Highlights from the Workshop

Welcome, Ann Lion Coleman (USAID)
Lion Coleman provided a context for the day, including noting findings and challenges faced under the USAID supported PRIME II Project, which underscored the need for new models of supervision. She noted that the Capacity Project had invited experts from outside of the international development field, from U.S.-based health care services and the corporate sector, to stimulate broader and creative thinking. She expressed her hope that this workshop would produce some guidance and advice on innovative models that could be further field tested in order to improve the important area of supportive supervision.

Welcome, Laurie Noto Parker (the Capacity Project)
Parker stated the mandate of the Capacity Project (helping developing countries to get the right provider in the right place with the right skills) and noted the importance of support to the primary level providers. She asked participants to contribute thoughts on the importance of the primary provider to public health objectives and how challenging the work experience is for many of them.

Overview, Purpose and Agenda for the Day, Dr. James McCaffery (the Capacity Project)
McCaffery outlined the program for the day, which included two sets of presentations by a panel of experts and two brainstorming sessions with all workshop participants. McCaffery called attention to the fact that the visiting-supervisor model, the status quo in supervision, does not appear to be working, so the agenda was designed to stimulate discussion on innovations in the field of health care supervision.

Setting the Stage: Why Is Supervision So Important? Dr. James Shelton (USAID)
Shelton asked several questions and reminded participants that supervision challenges are intertwined with other health care challenges. Specifically he noted that improving supervision skills and approaches is, at its core, a behavior change issue, and we have learned a good deal about behavior change and how challenging it can be. He recommended and shared copies of two resources related to the topic that might support and illuminate further discussion ("The Provider Perspective: Human After All" by James D. Shelton, International Family Planning Perspectives, Volume 27, Number 3, September 2001, and "The Changing Organization of Work and the Safety and Health of Working People: Knowledge Gaps and Research Directions," Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, April 2002). He also recommended considering the role and action of supervisors in the context of 1) decentralization and delegation of authority; 2) scaling up of services as a major trend, especially in antiretroviral therapy; 3) the need for high-quality services based on accepted standards and guidelines; and 4) the need to be clear about performance standards and expectations.

Panel 1

Presentation: The visiting supervisor model: What is the evidence?
Marc Luoma (the Capacity Project)

Luoma examined existing literature on the topic of the visiting-supervision model as well as the tacit knowledge of the experts in attendance in order to provide context and background for the subsequent presentations and working sessions. The presentation examined five supervision models, in the DR Congo, Nepal, Niger, Sudan and Peru, asking the questions 1) Do supervisors visit? 2) What happens during a visit? and 3) What makes the visit effective?

The evidence suggests that the visiting-supervisor model does not work to improve the quality, access or use of services because the supervisors do not visit very often, and when they do, most talk only to the site supervisor and not to the other providers; and they do not engage in support or problem solving or follow up on problems. The data also suggest that there does not appear to be a relationship between the number of visits and provider or site performance (that is, even if supervisors did visit more often, it may not make a difference in performance). This presentation clearly outlined the need to review and further test alternative supervision approaches.

Presentation: Leadership for performance improvement: A new approach for "supervision"
Dr. Joan Galer, MSH

The supervision model that Dr. Galer presented brings a leadership approach to supervision and supervisors' training, resisting the assumption that for quality performance a supervisor must be the inspector or responsible for results (rather than the actual service providers). Galer contends that individuals are motivated less by the notion of inspection, oversight and fear and more by relationships and joint problem solving.

The supportive supervision approach, outlined in "Leadership for performance improvement," contends that a better approach is "enabling service provision teams to identify and face their own challenges and achieve results with support from supervisors." The main features of this model are: 1) providers work in motivated and committed on-site teams; 2) team work is respected and everyone is involved, from doctors and nurses to administrators and support staff; 3) providers set their own vision for the service delivery site and conduct their own analysis of their problems; and 4) motivation is based on the satisfaction of providing good services and of receiving recognition from the team/on-site colleagues (and/or clients). Using this paradigm, provider teams follow these steps: 1) scan client and community needs; 2) develop and focus on a shared vision of the services they want to provide; 3) align and mobilize their resources inside the clinic and outside in the community; and 4) inspire themselves by producing results using only their own resources.

This model is based on self-motivation and is led at the service delivery point. It also emphasizes the importance of a supportive relationship between the providers at the service delivery site and the assigned supervisor at the next level. The supervisors from outside may seem less important in this model, but they do have a role in offering support to units as they set their priorities and work to solve their problems and should form a supportive relationship based on expressing their confidence in the teams and recognizing their successes. The provider/service delivery teams produce and use data that they generate themselves and become very personally committed to achieving their desired results. The teams often train and help each other — and in some cases even train their supervisors. This is also a low cost approach.

Presentation: Supervision training: Some lessons from Kenya
Dr. Pamela Lynam and Nancy Koskei, presented by Julia Bluestone, JHPIEGO

Bluestone's presentation reflects a performance improvement approach to supervision, which seeks to address the lack of appropriate training and practical tools for supervisors. The five-day supervision course uses a Performance and Quality Improvement Process, a comprehensive way to identify and address gaps in performance. The training course is structured to link training to specific problems and is designed to focus visiting supervisors on problem solving rather than merely identifying errors or taking a punitive approach.

