 Observe HSPs perform tasks

 Note tasks done well and those areas which have
problem in performing
 In the absence of an external client, interview the
supervisee (internal client) to establish level of
knowledge for a given task
 Demonstrate correct way of performing problem tasks
(if you have up to date knowledge and skills) and ask
supervisee for return demonstration. Make correction
accordingly.

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 Stage III: Immediate feedback – 1/3

The supervisor meets with the supervisee to discuss

findings from the respective areas:
 Find an appropriate place with privacy for feedback
 Apply sandwich approach when giving a feedback,
starting with positives, then areas for improvement and
finish with positives (strengths)
 Encourage the supervisee to point out their strengths
and weaknesses using the supervisors tool
 Praise the HSPs for tasks done well without going into
specifics

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 Stage III: Immediate feedback – 2/3

The supervisor meets with the supervisee to discuss

findings from the respective areas:
 Ask for feedback from the management team (areas
done well and those needing improvement, referring to
the previous report)
 Stimulate HSPs to think on how to solve problems on
their own.
 Prepare an action plan for the weaknesses observed
during the supportive supervision

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 Stage III: Immediate feedback – 3/3

The supervisors meet with the respective Health Facility

Management Team (HFMT) to discuss findings.
 Apply a sandwich approach
 Praise the HFMT for tasks done well without going into
specifics
 Ask for feedback from HFMT (areas done well and those
needing improvement referring to the
 previous supportive supervision report (internal/external))
 Discuss with them on problem areas
 Work out together on feasible solutions and agree on
areas for improvement
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 Stage IV: Final feedback and follow-up
action
 Supportive supervision reports shall be circulated to
relevant stakeholders at national, regional and respective
councils. Councils should make sure that they send extracts
of the reports to respective facilities that were supervised.
 Supervisory reports should be discussed in planned RHMT,
CHMT and HFMT meetings.
 Recommendations and follow-up actions should be laid
down in the minutes of meetings and be shared with
relevant stakeholders
 Responsible officers at national/ regional/ district/ facility
levels to ensure actions are taken on identified problems;
including informing other programmes and or officers likely
to address the problems.
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 Types of Supportive Supervision

1. Self
Types (mechanisms)
Expectations
Internal
Self/Peer Supervision
supervision 2. Monitor and
Assess
Performance

External 3. Identify
Supervision Problems and
Opportunities

4. Take Actions

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 What is Self- or Peer Supervision?

 The process by which:

 individuals monitor and improve their own Skills; and
 performance or that of their colleagues.

 The process encompasses:

 setting clear performance expectations including
professional standards;
 assessing skills and measuring performance; eliciting
customer feedback; and
 monitoring health outcomes, among others.

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 What is internal supervision?

 Refers to the process in a particular facility or

department to oversee the performance of
individuals and the quality of service delivery.
 Internal supervisors:
 Set and monitor standards;
 Support and motivate providers with materials,
 Training, and recognition;
 Build teams and promote team-based approaches to
problem-solving;
 Foster trust and open communication; and collect and
 Use data for decision-making.
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 What is external supervision? - #1

 The process used to oversee the

operations and performance of
individuals and facilities within a
larger system, such as a district,
regional, or national health system.

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 What is external supervision? - #2

 External supervisors:
 Make site visits;
 Set and implement clear program goals and standards;
 Jointly define performance expectations with
supervisees;
 Monitor performance against those expectations;
allocate
 Resources within the system;
 Facilitate supervision at lower levels of the system; and
 Follow up to solve problems that require intervention
from higher levels of the health system.
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 Qualities of a Supportive
supervisor - #1

 Technical skills: Adequate knowledge of the work

being supervised or relevant technical skills

 Leadership skills: Ability to inspire others, establish

and maintain trust and promote teamwork spirit

 Interpersonal (communication) skills: Able to work

with others and respect them, active listening and
constructive feedback

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 Qualities of a Supportive
supervisor - #2
 Conceptual skills: analyze situations, problems and
formulate solutions

 Authority:
 sufficient influence in the system
 to influence decision and action
 but is also flexible

 Openness to new ideas

 Ability to train or convey information to others and learn

from them

 Desire to empower others and provide opportunities for

advancement 33
 Qualities of a Supportive
supervisor - #3

 Additional: familiar with:

Conceptual framework for health planning
Health system concept, supportive supervision
and monitoring
Main objectives of supervision
Essential Healthcare Interventions Package
Meaning of quality health care
Roles and responsibilities of supervisees.

