Training for mid-level managers (MLM): module 4: supportive supervision

Immunization, Vaccines and Biologicals Training for mid-level managers (MLM) Setting up a supportive supervision system Planning regular supportive supervision visits Conducting a supervisory visit Follow-up activities 4. Supportive supervision IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc Training for mid-level managers (MLM). Module 4: supportive supervision ISBN 978-92-4-001569-2 (electronic version) ISBN 978-92-4-001570-8 (print version) This publication was originally published under WHO reference number WHO/IVB/08.04. © World Health Organization 2008, republished 2020 under the CC BY-NC-SA 3.0 IGO licence Some rights reserved. This work is available under the Creative Commons Attribution- NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 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Suggested citation. Training for mid-level managers (MLM). Module 4: supportive supervision. Geneva: World Health Organization; 2008, republished 2020 under the licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The menWion of specific companies or of cerWain manXfacWXrers¶ prodXcWs does noW impl\ WhaW they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. >BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) ?djheZkYj_edjej^[i[h_[i This new series of modules on immunization training for mid-level managers replaces the version published in 1991. As there have been many changes in immunization since that time, these modules have been designed to provide immunization managers with up-to-date technical information and explain how to recognize management and technical problems and to take corrective action and how to make the best use of resources. More and more new, life-saving vaccines are becoming available, yet the introduction of a new vaccine does not necessarily require a separate plan and separate training. This new series for mid-level managers integrates training for new vaccine introduction into each subject addressed by the modules. In this way, introduction of new vaccines is put into its day-to-day context as part of the comprehensive range of activities required to improve immunization systems. In the context of these modules, mid-level managers are assumed to work in secondary administrative levels, such as a province ; however, the modules can also be used at national level. For district managers (third administrative level), a publication on ‘immunization in practice’1 is widely available. As it contains a large amount of technical detail, it is also recommended for mid-level managers courses. In writing these modules, the authors tried to include essential topics for mid-level managers, while keeping the modules brief and easy to use. They are intended to complement other published materials and guidelines, some of which are referred to in the text. Many more documents are available on the CD-ROM which accompanies this series. Each module is organized in a series of steps, in which technical information is followed by learning activities. Some knowledge and experience are needed to complete the learning activities, but even new readers should be imaginative and constructive in making responses. Facilitators should also be aware that the responses depend on the national context. Thus, there are no absolutely right or wrong answers, and the series does not set down new ‘policies’ or ‘rules’. The authors hope that the readers of these modules will find them informative, easy to read and an enjoyable learning experience. Modules in the mid-level managers series Module 1 : Cold chain, vaccines and safe-injection equipment management Module 2 : Partnering with communities Module 3 : Immunization safety Module 4 : Supportive supervision Module 5 : Monitoring the immunization system Module 6 : Making a comprehensive annual national immunization plan and budget Module 7 : The EPI coverage survey Module 8 : Making disease surveillance work 1 Immunization in practice : A practical guide for health staff. Geneva, World Health Organization, 2004. >> BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) 7Yademb[Z][c[dji This new series of modules on immunization training for mid-level managers is the result of team work between a large number of partners including the Centers for Disease Control and Prevention (CDC), IMMUNIZATIONbasics, Program for Appropriate Technology in Health (PATH), United Nations Children’s Fund (UNICEF), United States Agency for International Development (USAID) and the World Health Organization (WHO). The authors are especially grateful to the consultants from the University of South Australia who have made a major contribution to the development of the modules. >>> BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) 9edj[dji Introduction to the series I Modules in the mid-level managers series I Acknowledgements II Abbreviations and acronyms IV Introduction to Module 4 1 Purpose of this module 1 Controlling supervision versus supportive supervision 1 1. Setting up a supportive supervision system 3 1.1 Training a core of supportive supervisors 3 1.2 Right tools 5 1.3 Ensuring adequate resources are available for conducting visits 9 2. Planning regular supportive supervision visits 10 2.1 Where to conduct supportive supervision visits 10 2.2 When to conduct a supportive supervision visit 11 2.3 What to cover during the visit 11 3. Conducting a supervisory visit 16 3.1 Collecting information 16 3.2 Problem-solving and feedback 19 3.3 On-the-job training 21 3.4 Recording the results of supervision 21 4. Follow-up activities 24 4.1 What to do after a supervision visit 24 4.2 Conducting follow-up visits 24 Annex 1 : Sample supervisory checklist 26 >K BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) 7XXh[l_Wj_ediWdZWYhedoci The following abbreviations have been used in this document. AD auto-disable (syringe) AEFI adverse events following immunization CDC United States Centers for Disease Control and Prevention DTP diphtheria-tetanus-pertussis EPI Expanded Programme on Immunization HepB hepatitis B (vaccine) IEC Information, education & communication IIP Immunization in practice MLM mid-level manager MOH Ministry of Health PATH Program for Appropriate Technology in Health (USA) TT tetanus toxoid UNICEF United Nations