A field test in Kenya led to the following results: improved infection prevention practices, clearly defined and posted standards, collection and use of community feedback on services, more effective staff meetings and improved staff morale.

Working Session 1: Small groups tackled an assignment: Analyze and identify promising practices to inform new supervision approaches.

Three groups convened during Working Session 1 to 1) discuss their reactions to the panels; 2) provide their thoughts on the most promising practices; and 3) present proposals for two to three promising practices that should be further tested. The groups presented their promising practices, which are outlined here.

Group A suggested further testing of a supervision approach that included community-driven quality, self-assessment and organized shared learning (with the support of technological tools such as the web or mobile phones).

Group B suggested initiating new approaches at the district level (which they perceived as less bureaucratic and less interested in a controlling supervisory system); focusing supervision efforts on clear, measurable results; and identifying a senior level champion or leader to promote a new paradigm or culture for supervision.

Group C suggested blending promising features from several existing models that would include the following: use of standards, self-assessments by the on-site team against the standards, on-site team reviews of problems and problem solving and perhaps outside mentoring and support (from an outside "supervisor," perhaps better called a mentor or coach). The model could also include peer and community reviews, feedback and dialogue.

Panel 2

Presentation: Guiding principles for supervising success: A case study from Pizza Hut
Marcia Thomsen (Independent private-sector business consultant)

Thomsen noted that certain concepts of supervision are very important and a part of the corporate culture in America. Based on the discussions so far during the day, she recognized that supervision in our context of health care in low-resource settings was particularly challenging, for example, because information is scarcer and travel and communication are more difficult. However, her presentation showed that there are lessons from corporate models that can be very helpful.

The Pizza Hut model of supervision is structured around four guiding principles:

1) Set clear goals

  • Articulate precisely what is expected (should be quantified)
  • Focus entire workforce against same goals
  • Translate goals for every business unit
  • Communicate, communicate, communicate.

2) Ensure infrastructure is in place

  • The physical component (e.g., qualified, trained people)
  • The philosophical component (e.g., training, coaching and enabling mentality).

3) Measure and record results

  • Every goal has to be measurable (in corporate culture, self-reporting is not measurable or appropriate)
  • Data collection must be credible (no excuses or questioning the data)
  • Results must rule
  • There must be regular reporting to all levels (each site must have and use data on their performance, all levels see the same data, the data fosters some competition across sites)
  • Data drives decision making.

4) Recognize and reward performance

  • Remember that results equal rewards (rewards cannot seem biased or random)
  • Structure incentives to reinforce desired results
  • Use all available incentives to drive the team (e.g., personal recognition, ceremonies, newsletters, appreciation/recognition letters and phone calls, plaques, pins, bonuses, promotions).

Other features of the Pizza Hut model that may prove useful for the health sector include a focus on the ultimate customer with the motto "We serve those who serve the customer" and the idea of categorizing sites by performance (e.g., healthy, recovering, intensive care) and tailoring rewards or assistance accordingly.

Presentation: U.S. and Western perspectives about and models for supervision in the health professions
Dr. Violet Barkauskas (School of Nursing, University of Michigan at Ann Arbor)

Barkauskas presented health provider supervision models from the U.S. and Western perspective, which, she explained, are based on a hierarchical system of oversight and weighted toward clinical supervision because of concern for patients, patient safety, certification regulations and legal ramifications.

Within the context of the U.S. and Western health care systems, Barkauskas outlined three prevailing theoretical supervisory frameworks — Proctor, Heron and Powell — worthy of review when considering alternatives to the visiting-supervisor model. Proctor's model proposes three supervision functions: normative, restorative and formative. Normative functions include administration and quality assurance. Restorative functions relate to support and assistance with coping. Formative functions are concerned with educational and professional development.

Heron's model presents two types of supervision interventions: authoritative and facilitative. Authoritative interventions are prescriptive, informative and confronting. Facilitative interventions are cathartic, catalytic and supportive.

In Powell's model for on-site supervision, the ideal supervisor is a servant leader who is self-aware; operates with focus and energy; is proficient in many aspects of the job; shares power; makes the organization's mission and vision clear by standing ahead of followers and standing behind their actions; and values people by caring for them.

While recent supervision debates from the Western perspective include discussion about the qualifications of supervisors (disciplines, expertise), the merits of guided reflection versus more traditional clinical supervision and whether collaborative supervision inhibits challenge, there is consensus on the qualities that make supervisors successful. Barkauskas summarized the characteristics of effective supervisors as empathetic, supportive, flexible, respectful, knowledgeable, practical and engaged in problem solving. She recommended that the most important content areas for supervisor training include: assessment of learning needs; teaching the adult learner; counseling; provision of feedback; issues of power and social stratification; and transcultural relationships.