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 Areas to supervise – 1/2

 Priority area 1: Medicines and medical equipment,

medical and diagnostic supplies management system.
 Priority area 2: Reproductive, Maternal, Newborn and
Child Health
 Priority area 3: Communicable Disease Control
 Priority area 4: Non – Communicable Disease Control
 Priority area 5: Treatment and care of other common
diseases of local priority within the Council
 Priority area 6: Environmental Health and Sanitation
 Priority area 7: Strengthen Social Welfare and Social
Protection
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 Areas to supervise – 2/2

 Priority area 8: Strengthen Human Resources for Health,

Management Capacity for improved health services
delivery
 Priority area 9: Strengthen Organizational Structures and
institutional management at all levels.
 Priority area 10: Emergency preparedness and response;
referral system
 Priority area 11: Health Promotion / Behavior Change
Communication (BCC).
 Priority area 12: Traditional and alternative medicine.
 Priority area 13: Construction, rehabilitation and planned
preventive maintenance of physical infrastructure of HFs.36
 Duration and Frequency of SS - #1

 Determinants for duration and frequency of each

visit:
 the objectives of the supervision,
 expected workload,
 accessibility
 expected output.
 For effective supportive supervision:
 at least two days for consultant hospital,
 one day for regional/council hospital
 not more than two FLHFs should be visited per day.
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 Duration and Frequency of SS - #2

 CMO’s Office through DQHA shall co-ordinate

general supervisory visits at the national level.

 A team from the National level shall visit

national referral hospitals, specialized hospitals,
consultant private hospitals and regional
hospitals at least twice in a year.

 The RHMT shall visit each district quarterly

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 Duration and Frequency of SS - #3

 The CHMT shall visit each health facility at

least once every quarter.

 The health centre shall visit each

dispensary in its catchments area at least
once every quarter.

 Dispensaries shall supervise community

based health-care services once every
quarter. 39
 Methods for data collection

 Direct observation

 Exit interviews with clients /patients

 Review of records

 Interview with healthcare workers

 Assessing resource availability

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 Barriers to Effective Supervision

 Narrow focus of supervision on inspection of

certain areas (1)
 Punitive approach (2)
 Lack of supervisory skills and knowledge (3)
 Lack of supervisor authority to reward or
sanction performance (4)
 Infrequent or irregular supervision due to lack of
resources (5)
 Lack of direction and accountability in the overall
health system (6)
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 How each barrier Limits the Performance
of Basic Supervision Tasks - #1
The explanations
Barrier How it limits
(1) Emphasizes monitoring to the detriment of other key
supervisory tasks, especially problem-solving and
taking action
(2) Inhibits problem-solving and demoralizes staff

(3) Inhibits supervisors from effectively performing any

of the basic supervision tasks and undermines
supervisor credibility

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How each barrier Limits the Performance
of Basic Supervision Tasks - #2
The explanations
Barrier How it limits
(4) Deters supervisors and staff alike from taking
action, because no consequences (positive or
negative) result

(5) Undermines continuity and limits supervision

to only certain tasks, such as facility
assessment
(6) Undermines the performance of all supervision
tasks and demoralizes staff and supervisors
alike
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 Making supervision effective – 1/2

 Make preparation prior to the visit:

Orientation of supervision team on Dos and
Don’ts
Selection of supervision sites
Duration, frequency & nature of supervision,
 Select team members who have required
knowledge and skills
 Establish Terms of Reference (ToR)
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 Making supervision effective – 2/2

 Use effective communication during SS and

feedback
 Differentiate SS from inspection visits
 Build positive supervisory relationship
 Be proactive aiming at closing performance
gaps and future problem
 Focus work processes and support system
♦ Supervisors should remember that the primary
purpose of SS is to facilitate supervisees to
improve performance, hence, quality of services
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 What is Mentoring? - #1

 Mentoring may be defined as a caring

and supportive interpersonal relationship
between:
an experienced, more knowledgeable
practitioner (mentor); and
a less experienced, less knowledgeable
individual (prote´ge´ or mentee) in which the
prote´ge´ receives career-related and
personal benefits
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 What is Mentoring? - #2

 Mentoring facilitates:
the transfer of knowledge, skills, attitudes,
beliefs, and values between an experienced
and a less experienced practitioner.