Children’s Fund USAID United States Agency for International Development VPD vaccine-preventable disease VVM vaccine vial monitor &BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) ?djheZkYj_edjeCeZkb[* EjgedhZd[i]^hbdYjaZ Do the supervisory visits in your area help your staff to solve their problems in implementing a good quality immunization service? How are your supervisors carrying out their duties? Are they well informed? Are they like teachers, or are they like the police ? This module will help the mid-level manager to obtain the maximum benefit from every supervisory visit, from the training of supervisors, through managing a system of supervisory visits to following up and solving problems after the supervisory session. Supportive supervision is a process of helping staff to improve their own work performance continuously. It 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 perform- ance 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. Supportive supervision is helping to make things work, rather than checking to see what is wrong. Traditionally, many countries have used an authoritarian, inspection or control approach to supervision. This approach is based on the thinking that health workers are unmotivated and need strong outside control to perform correctly. However, it has been shown that a supportive approach, where supervisors and health workers work together to solve problems and improve performance, delivers improved results for the immunization programme. Table 4.1 compares the characteristics of the control approach and the supportive approach. IVWaZ)#&/8dbeVg^hdcWZilZZchjeZgk^h^dcVeegdVX]Zh 8dcigdaa^c\hjeZgk^h^dckZghjhhjeedgi^kZhjeZgk^h^dc Control approach Supporting approach s &OCUSONlNDINGFAULTSWITH individuals. s 3UPERVISORISLIKEAPOLICEMAN s %PISODICPROBLEM SOLVING s ,ITTLEORNOFOLLOW UP s 0UNITIVEACTIONSINTENDED s &OCUSONIMPROVINGPERFORMANCE and building relationships. s -ORELIKEATEACHERCOACHMENTOR s Use local data to monitor performance and solve problems. s &OLLOWUPREGULARLY s /NLYSUPPORTPROVIDED HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) ' Setting up a supportive supervision system Planning regular supportive supervision visits Conducting a supervisory visit Follow-up activities > > > Setting up a supportive supervision system s 4RAININGACORESETOFSUPERVISORS s #REATINGCHECKLISTSANDRECORDINGFORMS s %NSURINGAPPROPRIATERESOURCESAREAVAILABLEˆVEHICLESPERDIEMAREASFOR collaboration with other programmes. Planning regular supervisory visits s 7HEREUSINGDATATODECIDEPRIORITYSUPERVISIONSITES s 7HENSCHEDULESUPERVISIONVISITSUSINGAWORKPLAN s 7HATSUBJECTSTOTRAINIDENTIFYTRAININGNEEDSANDSKILLSTHATNEEDUPDATING Conducting supportive supervision visits s /BSERVATION s 5SEOFDATA s 0ROBLEM SOLVING s /N THE JOBTRAINING s 2ECORDINGOBSERVATIONSANDFEEDBACK Follow-up s &OLLOWUPONAGREEDACTIONSBYSUPERVISORSANDSUPERVISEDSTAFF s 2EGULARDATAANALYSIS s &EEDBACKTOALLSTAKEHOLDERS This module is organized into the following steps : BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) (HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je '$I[jj_d]kfWikffehj_l[ikf[hl_i_ed ioij[c The three main ’Rs’ for an effective supportive supervision system are : 1) RIGHT SUPERVISORSˆACORESETOF SUPERVISORSWELL TRAINEDONSUPPORTIVE supervision techniques and with updated information and skills on immunization issues. 2) RIGHT TOOLSˆAVAILABILITYOF TRAININGMATERIALSAND JOBAIDS TOUPDATESKILLS of health workers during supervision visits, and checklists and forms for recording recommendations and following up. 3) RIGHTRESOURCESˆSUFlCIENTVEHICLESPERDIEMSTIMEALLOCATEDFORSUPERVISION and follow-up. &#&IgV^c^c\VXdgZd[hjeedgi^kZhjeZgk^hdgh As the supervisors will be providing on-the-job training to health workers, it is important that the supervisors are themselves well informed and trained. The initial step will be to provide refresher training for the core of supervisors. To identify the training needs of supervisors, start by asking the following questions : s (AVE THERE BEEN ANY MAJOR CHANGES IN THE IMMUNIZATION SYSTEM WHICH require training (e.g. introduction of new vaccines, new policies or reporting procedures)? s $OTHESUPERVISORSREQUIRETRAININGONSUPPORTIVESUPERVISIONTECHNIQUESAND participatory approaches (e.g. problem identification, problem-solving, training adults, time management, two-way communication, coaching, on-site train- ing, etc.) ? s !RE THERE AREAS THAT CAN BE STRENGTHENED BY SUPPORTIVE SUPERVISION AND will therefore require supervisor training? You may, for instance, decide that the country’s disease surveillance needs to be enhanced and therefore supervisors themselves need training. HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) ) Learning activity 4.1 : Supervisors’ training topics Table 4.2 below provides examples of changes in an immunization programme. 1) Identify the main topics to include in the supervisors’ training so that supervisors can in turn train health staff during supervisory visits. 2) Are there other areas that require training e.g. current immunization policies, how to interpret data on immunization, and how to access the resources needed for outreach services and supervision itself? Add them to the list. Developing and adapting training materials Once you have prioritized the main training issues, you must check to see if there are existing training materials that can be used or adapted, and identify the need for developing new materials. IVWaZ)#'/HjeZgk^hdghÉigV^c^c\ide^Xh Change in the immunization system Main training topics for supervisors’ training 1 A new vaccine introduced recently Vaccine schedule and presentation ; storage ; preparation ; injection ; side-effects ; communication with parents and community ; reporting 2 A new vaccine combination (DTP-HepB instead of DTP and monovalent HepB introduced recently) Cold-chain and logistics issues for new vaccine 3 Change in immunization schedule (measles second dose) How to record and monitor the second dose 4 New type of AD syringes introduced Improving the vaccine distribution system to avoid stock-outs 5 New guidelines on multi-dose vial policy, and use of VVM Using simple training material for every immunization site 6 New monthly reporting form with new items, such as reporting AEFI How to investigate AEFI 7 Policy that supportive supervision be provided in every health facility at least twice a year Making and monitoring a supervisory plan 8 Many health facilities with kerosene refrigerators now replaced with electric refrigerators 9 Coverage monitoring charts to be used at each health facility 10 Use of a drop-out tracking system in every health facility 11 New disease reporting form with reporting on VPDs and other diseases 12 Measures to prevent freezing of vaccines 13 New team of community mobilizers added 14 15 16 BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) *HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je &#'G^\]iiddah In addition to training supervisors, it is important to have the right tools available to assist supervisors and to standardize the supervision system. These tools include : 1) Supervisory checklist. 