Supervision in Health

Supervision is a process of guiding, helping, training, and encouraging staff to improve their performance in order to provide high-quality healthcare services.
A guideline has been published by Managemnt Division in 2066 BS to systematize the supervision process at different levels which specialy focuses on supportive and integrated supervision.
n conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.

1. Supervision in Health Presenter: Sunita Poudel MPH 2nd Sem Roll no: 8

2. Outline of presentation Supervision in Health, Unit VI, PHSM Introduction Types of Supervision Role of supervisor Supervision in health system of Nepal Sample supervisory checklist Problems/ challenges regarding supervision Conclusion and recommendations References

3. Supervision Supervision in Health, Unit VI, PHSM Supervision is a process of guiding, helping, training, and encouraging staff to improve their performance in order to provide high-quality healthcare services. Way of ensuring staff competence, effectiveness and efficiency through observation, discussion, support and guidance to make the best use of their knowledge, skills and to improve their abilities. Contribute postively toward accomplishing the organizations goal and objectives .

4. Types of supervision Supervision in Health, Unit VI, PHSM 1. Direct Supervision Field Visit/Observation Check-list Interview Feedback Client's exit interview 2. Indirect Supervision Reports/Records Appraisal of work-plan Questionnaire Daily diary Consumer's feedback

5. Role of supervisor Administrative Role: Planning, organizing, controlling, performance appraisal, development of check-list, reporting and follow-up Technical Role: Support and guidance in implementing the tasks and correcting the problems Human relation Role: Behaviour, team spirit, motivation, conflict resolution, personal contacts, communication Development Role: Training and development for better performance, career development Supervision in Health, Unit VI, PHSM

6. 4*4*4 model of Supervision Supervision in Health, Unit VI, PHSM Figure: 4 x 4 x 4 model of supervision (Wonnacott, 2012, p54)

7. Supervision in Health, Unit VI, PHSM 4*4*4 model of Supervision

8. Supervision as Performance Improvement Supervision in Health, Unit VI, PHSM

9. Supervision in Health System of Nepal A guideline has been published by Managemnt Division in 2066 BS to systematize the supervision process at different levels which specialy focuses on supportive and integrated supervision. Supervision in Health, Unit VI, PHSM

10. I. Supportive Supervision Supportive supervision is a process of helping staff to improve their own work performance continuously and is carried out in a respectful and non-authoritarian way with a focus on using supervisory visits as an opportunity to improve knowledge and skills of health staff. Supportive supervision encourages open, two-way communication, and building team approaches that facilitate problem-solving. It focuses on monitoring performance towards goals, and using data for decision-making, and depends upon regular follow-up with staff to ensure that new tasks are being implemented correctly. Supervision in Health, Unit VI, PHSM

11. Supportive supervision-Module Supervision in Health, Unit VI, PHSM

12. Supervision in Health, Unit VI, PHSM 1. Setting up a supportive supervision system Training a core set of superviors. Creating checklist and recording forms. Ensuring appropriate resources available: vehicles, per diem, areas for collaboration with other programs. 2. Planning regular supervisory visits Where: using data to decide priority supervision sites When: schedule supervision visits using a workplan What subjects to train: identify training needs and skills that need updating.

13. Supervision in Health, Unit VI, PHSM 3. Conducting supportive supervision visits Observation Use of data Problem-solving On-the-job training Recording observations and feedback 4. Follow-up Follow up on agreed actions by supervisors and supervised staffs Regular data analysis Feedback to all stakeholders

14. II. Integrated Supervision Supervision in Health, Unit VI, PHSM Action Plan Supervisor visit Implementation and feedback Reporting Intrgrated Supervision Cycle Figure: Integrated supervision Cycle

15. 1. Action Plan It is the pre-determined periodic plan for the conduction of supervision in well managed manner. It includes the determination of supervisor and their time schedule of supervision. Every conducting supervision should prepare periodic (annual, quarterly and monthly) supervision plan which has to be approved by the higher authority, District health office in case of PHC and HP. Supervision in Health, Unit VI, PHSM

