CDI Module 12: Introduction to Health
Services Supervision
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on CommunityDirected Intervention (CDI) to Improve
Access to Essential Health Services
Module 12 Objectives
By the end of this module, learners will:
 Differentiate between traditional and supportive
supervision
 Define supervision
 Describe who is a supervisor and the
supervisor’s responsibilities
 Describe the skills and personal characteristics
expected of a supervisor
2
Module 12 Objectives (continued)
By the end of this module, learners will:
 Define desired standard performance
 State the relationship between training and
supervision
 Describe the use of checklists during supervision
and assessment for quality improvement
 Describe the process of root cause analysis and
selection of problem-solving interventions
3
How Do Site Staff React to the Arrival of
the “Traditional” Supervisors?
Let’s run. Those
guys are here
again!
TS RURAL HEALTH CENTER
THE TRADITIONAL
SUPERVISORS
4
How Do Staff React to the “Supportive”
Supervisor?
SUPPORTIVE
SUPERVISOR
Hi,
Everyone.
PARADISE
HEALTH CENTER
Mike, we are
glad to see
you.
5
What Is Supervision?
Health services supervision is defined as:
“A process of guiding, helping, training
and encouraging staff to improve their
performance in order to provide highquality health services”
6
Two Crucial Levels of CDI Supervision
Supervision of the
community-directed
intervention (CDI) process
at the frontline health
facility
Supervision of the CDI
process in the
community
7
Who Supervises?
 Supervision is carried out by a person who is
responsible for the performance of clinical and
non-clinical staff
 Supervision can be conducted internally by an
on-site supervisor or externally by someone who
makes periodic supervision visits
 Community-directed distributors (CDDs) can
supervise themselves and each other by
discussing and assessing their performance at
their regular meetings
8
Internal and External
 The internal, or on-site, supervisor conducts
supervisory activities as part of everyday activities
 Many internal supervisors also provide clinical
services at the site
 External supervisors periodically visit health care
delivery sites—where they do not work on a day-today basis—to help staff improve and maintain
performance and quality
 A CDI focal person at a frontline facility is an
“external” supervisor to the community
9
Defining Supervision
A supervisor may:
 Supervise from one person to many people
 Work at a small rural health post or a large regional
hospital
 Be a clinician, public health technician or other
health care worker
 Work at a clinical site and supervise people at that
site, or work at a district or regional level and
conduct supervision through visits
10
Defining Supervision (continued)
A supervisor may:
 Have the word “supervisor” in her/his job title, or be
called a manager, an “in-charge” or something other
than supervisor
 Have received some formal training in supervision,
or have had no training in how to supervise people
11
Supervisor Responsibilities
Supervisors:
 Identify standards of good performance and
communicate to staff members
 Work with staff to assess their performance,
periodically, compared to these standards
 Provide feedback to workers about their
performance
12
Supervision Solves Problems
Supervisors work with staff and the community
to:
 Identify appropriate interventions that will lead to
improved worker performance and delivery of
high-quality services
 Mobilize resources from many different sources
to implement interventions
 Ensure that interventions have had the intended
effect
13
CDI Meetings Raise Common Problems
and Seek Solutions
14
Supervisor Skills
Supervisors:





Demonstrate technical competence
Facilitate team building
Motivate others
Facilitate meetings and discussions
Identify strengths of staff members and build on
positive aspects
 Provide constructive, timely and interactive feedback
 Communicate effectively with staff and decisionmakers
 Delegate duties to staff
15
Supervisor Personal Characteristics
A supervisor has:
 Leadership skills and
the ability to inspire
others
 A desire to help others
achieve their full
potential
 A commitment to the
provision of high-quality
health services
 Openness to new and
creative ideas
16
What Is Supervision for
Performance and Quality Improvement?