2) Learning materials and job aids to be used by supervisors during supervision visits. &#'#&EgZeVg^c\VhjeZgk^hdgnX]ZX`a^hi The supervisory checklist is a list containing priority issues that must be observed and recorded by the supervisor. The checklist helps the supervisor to focus on priority issues and reminds him/her to observe and record them. The information collected should help the supervisor to decide what corrective action can be taken during the visit, and what issues need to be followed up for action in the longer term. A checklist contains items to be checked at EVERY site visit. However it should not deter the supervisor from recording and following up on other critical issues that he/she has observed but that are not included in the checklist. Three ‘Ss’ for a good quality checklist are : 1) Short : should include only priority areas to observe and record during supportive supervision visits. If the list is too long, filling it will become a mechanical exercise. Also, supervision for immunization is likely to be integrated with supervision for other services, which further limits the time available and highlights the need to check on the most critical aspects of immunization during supervision. 2) Specific : items should be specific, with details on what exactly needs to be observed. For example, a question such as “Does the health worker dispose of used syringes appropriately?“ is not specific, but “Does the health worker dispose of used syringes in the safety box?“ is more specific. The information collected should be critical and should help in taking mana- gerial decisions. 3) Simple : Additional observations or comments should be easy to complete and flexible to record. HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) + Learning activity 4.2 : Preparing a supervisors’ checklist You are a district supervisor about to visit a health facility. You have little time available as this will be one of the many health facilities that you have to visit. Your challenge is to create a checklist not more than one page long (maxi- mum 15 questions). Give priority to issues on which you can provide on-the-job support. The table lists the five main immunization-system components, and for each component you need to write the main questions to be included in the check- list. Annex 1 provides a more comprehensive checklist, and you may use this to choose the most relevant issues for creating your checklist, but be sure to adapt it to your country’s particular situation. Here are some examples. Vaccine and cold-chain management Is there an up-to-date stock-recording system? Monitoring and use of data Is the monitoring chart used regularly to track performance? What does it tell you about access, drop-out, and completion of the schedule? Communication with parents and links with the community How are parents informed about the next visit and about side-effects? How many meetings are held per year with the community to discuss/plan services? Immunization safety Are all used syringes disposed of in safety boxes? Planning How many planned outreach sessions were actually held? BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) ,HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je Vaccine and cold-chain management (include use of VVMs) Monitoring and use of data (include review of monitoring charts) Planning (include review of session plan and workplan) Immunization safety (include observation of injections, waste disposal) Communication with parents and community (include caretaker’s knowledge of when to return) In each row, write a question that can be used in a supportive supervisory checklist. &#'#'EgZeVg^c\aZVgc^c\bViZg^VahVcY_dWV^Yh A supervisory visit is an excellent opportunity to provide on-the-job training to individual health workers or with health-centre staff as a whole. As supervisors will be providing on-the-job training it is important to have standard materials available that : s ARESPECIlCTOTHESKILLSTHATNEEDTOBEIMPROVED s CANBEUSEDTOPREPAREFORTRAINING s SUPERVISORSCANREFERTODURINGTRAININGSESSIONS s HEALTHWORKERSCANUSETOPRACTICEANDREFERENCE Health workers need simple, easy-to-follow materials rather than heavy reference guides or training manuals. For health-facility staff, materials with clear explanations on how to do a particular task, preferably with drawings, worked examples, and practice exercises, are the most useful. The supervisor needs to be well prepared and fully knowledgeable about the topic and materials. HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) - Different training methods that a supervisor could use to help on-site training are: s PARTICIPATORYEXERCISES s GROUPDISCUSSION s SMALLGROUPWORK s CASE STUDY s PRACTICALEXERCISES s DEMONSTRATIONSPRESENTATIONS s ROLE PLAYING s QUESTION AND ANSWERSESSIONS L]Vi^hV_dWV^Y4 A job aid is a learning product available for on-the-job training which is designed to facilitate correct performance of the task by extending the performer’s capability to retain and utilize information. It is also called quick or easy reference. Often these are paper-based and posted on the wall in plain sight or in a small reference notebook. They can also take the form of posters, cards, manuals, etc. It might be useful to carry a known accurate thermometer along with other job aids. Job aids are useful as they target specific tasks or skills and allow the health worker to quickly refer to them without having to search through long training manuals. Some examples of job aids. 1) National immunization schedule. 