Barkauskas also highlighted the distinction between surveillance and supervision. Surveillance, which relies on inspection of data, scrutiny of results and other tracking methods, lends itself to a punitive-based system of oversight. Supervision, on the other hand, is grounded in a more complex interaction of relationships, including leadership, recognition, rewards and other more constructive administrative measures. She noted that these management systems are often confused and much of what actually occurs is surveillance, not supervision.

Working Session 2: The participants addressed the question: What can we learn from outside the international public health field to inform new approaches?

After the presentations from the second group of panelists, the workshop participants discussed ideas for successful alternatives to the visiting-supervisor model. Several themes and suggestions emerged as outlined below.

A Paradigm Shift

  • Work to change the dominant paradigm and culture of supervision, making it more supportive and less punitive
  • Use self-motivation and the desire of most providers to do good work as the foundation for a better supervisory/performance improvement approach
  • Shift the focus of supervision from "surveillance" and catching errors to helping the on-site team with problem solving
  • Consider the use of new language to foster a paradigm shift; for example, rather than supervision, use coaching or mentoring, and rather than supervisory systems, use performance support systems or supportive supervision system
  • Recognize that a paradigm built on an empowering, team-based approach at the service delivery point will be unfamiliar in many settings and will require significant behavior change, practice, the development of new skills and leadership.

On-Site, Team-Based Approaches

  • Place the responsibility for quality and good performance on the on-site service delivery team (including providers and all support staff) and provide them with tools and approaches to assist them in self-assessment and problem solving
  • Foster an empowering, team-based approach, allowing the on-site teams to set standards, assess their progress using their own data and engage in problem solving
  • Use guided processes for on-site self-assessment for feedback and motivation rather than relying entirely on outside supervision (tapping into the strong self-motivation of most providers)
  • Make widely accepted quality standards and protocols available to service delivery teams as the foundation for their self-assessment efforts
  • Foster outside mentoring, which could be responsive to requests for specific assistance from the service provision teams (the outside mentors should not take control, but should facilitate and assist the on-site teams in establishing their objectives, assessing their problems and solving the problems)
  • Build the skills of the mentors or supervisors in fostering team work, building problem solving skills in teams and using reward and recognition
  • Incorporate feedback from the community (community-driven quality) and allow community members to help with the traditional role of supervisors (e.g., community stakeholders could help in setting performance expectations, providing motivation and recognition and meeting other needs such as improvements to physical infrastructure or help with transport and referrals)
  • Consider cross learning and support/technical assistance across service delivery site teams.

Role of Distance "Supervisors"

  • Recognize the importance of a supportive relationship between supervisor and the service provision team
  • Encourage supervisors to build on strengths and use more recognition and rewards
  • Focus on communication ("Ministries may have strategies and priorities, but they do not trickle down so that all levels are moving in the same direction")
  • Set clear performance expectations for supervisors, make them measurable and have some kind of rewards and consequences related to the expectations (the expectations should be grounded in the elements of supportive supervision)
  • Recognize needs of supervisors for training and skills in new approaches to supervision, such as team building and empowerment of provider teams
  • Incorporate peer review as one quality assurance mechanism.

Use of Data

  • Foster a "show me" mentality that values data and uses it for decision making
  • Reduce the number of performance indicators used and focus on a few key indicators
  • Encourage collection and use of data at the service delivery point
  • Design a performance support system that sets a few clear priority indicators and has clear rewards for achievement of performance objectives.

Other

  • Foster increased recognition among health sector leaders of the importance of supervision and the need for new supervision models
  • Start innovations at lower levels first, building on successes to foster national level leadership and scale up
  • Increase the client/customer focus in the supervisory approach
  • Bring the notion of "branding" to health care — make it more explicit what the Ministry brand of health care stands for and set standards for that brand that can motivate service delivery teams and providers.

Conclusions

The participants of this workshop concluded that it is time to move away from the visiting-supervisor model, which has proven inadequate, and to promote more effective performance and quality assurance models. Although the participants did not work on the details of a specific model or models to test, some key ideas emerged and are summarized in the chart below.

Key Features for an Improved Supervision Approach — Contrasted with the Traditional Supervisory Model
Traditional Distance Supervision Possible Elements for Improved Approach
Surveillance Support (based on performance factors)
Inspection and catching errors Joint problem solving
Built on fear Built on self-motivation of the service provision team
Punishment Recognition and rewards
Oversight from outside experts Self-directed team approach
Variable quality standards (at times personality driven) Standards driven (clear performance expectations based on national or international health care standards)
Hierarchical (top-down command structure) Empowering (on-site team sets goals, uses their own data to measure progress)
Controlling Coaching


Closing and Next Steps

Laurie Noto Parker, the Capacity Project Director, thanked USAID, the panelists, participants and workshop organizers. She noted that the Project staff plan to test one or more innovative models of supervision over the next few years and that the promising practices reviewed and recommended by the participants in this workshop will greatly influence the design of these models. The Project Director committed to share the data and results from these trials. She expressed her enthusiasm about promoting a new paradigm that builds on the dedication and self-motivation that drives most public health professionals and which was very evident in the workshop participants, who brought so much energy and creativity to this challenge.