This type of supervision:
 Has the goal of providing high-quality health
services
 Uses standardized performance criteria
 Is a process of continuous performance and quality
improvement
 Is a style of encouraging, inclusive and supportive
interaction
 Involves the people being supervised in identifying
their own needs and planning improvements
17
Performance Improvement Framework
Get and Maintain Stakeholder Agreement
Consider
Institutional
Context
Mission
Goals
Strategies
Culture
Define
Desired
Performance
Find
Root Causes
Select
Interventions
Implement
Interventions
Describe
Actual
Performance
Client and
Community
Perspectives
Monitor and Evaluate Performance
18
What Is Desired Performance?
 To perform well, people must know what they
are supposed to do
 Performance standards need to be set
 Staff must know not only what their job duties
are but also how they are expected to perform
them
 Desired performance should be realistic and
based on the shared vision, the expectations of
the community and the resources at your site
19
Relationship: Training and Supervision
Training
Objectives and
Tasks
Performance
Standards
20
Assess Performance
 Your team will need to assess, continually, how
team members are performing compared to how
they are expected to perform
 This assessment can be done on an ongoing
basis, informally, or more formally on a periodic
basis, by observing staff, conducting selfassessments or obtaining feedback from clients
 Performance assessment is equivalent to post
training evaluation and can lead to diagnosis of
new training needs
21
Types of Supervisory Tools
 A supervisory tool is often a checklist that guides
both the supervisor and the staff to review the:
 General environment where services are provided
 Correctness and completeness of recordkeeping systems
 Availability of supplies, materials and equipment
 Performance of basic service provision skills
 It helps if checklists or guidelines are available so
that everyone can review and mark these together
 After using the checklists, everyone should sit
together and discuss the results
 (Pass around copies of tools actually used in your
country and talk about them)
22
Example of Simple Checklist
on Malaria in Pregnancy Services
Malaria in Pregnancy Control
Tasks to Be
Observed
Provision of
IPTp
Verification Criteria
Observed, Satisfactory (2)
Observed, Unsatisfactory (1)
Not Observed (0)
Comments
Determine eligibility for an IPTp dose
Give IPTp with DOT
Counsel on subsequent IPTp
Record provision of IPTp
Provision of
ITN
Determine eligibility for ITN according to
availability and use of ITN in the home
Provide ITN as needed
Counsel on ITN setup and use
Record provision of ITN
Case
Management
Use appropriate diagnostic tools—lab
blood film examination or RDT
Treat with appropriate anti-malarial
according to trimester
Counsel on adherence/compliance to full
course of treatment
Give supportive care as needed (e.g., for
anemia)
Record provision of malaria treatment
23
Find Causes of Performance Gaps
 A performance gap exists if your team finds that
what is actually occurring does not meet the
performance standards that have been set
 If you find that this is the case, then you need to
explore carefully with staff why the gap is
occurring—what is hindering desired
performance
 Sometimes the reasons for poor performance
are not immediately obvious, and it may take
some time to find the real cause
24
Selecting and Implementing Interventions
 Once the causes of the performance gap have been
determined, you and your staff will need to identify,
put in order of priority, plan and implement
interventions to improve performance
 These interventions can be directed at improving the
knowledge and skills of staff, or they can be directed
at improving the environment or support systems
that enable staff to perform well
 Many different types of interventions can be put in
place to improve worker performance
 To save resources, it is important to select the
correct interventions
25
Monitoring and Evaluating Performance
 Once interventions have been implemented, it is
important to determine if interventions have had the
desired result
 Did the intervention cause performance to improve?
 Did it move you closer to meeting the established
standards?
 If not, your team will need to look at what is
hindering performance to make sure the
interventions are appropriately targeting the real
cause of the performance gap
 If performance has improved, it is important to
continue monitoring to make sure the desired level
of performance is maintained
26
Summary
 Supervision is a
process of guiding,
helping, training and
encouraging staff to
improve their
performance so that
they can provide highquality health services
 It is not fault-finding
and reprimanding
27