2) Checklist of things to carry to an outreach site. 3) One-page sheet with pictures showing how to administer different vaccines. 4) Poster put on the refrigerator showing how different vaccines should be stored. 5) Poster showing methods to prevent freezing. 6) Poster with standard case definitions and disease pictures.  )MPORTANTTELEPHONENUMBERSˆMEASLESPOLIOLABORATORIESSTATEHOSPITAL etc. BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) .HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je Learning activity 4.3 : Preparing job aids/training materials Many health workers at busy sites forget to inform mothers when they should next come. 1) Create a checklist that can serve as a quick reminder, with things to tell the mother/caretaker at every visit. 2) Discuss other job aids that may be useful. &#(:chjg^c\VYZfjViZgZhdjgXZhVgZVkV^aVWaZ[dg XdcYjXi^c\k^h^ih When setting up a supportive supervision system, you need to ensure that adequate resources are available. The following items should be included in the budget : s TRANSPORT s PERDIEM s DRIVERS s FUEL In addition to scheduled visits, supervisors should be able to interact with staff at opportunities such as monthly or quarterly meetings. IgVchedgiidk^h^ii]ZhjeZgk^hdgnh^iZh Supervisors must be mobile. The transport needed will depend on the location of the supervision sites. Sites that are difficult to access may need advanced planning for transport (e.g. mountainous places, places that cannot be reached during the rainy season, etc.). Options to consider include : s WHATARETHEBARRIERSTOTRANSPORTATION s CANTRANSPORTBEREQUESTEDFROMAHIGHERLEVEL s CANTHEVISITBEPLANNEDWITHOTHERHEALTHPROGRAMMESTOSHARETRANSPORT s CANPUBLICLOCALTRANSPORTBEUSED s ISITPOSSIBLETOSHARETRANSPORTWITHOTHERSUPPLIESGOINGTOTHESITEEGFOOD trucks)? Di]ZggZhdjgXZhidXdch^YZg Is adequate time allotted for supportive supervision activities? If not, what are some of the barriers, and what are some strategies to overcome this? Will supervisors receive per diem for the supervisory visit ? What are the per-diem policies of your immunization programme? HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &% ($FbWdd_d]h[]kbWhikffehj_l[ ikf[hl_i_edl_i_ji Planning for supportive supervision visits should be an integral part of the annual/quarterly work-planning exercise. It is important to look at the data when you plan for supervision visits. The plan should indicate : s where to conduct visits s when to conduct visits s what are the objectives to cover during the visit. '#&L]ZgZidXdcYjXihjeedgi^kZhjeZgk^h^dck^h^ih You need to decide priority areas, as certain ones, such as districts/health facilities, will need more supportive supervision visits. You must use immunization data and information from previous supervision visits to select priority areas for supervision. Review your priority plan with the Expanded Programme on Immunization (EPI) Manager. The most common criteria used for selecting priority areas include : s HIGHESTNUMBEROFUNIMMUNIZED s HIGHDROP OUTRATES s LOWCOVERAGERATES s POORREPORTSFROMPREVIOUSSUPERVISIONVISITS Other criteria could include : s AREASWITHFEWORNOVISITSINTHEPAST s AREASWITHRECENTOUTBREAKSOFMEASLES!%&)CASES s FREQUENTSTOCKPROBLEMSOVERSTOCKORSTOCK OUTS  s NEWSTAFFWHOMAYNEEDMONITORINGTRAININGONIMMUNIZATIONPRACTICES s PROBLEMSIDENTIlEDBYHEALTHSTAFFORTHECOMMUNITY s GOODCOVERAGEINTHEPASTBUTDROPINCOVERAGEORLOWCOVERAGENOW s HIGHRISKDISTRICTSFOR44MEASLES s COVERAGERATESABOVEORDROP OUTRATESTHATARENEGATIVE s PRIORITIZEDDISTRICTSFORNEWVACCINEINTRODUCTION s AREASSUBMITTINGNOREPORTSORINCOMPLETEREPORTS BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &&HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je '#'L]ZcidXdcYjXiVhjeedgi^kZhjeZgk^h^dck^h^i Once you have prioritized areas to be visited over the next quarter/year, you need to prepare a supportive supervision schedule. The annual/quarterly work- plan of activities should be consulted when scheduling supportive supervision visits. The following issues should be considered. s 6ISITSSHOULDPREFERABLYBEONDAYSWHENTHEREISANIMMUNIZATIONSESSION (fixed or outreach) planned. s 2OUTINEASWELLASOUTREACHANDMOBILESESSIONSSHOULDBESUPERVISED s 4HEHEALTHWORKERUNDERSUPERVISIONSHOULDBEINFORMEDOFTHESCHEDULE s 4HE SCHEDULE SHOULD BE FEASIBLE AND PRACTICAL TAKING INTO ACCOUNT THE distance, transportation difficulties, or constraints due to weather and travel conditions. s 4HE SUPERVISOR SHOULD SCHEDULE ENOUGH TIME TO VISIT THE SITE FULLY AND IF possible provide on-site training. It is important to conduct the visit according to the plan. If the visit cannot happen as planned, the health worker concerned should be informed in advance. It is important to monitor planned visits versus held visits and record the reasons for not holding any visit as planned (e.g. lack of transport, competing priorities, etc.). The frequency of supervisory visits will vary with the situation. s 0ROBLEM SOLVINGANDMOTIVATIONOFSTAFFWILLDEMANDFREQUENTSUPERVISIONIF they are to result in improved performance. s .EWHEALTHCENTRESORMAJORCHANGES INEXISTINGHEALTHCENTRES EGNEW staff, new responsibilities) will require frequent visits. As the centre becomes more firmly established and the staff gain in experience and confidence, supervision can be reduced or re-prioritized. each health facility. When planning the schedule, ensure that adequate time is available ; for example it may take two hours or more to meet the needs of a single supportive supervision visit. '#(L]ViidXdkZgYjg^c\i]Zk^h^i It is important to have a clear understanding of the main objectives of the visit. This could include main tasks to observe, or main topics on which training should be given, etc. A review of previous supervision reports, checklists, or data analysis, can assist in identifying which topics to cover during supportive supervision visits. It will be necessary, however, to undertake at least two visits per year to HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &' s !LWAYSBEPREPAREDTOUSEDATA - review the local data on site during the visit ; - bring summary data, monthly reports, etc. as reference material. s 0REPAREANAGENDAFORTHEVISIT INADVANCE4HEAGENDASHOULDINCLUDEONE or two issues that have already been identified as priorities for the area. Although certain training topics can be planned in advance, some training needs may become evident during the visit or during discussions with health staff. Section 2.1 also provides some criteria for deciding on training topics. Learning activity 4.4 : Supportive supervision planning You need to plan supervision visits for the first quarter. Health facilities A, B, C, E and M are part of your district. Look at the data provided to answer the following questions. 