16. Things to be included in Action plan Period of action plan (monthly, quarterly, annual) Name of the supervisor Supervision period and date Name of the health facilities to be supervised Name of personnel by whom the plan is prepared and approved Supervision in Health, Unit VI, PHSM

17. Aspects to be considered during preparation of Action plan Number of the health facilities to be supervised, total number of staffs Allocated Target and budget of the supervision Distance of the health facility to be supervised, availability of transportation facility and estimated time period Geography and climatic condition of the health facility to be supervised Strategic direction of the integrated supervision guideline about the minimum frequency of the supervision at different level Priority should be given to the health facilities that are not able to achieve the expected targets. Supervision in Health, Unit VI, PHSM

18. 2. Supervisory Visit The following aspects of the health facility to be supervised is to be studied prior to supervision: Demographic status and the targets of different program Physical and financial achievement status of the targeted program of health institution Report of the previous supervision and the implementation status as suggested by the report. Supervision in Health, Unit VI, PHSM

19. Methods of Supervision Group or individual discussion with the staffs of health facility Study of the records of the different program. i.e. HMIS records Study of reports and monthly monitoring sheet. Direct observation Study of meeting minute Discussion with community people, members of HFOMC, client and FCHV. Supervision in Health, Unit VI, PHSM

20. Categorization of problems Every supervisor being the part of integrated supervision, should have to analyze the status of the supervised health facility and categorize the problems into two parts: Problems that can be solved locally by health facility Problems that need the higher authority Supervision in Health, Unit VI, PHSM

21. Tools of supervision Supervision Checklist: Every supervision should be conducted with the proper use of integrated supervision checklist provisioned by Management division. Supervision Diary: Different aspects of the health facility that can't be stated on the check-list are to be recorded in diary such as problems and their causes, local initiations to solve the problems etc. Supervision booklet: Every heath institution should have supervision booklet so that the supervisor can record different aspects of the supervisory visit of respective health facility. Supervision in Health, Unit VI, PHSM

22. Tools of supervision Supervision report: Supervision report is to be prepared with the use of check list and supervision diary. Supervision record (log-book): Every institution conducting supervision of health facility under it, has to record the integrated supervision visit in supervision log- book. This log book helps to know the details of supervision in one shot which could be very beneficial in future supervision of same health facility. Supervision in Health, Unit VI, PHSM

23. 3. Reporting Every supervisor has to submit the supervision report to the authorized person or institution using standard format. The timely submission of the report can help to address the problem in time. Usually the report has to be submitted within 7 days of supervision to the authority. Supervision in Health, Unit VI, PHSM

24. The report consists of: Name of the health facility, date of supervision and to whom report is submitted with date. Strengths of the health facility in brief Problems or things to be improved Underlying causes of the problems Immediate efforts done by the supervisor to solve the problem at spot Actions that has to be taken by higher authority Suggestions in brief (remarkable activities done by HF, reward, motivation or any punishment etc) Name of the supervisor and their designation Supervision in Health, Unit VI, PHSM 3. Reporting

25. 4. Implementation and Feedback The submitted report should be studied and reviewed by the authority of the respective institution discussing with the supervision team. The immediate actions that could be conducted by the authority should be taken to address the necessary and appropriate problems. The problems that could be addressed by higher authority should be forwarded as suggestions in written form. Follow up of the implementation of the suggestions should be done in periodic basis. Supervision in Health, Unit VI, PHSM

26. The feedback should be done in two steps after the completion of the supervision followed by submission of report. Spot feedback during supervision, if possible, should be given, otherwise it should be forwarded as soon as possible. The actions that has to be taken by the respective or higher level authority to address the issues diagnosed by the supervision should be forwarded. The supervision work has to be monitored and reviewed in continuous manner so as to make it more effective in future. Supervision in Health, Unit VI, PHSM 4. Implementation and Feedback

27. The concept is very important to bring overall change in the system rather than the individual knowledge, attitude or skill. Using a team approach to supervision requires that the supervisor disregard conventional disciplinary attitudes and shift from the role of "inspector" to the role of "facilitator." Team supervision is oriented toward teamwork, where problem solving is the main focus of the interaction, and supervisors become on-the-job teachers who support their staff. Supervision in Health, Unit VI, PHSM III. Team Approach Supervision