The essence of the relationship is that the

experienced practitioner takes a direct and
personal interest in the education and
development of the younger or less
experienced individual

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 Components of a Mentoring Program

 Mentoring incorporates several systematic

steps:
1) identifying the meentee’s interests and
needs,
2) developing a mentoring plan or agreement,
3) providing assistance as the mentoring plan is
executed; and
4) evaluating the mentoring plan’s effectiveness.

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 What is Coaching? - #1

 Coaching evolved from athletic training models,

clinical supervision in education, and staff
development with educators.
 It is a method used for:
improving instructions and teaching strategies
experimenting with new approaches
experimenting with new techniques and
problem solving; and
building collegial relationships

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 What is Coaching? - #2

 Coaching provides professionals with the

following opportunities:
 To receive support and encouragement through the
opportunity to:
o review experiences,
o discuss feelings,
o describe frustrations, and
o check perceptions with a partner
 To fine-tune skills or strategies through technical
feedback and technical assistance from a coaching
partner
 To analyze practices and decision making at a
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conscious level
 What is Coaching? - #3

 Coaching provides professionals with the

following opportunities: cont…..
 To adapt or generalize skills or strategies by
considering:
o what is needed to facilitate particular outcomes,
o how to modify the skill or practice to better fit
interactions with specific families or
practitioners, or
o what results may occur from using the skill or
practice in different ways
 To reflect on what they perceive or how they make
decisions, which helps improve their knowledge and
understanding of professional practices and activities51
 Components of Coaching #1

Coaching involves the following five steps:

Step 1: Motivation - gaining the staff’s
commitment to acquiring the new behavior
Step 2: Modeling - competently demonstrating
and explaining the new behavior, with the
opportunity for the trainee to ask questions
Step 3: Practice -giving trainees the opportunity to
apply and to demonstrate their ability to
perform the new behavior, under the
supportive supervision of the trainer
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 Components of Coaching #2

Step 4: Constructive feedback - having the trainer

share his or her evaluation of the trainee in a
concrete, respectful, two-way interchange of
ideas
Step 5: Skills transfer -transferring skills gradually as
the trainer allows the trainee the opportunity to
undertake and demonstrate an increasing
number of the sub skills involved in the new
behavior, after which the trainee becomes
competent to carry out the new behavior
without supportive supervision.
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 Advantages of Coaching

 It allows staff to learn while on the job.

 It allows staff to immediately apply what
they are learning and see how well it
works.
 It promotes a positive working relationship
with staff, who previously may have
considered the supervisor a critic.
 It makes staff feel supported and
important.
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Challenges in Implementing Supportive
Supervision
 Too many actors involved with diffuse
responsibilities

 More labour intensive

 Motivation and behaviour change of supervisors

 Sustaining improvements over time

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Lessons in Implementing and sustaining
Supportive Supervision - #1
 It requires motivation on the part of
supervisors and other staff to adopt new
behaviours
 Offers a wide range of mechanisms to
accomplish supervisory tasks
 Requires locally appropriate and tested
tools
 Need time and investment to establish
 Top management must be committed to it
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Lessons in Implementing and sustaining
Supportive Supervision - #2
 Should be integrated into the existing
human resource management system,
rather than introduced as an isolated
intervention or parallel system

 Build on success to improve sustainability

of change

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 Lessons in Implementing and sustaining
Supportive Supervision - #3

 Long – term sustainability depends on public

sector institutions it:
 Ministry of Health and its Appended structures
 Major donors
 Vertical programmes

 Some decision making authority must be

decentralized for it to work:
 Empower frontline supervisors and healthcare providers
for some decision to solve problems
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Lessons in Implementing and Sustaining
Supportive Supervision - #4
 Need to study the costs of supportive
supervision:
Start-up costs

Recurrent costs

Need to document on cost-effectiveness of

different mechanisms of supportive
supervision.
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 Conclusion

 Supervision, mentoring, and coaching all offer

opportunities for practitioners to obtain needed
support and to refine their practices.

 A consistent theme is the need for these

mechanisms to be routinely included as part of a
comprehensive personnel development
package, although perceived lack of resources to
adequately support these activities continues to
be a barrier.
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