1) Identify three health facilities which are a priority for supportive supervision. 2) Decide the schedule bearing in mind : a) you are busy with other activities 1–15 January ; b) village C is far from your office and inaccessible during March due to the heavy rains ; c) you can schedule only one supervisory visit per month because of limited resources. 3) Complete the ‘Supervision Plan’ and provide a justification. Health-facility name When Where (fixed or outreach) Main topics to cover A B C E M HjeZgk^h^dcEaVc BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &(HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je IV Wa Z )# ( /9 Vi V Vc Va nh ^h iV Wa Z A re a n am e C o m p ile p o p u la ti o n , i m m u n iz at io n co ve ra ge d at a in p re vi o u s 12 m o n th A n al ys e p ro b le m P ri o ri ti ze ar ea vi lla ge n am e Ta rg et po pu la tio n Do se s of v ac ci ne a dm in is te re d Im m un iza tio n co ve ra ge (% ) Un im m un ize d (N o. ) Dr op -o ut ra te s (% ) Id en tif y pr ob le m M ea sl es M ea sl es M ea sl es Ac ce ss Ut ili za tio n Pr io rit y 1, 2, 3… a b c d e f g h i j k l m n o A 58 0 61 5 35 2 27 2 10 6% 61 % 47 % 22 8 30 8 43 % 56 % Go od Po or B 38 7 36 5 23 2 33 2 94 % 60 % 86 % 15 5 55 36 % 9% Go od Po or C 36 2 16 4 75 25 45 % 21 % 7% 28 7 33 7 54 % 85 % Po or Po or E 39 9 44 7 25 6 19 0 11 2% 64 % 48 % 14 3 20 9 43 % 57 % Go od Po or M 13 4 10 5 75 41 78 % 56 % 31 % 59 93 29 % 61 % Po or Po or H ea lt h -f ac ili ty n am e A d d it io n al in fo rm at io n A R ep or ts in ac cu ra te a nd in co m pl et e. B N ew h ea lth w or ke r. C S to ck -o ut r ec en tly , A E FI d ea th la st y ea r. E N o su pe rv is or y vi si t in t he la st t w o ye ar s. M C om m un ity r ep or te d he al th w or ke r is o ft en o ff d ut y. A dd iti on al in fo rm at io n ab ou t ea ch h ea lth fa ci lit y DT P1 DT P3 DT P1 DT P3 DT P3 DT P1 -D TP 3 M ea sl es DT P1 - HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &) IV Wa Z )# ) /9 ^h ig ^X i^ b b jc ^o Vi ^d c l dg `e aV c He al th Ce nt re 1. Ja n W ed 2. Ja n Th u 3. Ja n Fr i 4. Ja n Sa t 5. Ja n Su n 6. Ja n M on 7. Ja n Tu e 8. Ja n W ed 9. Ja n Th u 10 .J an Fr i 11 .J an Sa t 12 .J an Su n 13 .J an M on 14 .J an Tu e 15 .J an W ed 16 .J an Th u 17 .J an Fr i 18 .J an Sa t 19 .J an Su n 20 .J an M on 21 .J an Tu e 22 .J an W ed 23 .J an Th u 24 .J an Fr i 25 .J an Sa t 26 .J an Su n 27 .J an M on 28 .J an Tu e 29 .J an W ed 30 .J an Th u 31 .J an Fr i M Fi xe d M Ou tre ac h at K Ou tre ac h at L Ou tre ac h at P E Fi xe d E Ou tre ac h at D C Fi xe d C Ou tre ac h at J Fi xe d C B Fi xe d B Ou tre ac h at R Fi xe d B A Fi xe d A Fi xe d A M ob ile to S & W M ob ile to T & X Fi xe d A Fi xe d A He al th Ce nt re 1. Fe b Sa t 2. Fe b Su n 3. Fe b M on 4. Fe b Tu e 5. Fe b W ed 6. Fe b Th u 7. Fe b Fr i 8. Fe b Sa t 9. Fe b Su n 10 .F eb M on 11 .F eb Tu e 12 .F eb W ed 13 .F eb Th u 14 .F eb Fr i 15 .F eb Sa t 16 .F eb Su n 17 .F eb M on 18 .F eb Tu e 19 .F eb W ed 20 .F eb Th u 21 .F eb Fr i 22 .F eb Sa t 23 .F eb Su n 24 .F eb M on 25 .F eb Tu e 26 .F eb W ed 27 .F eb Th u 28 .F eb Fr i M Fi xe d M Ou tre ac h at K Ou tre ac h at L Ou tre ac h at P E Fi xe d E Ou tre ac h at D C Fi xe d C Ou tre ac h at J Fi xe d C B Ou tre ac h at R Fi xe d B Fi xe d B A Fi xe d A Fi xe d A Fi xe d A Fi xe d A He al th Ce nt re 1. M ar Sa t 2. M ar Su n 3. M ar M on 4. M ar Tu e 5. M ar W ed 6. M ar Th u 7. M ar Fr i 8. M ar Sa t 9. M ar Su n 10 .M ar M on 11 .M ar Tu e 12 .M ar W ed 13 .M ar Th u 14 .M ar Fr i 15 .M ar Sa t 16 .M ar Su n 17 .M ar M on 18 .M ar Tu e 19 .M ar W ed 20 .M ar Th u 21 .M ar Fr i 22 .M ar Sa t 23 .M ar Su n 24 .M ar M on 25 .M ar Tu e 26 .M ar W ed 27 .M ar Th u 28 .M ar Fr i 29 .M ar Sa t 30 .M ar Su n 31 .M ar M on M Fi xe d M Ou tre ac h at K Ou tre ac h at L Ou tre ac h at P E Fi xe d E Ou tre ac h at D C Fi xe d C Ou tre ac h at J Fi xe d C B Ou tre ac h at R Fi xe d B Fi xe d B A Fi xe d A Fi xe d A Fi xe d A Fi xe d A U se t he d is tr ic t w or kp la n to s ch ed ul e su pe rv is or y vi si ts t o he al th fa ci lit ie s. BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &*HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je CdiZh/ HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &+ )$9edZkYj_d]Wikf[hl_iehol_i_j During a supervisory visit to the health facility, the supervisor should conduct the following main steps. 1) Collecting information. 2) Problem-solving and feedback. 3) On-the-job training. 4) Recording the results of supervision. (#&8daaZXi^c\^c[dgbVi^dc Supervisors can collect information using a number of methods/tools including : s OBSERVING THE HEALTH FACILITY ENVIRONMENT AND THE HEALTH WORKER GIVING immunizations ; s LISTENINGTOHEALTHWORKERS s REVIEWINGTHERECORDS s USINGACHECKLIST s TALKINGWITHPARENTSANDCOMMUNITYMEMBERS s REVIEWINGRECOMMENDATIONSFROMPASTVISITS s CONDUCTINGARAPIDCOMMUNITYSURVEY (#&#&DWhZgk^c\i]Z]ZVai]"[VX^a^inZck^gdcbZciVcY]ZVai]ldg`Zg \^k^c\^bbjc^oVi^dch Supervisors can obtain a lot of information by simply observing the health- facility environment. For example, they may observe the following : s AREINJECTIONPRACTICESCORRECT s ISTHEHEALTHFACILITYCLEAN s ARE THERE ANYSYRINGESOROPENSAFETYBOXES LYINGAROUND THAT COULDPOSE a threat to the community? s ARETHEREFROZENVACCINESOREXPIREDVACCINEVIALSINTHEREFRIGERATOR s ISTHEHEALTHWORKERINTERACTINGWELLWITHTHECOMMUNITYANDINFORMINGTHEM about services? s ANDOTHERMEMBERSOFTHECOMMUNITY s ARE)%#POSTERSMONITORINGCHARTSETCDISPLAYEDONTHEWALLS BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &,HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je As a supervisor you should watch the health worker doing the work, rather than simply listening to health staff talking about what he/she usually does. When observing the health worker, watch how he/she : s LOADSTHEREFRIGERATOR s SCREENSINFANTS s PREPARESVACCINATIONS s IMMUNIZESINFANTS s