28. Supervision flowchart-Federal level Supervision in Health, Unit VI, PHSM Ministry of Health and Population Health Emergency and Disaster Management Unit Department of Health Services Department of Drug Administration Divisions PPMD HCD QARD PMD AD Department of Ayurveda

29. Supervision flowchart-Provincial level Supervision in Health, Unit VI, PHSM

30. Supervision flowchart- Local level Supervision in Health, Unit VI, PHSM

31. Sample supervisory checklist: Immunization program Supervision in Health, Unit VI, PHSM

32. Sample supervisory checklist: Immunization program Supervision in Health, Unit VI, PHSM

33. Example: Supervision of National TB Program Supervision in Health, Unit VI, PHSM Figure 1: NTP line supervision Figure 2: NTP review system

34. Problems /Challenges regarding supervision in health system of Nepal Supportive supervision not in place Inadequate supervision both in frequency and quality Insufficient amount of training for integrated supervision and not practical in every context. Eg. Gynecologist as a supervisor could not supervise paediatric ward Level of supervisor as an issue in federal context. Eg: 7th level supervisor, 8th level superivisee Supervision in Health, Unit VI, PHSM

35. Problems /Challenges regarding supervision in health system of Nepal Lack of clear guidelines, tools and checklist No definite award and punishment based on supervision Low budget and use of supervisory budget in other activities Poor reporting and documentation Supervision not as mandatory, supervision report without visit Traditional system of supervision Supervision in Health, Unit VI, PHSM

36. Conclusion and recommendations Update and implement integrated supervision checklist, supervision plan and feedback tools Deploy functional feedback mechanism with provision of coaching and mentoring services Develop monthly integrated online supervision calendar and submit to higher authority to monitor effective execution at all levels Introduce reward and punishment system based on supervision results Integrate digital supervision data into supervision processes Increase use of health system information and performance data when planning supervision visits to prioritize lowest-performing areas Supervision in Health, Unit VI, PHSM

37. Conclusion and recommendations Expand and institutionalize supervision to reach, prepare, protect, and support frontline health workers, especially during health emergencies Scale and replicate successful models across service delivery areas and geographies. Supervision in Health, Unit VI, PHSM In conclusion, effective health worker supervision is informed by health system data, uses continuous quality improvement (QI), and employs digital technologies integrated into other health system activities and existing data systems to enable a whole system approach. Effective supervision enhancements and innovations should be better integrated, scaled, and sustained within existing systems to improve access to quality health care.

38. References Garrison K, Caiola N, Sullivan R, Lynam P. Supervising Healthcare Services: Improving the Performance of People Deepak Karki. The Basics of Monitoring, Evaluation and Supervision of Health Services [Internet]. 22:57:19 UTC [cited 2023 Jan 24]. Available from: https://www.slideshare.net/dekarki/the-basics-of-monitoring-evaluation-and-supervision-of-health-services-in-nepal-37391386 Safal’s Public Health Officer Loksewa Comprehensive Review [Internet]. Heritage Publishers & Distributors Pvt. Ltd. [cited 2023 Jan 24]. Available from: https://heritagebooks.com.np/product/safals-public-health-officer-loksewa-comprehensive-review/ Annual Report FY 2077/78 (2020/21) [Internet]. 2022 [cited 2023 Feb 1]. Available from: https://dohs.gov.np/annual-report-fy-2077-78-2019-20/ Achieving effective supervision [Internet]. Iriss. 2015 [cited 2023 Jan 21]. Available from: https://www.iriss.org.uk/resources/insights/achieving-effective-supervision Deussom R, Mwarey D, Bayu M, Abdullah SS, Marcus R. Systematic review of performance-enhancing health worker supervision approaches in low- and middle-income countries. Hum Resour Health. 2022 Jan 6;20:2. Supervision in Health, Unit VI, PHSM

39. Thank You!