COMPLETESTALLYSHEETSANDIMMUNIZATIONREGISTER s HANDLESUSEDNEEDLESANDSYRINGES s COMMUNICATESWITHPARENTS Important : Do not intervene or correct the health worker while he/she is working (unless you feel that harm will be done to the visiting child or mother without your intervention). (#&#'A^hiZc^c\id]ZVai]hiV[[ Listening to health workers’ concerns is critical in providing appropriate support. During discussions with health workers you should explain the purpose of your visit, and offer them the opportunity to share their concerns. If possible, try to meet with each staff member individually, and explain the reason for the visit. Sample questions to ask individual health workers include : s ARETHEYABLETOGETTHEIRWORKDONE)FNOTWHYNOT s DOTHEYHAVEASPECIALINTERESTINANYPARTICULARASPECTOFTHEIRJOB s DO THEY HAVE ANY IDEAS ABOUT HOW THE HEALTH FACILITY COULD BE ORGANIZED so that the community receives a better immunization service? Try to ask questions that require more than a “yes” or “no“ answer. For instance, ask open-ended questions. Example of a closed-ended question “Do you know how to use VVM?“ Example of an open-ended question “How would you know if the vial needed to be discarded?“ (#&#(GZk^Zl^c\YViVVcYjh^c\VhjeZgk^hdgnX]ZX`a^hi Reviewing data can provide useful information about a health worker’s perform- ance. It may also provide information on any gaps in the knowledge and skills of health workers, or alternatively any lack of equipment. Table 4.5 provides some data records that should be reviewed during a supervisory visit. HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &- IVWaZ)#*/9ViVgZXdgYhidZmVb^cZYjg^c\VhjeZgk^hdgnk^h^i Key components Main data records to examine Immunization coverage status. s )MMUNIZATIONCOVERAGEMONITORINGCHARTS s 4ALLYSHEETSREGISTERS s $EFAULTERTRACKINGSYSTEM s -ONTHLYIMMUNIZATIONREPORTS s )MMUNIZATIONWORKPLAN Disease surveillance activities. s 0ATIENTREGISTER s -ONTHLYDISEASESURVEILLANCEREPORTS s 6ARIOUSGRAPHSONDISEASETRENDSANDMAPS Cold chain, vaccine safety and vaccine management. s 2EFRIGERATORTEMPERATURECHARTS s 6ACCINEANDOTHERSUPPLIESSTOCKRECORDS Communication and links with community. s )%#MATERIALSPOSTEDONWALLS s -INUTESOFCOMMUNITYMEETINGS During the visit the supervisor may also use a set of predetermined indicators that are formatted into a checklist (discussed in Section 1.2). (#&#)IVa`^c\idi]ZeVgZcihVcYXdbbjc^inbZbWZgh Talking with parents and members of the community is the only way supervisors can learn how community members view the health services provided. It is especially useful to talk to women as they leave the health centre (exit interviews) and to visit members of the village health committee. Refer to Module 2: Partnering with communities. BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) &.HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je (#'EgdWaZb"hdak^c\VcY[ZZYWVX` (#'#&EgdWaZb"hdak^c\l^i]hiV[[ Step 1 : Describe the problem and its impact s &OCUS ON THE PROBLEM AND NOT INDIVIDUALS "E SURE AND IDENTIFY IF THE problem is due to a lack of skills or to an external factor that prevents the health worker from doing his/her job? s %XPLAINTHEIMPACTLONG TERMANDSHORT TERM OFTHEPROBLEM s 4ACKLEONEPROBLEMATATIME s "ESPECIlCINEXPLAININGTHEPROBLEM)FPOSSIBLEBACKITUPWITHFACTSRATHER than judgment alone. Step 2 : Discuss the causes of the problem with health staff s )DENTIFYINGTHECAUSEOFTHEPROBLEMINVOLVESASKINGvwhy” repeatedly. s 4HISSHOULDNOTBEANOPPORTUNITYTOBLAMEOTHERSORBLAMETHESYSTEM s )T MAY SOMETIMES BE NECESSARY TO SEEK CAUSES IN OTHER SOURCES EG community members, data, etc.). s 0RIORITIZECAUSESACCORDINGTOTHOSETHATCANMOREEASILYBEADDRESSED Step 3 : Implement solutions and monitor regularly s 3OLUTIONS TOBE IMPLEMENTEDSHOULD REACHACOMMONAWARENESSOFWHAT needs to be done and by whom. s 3OLUTIONSTHATCANBEIMPLEMENTEDIMMEDIATELYSHOULDBEIMPLEMENTEDlRST e.g. training on how to assemble a safety box. s $EVELOPANIMPLEMENTATIONPLANTHATDETAILSWHATHOWWHOANDWHEN s &OLLOWUPONPROGRESS (#'#';ZZYWVX`idi]Z]ZVai]hiV[[XdcXZgcZY In the first instance, feedback must be to the supplier of the information, i.e. the health worker under supervision. When data collection is completed, the super- visor should work with health-facility staff as a team, describing each problem in detail and making constructive comments. If you have some bad behaviour to comment on, begin with the positive, and be specific about weaknesses, rather than simply saying, “That was not done well”. Give learners reasons for their success or failure. Don’t just say “Well done” but give a reason – “Well done. You correctly read the VVM and took appropriate action”. Don’t say “You are wrong” but rather “There may be a problem” and explain it. Example : “The data from your tally sheet do not match the data in the reporting form. How can this be corrected?” HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) '% Learning activity 4.5 : Problem-solving Below is an example of a checklist from a supervisory visit. Some comments have been entered, in the form of problems observed. What corrective action can the supervisor take to solve the problems observed, both on site during the visit, and in the longer term? Question Yes/No Comment (problems observed) On-site Corrective action Longer term Corrective action 1 Is the session organized efficiently ? Yes 2 Are immunization cards in use for every infant and pregnant woman ? Yes 3 Is the register used for recording information on each child/mother/pregnant woman ? Yes Not filled correctly 4 Are parents advised on when to return ? No 5 Does the health facility have a monitoring chart displayed ? Yes 6 Does the health facility have a map of the catchment area displayed ? No 7 Does the health facility have a workplan for the quarter ? Yes Available but not used 8 Are planned sessions monitored for completeness/timeli-ness ? No 9 Is there a system for tracking defaulters ? Yes 10 Does the health facility display a spot map of measles cases ? Yes 11 Is a temperature monitoring chart in use ? Yes 12 Are the vaccines stacked properly inside the refrigerator ? No HepB vaccine kept too close to freezer 13 Are there any expired vaccines inside the refrigerator ? No 14 Are there any vaccines with VVM reaching the discard point ? Yes 15 Do the health workers know how to read and interpret the VVM ? Ask them to describe the stages of the VVM and what they mean. Yes 16 Does the staff member know WHEN to perform the shake test ? Can he/she correctly perform the shake test ? (Ask them to demonstrate how they would do it). Yes 17 Is there an adequate supply of AD syringes for the planned sessions ? Yes 18 Are AD syringes used for every immunization ? Yes 19 Is the injection technique appropriate ? Yes 20 Are safety boxes used for each AD syringe and needle ? Yes 21 Are immunization posters displayed on the health-facility wall ? Yes 22 Is there a schedule of community meetings ? No 23 Is there a community volunteer involved with immunization ? No 24 Is there a stock register ? Yes 25 Does the stock register show adequate vaccines and supplies ? No AD syringes out of stock BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) '&HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je (#(Dc"i]Z"_dWigV^c^c\ Six main steps when teaching a skill. 1) Explaining the skill or activity to be learned. 2) Demonstrating the skill or activity using an anatomical model, or role-play. 3) Participants practising the demonstrated skill or activity. 4) Reviewing the practice session and giving constructive feedback. 5) Practising the skill or activity with clients under a trainer’s guidance. 6) Evaluating the participant’s ability to perform the skill according to the stand- ardized procedure, if possible as outlined in the competency-based checklist. Learning activity 4.6 : On-the-job training Prepare a short training session for health staff based on the following most common training issues. 1) Reading the VVM. 2) Arranging vaccines in the refrigerator. 3) Understanding the multi-dose vials policy. 4) Improving communication skills with parents. Think about relevant job aids/materials that health workers can refer to in future. new knowledge and skills. (#)GZXdgY^c\i]ZgZhjaihd[hjeZgk^h^dc (#)#&GZXdgY"Wdd`Vii]ZhjeZgk^hdgnh^iZ It is useful to maintain a supportive supervision record-book at each supervisory site. This should record the date of the visit, main observations, training given, and agreed follow-up actions. Think about what opportunities you will give to learners to practise their HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) '' IVWaZ)#+/HVbeaZ[dgbVid[Vhjeedgi^kZhjeZgk^h^dcgZXdgY"Wdd` Date of visit Basic tools (tick if available and up-to-date) Training/ guidance provided on Agreed follow-up actionMap Sessionplan Workplan Chart Drop-out tracking Stock recording system (#)#'EgZeVg^c\VhjeZgk^h^dcgZedgi After each supervisory visit, the supervisor must prepare a supervisory report. This report is vital for planning corrective measures, and also future super- visory visits. It should inform programme managers and others (e.g. Director of Medical/Health Services ; departmental heads ; other stakeholders ; community leaders ; partners and health workers) of the situation in the health centre and the findings of the visit. The supervision report must : s IDENTIFYWHOISBEINGSUPERVISED s LISTTHETASKSANDRESPONSIBILITIESOFTHESUPERVISEDPERSONSANDCOMMENTON how well they are performed; s ASSESSOVERALLPERFORMANCEOFHEALTHWORKERSATTENDANCEPUNCTUALITYSPIRIT of initiative ; creativity ; capacity to work in an independent manner) ; s DISCUSSEACHITEMINTHESUPERVISIONCHECKLIST s DESCRIBEWHATIMMEDIATECORRECTIVEACTIONSWERETAKENDURINGTHEVISIT s IDENTIFYTHENEXTSTEPSAGREEDWITHTHESTAFFMEMBERSCONCERNED s BESHAREDWITHTHESUPERVISEEEITHERACOPYORWRITTENVERBALSUMMARY  Other methods of sharing supportive supervision findings. s 0UBLISHANEWSLETTER4HISDOESNOTNEEDTOBESOPHISTICATEDORCOSTLY)TCOULD entail one or two pages of text with illustrations that could help make the document reader-friendly. Accounts of personal experiences or successes, provided such stories are presented positively, will enable staff to recognize themselves in the process. The distribution of the newsletter should be as wide as possible. s 0REPAREABULLETINANDSENDTHISTOVARIOUSPEOPLE s /RGANIZEASEMINARTODISCUSSTHERESULTSOFTHESUPERVISORYVISITS9OUMAY find that this results in interesting discussions, an exchange of ideas, or on- the-spot problem-solving ideas. s 3HAREINFORMATIONATMONTHLYMEETINGS BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) '(HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je CdiZh/ HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) ') *$<ebbem#kfWYj_l_j_[i )#&L]ViidYdV[iZgVhjeZgk^h^dck^h^i Supportive supervision does not end with the conducted visit. Back in the office the supervisor should plan for follow-up, which may include the following : s ACTINGONISSUESYOUAGREEDTOWORKON s INVOLVINGHEALTHWORKERSINTHEPLANNINGPROCESSANDWORKINGWITHTHEMTO develop checklists, job aids, monitoring tools, etc. ; s DISCUSSINGEQUIPMENTSUPPLYANDDELIVERYPROBLEMSWITHHIGHERLEVELS s REVIEWING MONTHLY REPORTS AND ESTABLISHING REGULAR COMMUNICATION WITH supervised staff to see if recommendations are being implemented ; s IDENTIFYING CAREER GROWTH OR LEADERSHIP OPPORTUNITIES FOR THE PERSONAL development of supervised health staff. )#'8dcYjXi^c\[daadl"jek^h^ih Follow-up visits provide continuity between past and future supervisory visits for a health worker, in the following ways : s ENSURINGPROBLEMSIDENTIlEDATAPREVIOUSVISITDONOTPERSIST s REINFORCINGWITHTHEHEALTHWORKERTHATISSUESFOUNDDURINGTHELASTVISITARE still important ; s SUPPORTINGTHEHEALTHWORKER)FTHEPROBLEMHASNOTBEENlXEDWHYNOT s CHECKINGIFPASTON THE SPOTTRAININGHASBEENEFFECTIVE s ENSURINGTHATTHEPERFORMANCEOFTHEHEALTHWORKERISBEINGMONITOREDAND improved. As a supervisor, you can also benefit from the follow-up visit in the following ways : s ALLOWSYOUTOGIVECONSISTENTMESSAGES s ENSURESTHATEVENIFYOUHAVENOTVISITEDTHISHEALTHFACILITYBEFOREYOUARE still able to confirm your visit is relevant, and based on previous visits and findings ; s ENSURESTHATEVENIFDIFFERENTSUPERVISORSVISITACLINICRELEVANTSUPERVISION can still be provided. BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) '*HZijehnhiZbÕEaVck^h^ihÕ8dcYjXik^h^ihÕ;daadl"je Steps for the follow-up visit include : s REVIEWINGTHESUPERVISORSREPORTFROMTHEPREVIOUSVISITANDCONTINUINGTO work on the issues raised in the report ; s TELLINGHEALTHWORKERSWHATYOUHAVELEARNEDFROMTHEPREVIOUSVISITINORDER to avoid repeating the same information ; s OBSERVINGHEALTHWORKERS TO SEE IF BADBEHAVIOURS OR ATTITUDESHAVEBEEN corrected and, if it is the case, congratulating them; s HIGHLIGHTINGTHEOBSERVATIONSFROMTHEPREVIOUSVISITTHATHAVENOTCHANGED and noting that these items still need to be followed up ; s CHECKINGIFANYPERCEIVEDLACKOFIMPROVEMENTISDUETOHIDDENPROBLEMSTHAT need to be addressed ; s FULlLLINGPROMISESMADEATTHEPREVIOUSVISITIEIFSUPPLIESORTECHNICALINFOR- mation/documentation had been promised). Learning activity 4.7 : Importance of follow-up supervisory visits Instructions for the group. Read through the following case study and discuss the questions below. Case Study As an EPI manager, you receive regular requests for supervision visits from districts facing problems that the health-management team cannot solve. Each time you make proposals regarding daily allowances, transport, fuel and other logistics items, you are told that supervisory visits are a waste of resources, especially now that the districts are autonomous, or under the administration of the local government authorities. The problem is that over the past year, the district supervisor could only make a single visit to about a half of the health centres. These visits revealed several problems that need to be followed up. 1) Why are supervision visits (from national to district level or from district to health facilities) difficult to conduct? 2) What could be the reason for poor perception of supervisory visits by the -INISTRYOF(EALTH-/( ˆWHOMAYREGARDSUCHVISITSASAhWASTEOF resources”? 3) What must be done to improve the effectiveness of supervision at all levels? 4) Are there other supervisory methods that do not necessarily require field visits? How do such methods ensure the effectiveness, reliability and quality of the supervision? '+ BdYjaZ)/Hjeedgi^kZhjeZgk^h^dc IgV^c^c\[dgb^Y"aZkZabVcV\ZghBAB"L=D$>K7$%-#%) 6ccZm&/HVbeaZhjeZgk^hdgnX]ZX`a^hi Question Yes No 1 Is the session organized efficiently ? 2 Are immunization cards in use for every infant and pregnant woman ? 3 Is the register used for each child/mother/pregnant woman ? 4 Are parents advised on when to return ? 5 Does the health facility have a monitoring chart displayed ? 6 Does the health facility have a map of the catchment area displayed ? 7 Does the health facility have a workplan for the quarter ? 8 Are planned sessions monitored for completeness/timeliness ? 9 Is there a system for tracking defaulters ? 10 Does the health facility display a spot map of measles cases ? 11 Is a temperature monitoring chart in use ? 12 Are the vaccines stacked properly inside the refrigerator ? 13 Are there any expired vaccines inside the refrigerator ? 14 Are there any vaccines with VVM reaching the discard point ? 15 Do the health workers know how to read and interpret the VVM ?Ask them to describe the stages of the VVM and what they mean. 16 Does the staff member know WHEN to perform the shake test, and can he/she correctly perform the shake test ? (Ask them to demonstrate how they would do it). 17 Is there an adequate supply of AD syringes for the planned sessions ? 18 Are AD syringes used for every immunization ? 19 Is the injection technique appropriate ? 20 Are safety boxes used for each AD syringe and needle ? 21 Are immunization posters displayed on the health facility wall ? 22 Is there a schedule of community meetings ? 23 Is there a community volunteer involved with immunization ? 24 Is there a stock register ? 25 Does the stock register show adequate vaccines and supplies ? The World Health Organization has provided technical support to its Member States in the field of vaccine-preventable diseases since 1975. The office carrying out this function at WHO headquarters is the Department of Immunization, Vaccines and Biologicals (IVB). IVB's mission is the achievement of a world in which all people at risk are protected against vaccine-preventable diseases. The Department covers a range of activities including research and development, standard-setting, vaccine regulation and quality, vaccine supply and immunization financing, and immunization system strengthening. These activities are carried out by three technical units: the Initiative for Vaccine Research; the Quality, Safety and Standards team; and the Expanded Programme on Immunization. The Initiative for Vaccine Research guides, facilitates and provides a vision for worldwide vaccine and immunization technology research and development efforts. It focuses on current and emerging diseases of global public health importance, including pandemic influenza. Its main activities cover: i) research and development of key candidate vaccines; ii) implementation research to promote evidence-based decision-making on the early introduction of new vaccines; and iii) promotion of the development, evaluation and future availability of HIV, tuberculosis and malaria vaccines. The Quality, Safety and Standards team focuses on supporting the use of vaccines, other biological products and immunization-related equipment that meet current international norms and standards of quality and safety. Activities cover: i) setting norms and standards and establishing reference preparation materials; ii) ensuring the use of quality vaccines and immunization equipment through prequalification activities and strengthening national regulatory authorities; and iii) monitoring, assessing and responding to immunization safety issues of global concern. The Expanded Programme on Immunization focuses on maximizing access to high quality immunization services, accelerating disease control and linking to other health interventions that can be delivered during including expansion of immunization services beyond the infant age group; ii) accelerated control of measles and maternal and neonatal tetanus; iii) introduction of new and underutilized vaccines; iv) vaccine supply and immunization financing; and v) disease surveillance and immunization coverage monitoring for tracking global progress. The Director's Office directs the work of these units through oversight of immunization programme policy, planning, coordination and management. It also mobilizes resources and carries out communication, advocacy and media-related work. immunization contacts. Activities cover: i) immunization systems strengthening, World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland E-mail: vaccines@who.int Web site: http://www.who.int/immunization/en/