Leadership for Performance Improvement: A new approach for “supervision” Management Sciences for Health Leadership, Management and Sustainability, Fall 2005

What is supervision: what are the assumptions behind it? Supervise: to oversee the performance of another. Assumption: for quality performance, a supervisor has to oversee, or inspect results. Question: when you have produced quality, was it because a supervisor was using a checklist to inspect you?

What are some weaknesses in current supervision? Supervisors often act as inspectors, using the checklist to find errors. Supervisors are often separate from day to day challenges the service providers are facing. Fear and reduction of incentives are often used as motivators resulting in demoralization and “mis-reporting” of results to avoid negative consequences.

Leadership in Supervision In Upper Egypt, a leadership approach is being added to supervision training. This leadership approach is enabling service provision teams to identify and face their own challenges and achieve results with support from “supervisors.”

Leadership: A shift in mindset From Inspection to Coaching-inquiring into the service provider teams ongoing process of improvement. From Blame to Shared Responsibility with the service provision team. From providing solutions to working with service providers on the challenge model to overcome obstacles and achieve results.

Leading Enabling others to face challenges and achieve results in complex conditions SCAN FOCUS ALIGN/MOBILIZE INSPIRE

Adding a Leadership Approach to Supervision The supervisors work together with the service provision team to identify their challenges and the results they want to achieve. Together they identify obstacles and root causes and make an implementation plan. They use the “CHALLENGE MODEL.”

M&L implemented pilot LDP in Aswan Governorate from June 2002-June Program involved 41 district and clinic managers, organized into 10 teams. M&L support ended in June 2003, however graduates decided to replicate and expand the LDP to other clinics and districts within the Governorate. End of health units (5 “generations”) and 35 facilitators are using original LDP approach and curriculum. Results due to the relevance of LDP to health professionals and to promotion of a few graduates to senior positions in FP/RH at the district and Governorate levels. Aswan Leadership Development Program

Service Provider Teams LEAD The service provider teams with support from supervisors use the leadership practices. They : – Scan client and community needs – Focus on a common vision of the services they want to provide – Align and Mobilize their resources inside of the clinic and outside in the community –Inspire themselves by producing results using only their own resources

Role of the external “supervisor” The supervisor works to support the team, and finds ways to support them in overcoming their obstacles. They use “coaching,” inquiring into the obstacles the service providers are facing, and helping them to find solutions. They empower the teams to take responsibility for results.

Beyond supportive supervision Leadership uses and builds on the supportive practices of facilitative supervision. What is different is that the service provider teams create a shared vision of the care they want to provide to fulfill client needs. They have a clear process – The Challenge Model – by which they are identifying their challenges and leading their teams to achieve results.

Using the “Checklist” The checklist is now used as a tool for self- assessment. It is used to enable the service providers to acknowledge themselves for strengths and target areas for improvements. It is used with other forms of assessment, including client interviews and community focus groups.

Service Providers work in teams and are motivated and committed “It is the first time that a program respects team work. The whole team existing at the clinic level; everybody is involved, the nurse, the clinicians and even the book keeper.” “It does not need lots of resources to implement, it does not need us to build a hospital or buy equipment. It deals with brains, ideas and mentalities. This work depends mainly on people’s motivation and commitment.”

Leadership Development enables providers to think for themselves “What is genius about this program is that it gives the people a chance to have their own vision and a point of view. These people had better solutions than we had, this happens all the time.” “The main idea of the leadership training is to analyze your own problems. People get involved because they feel this helps their sense of self-esteem, while they are providing the service, money is not everything, they feel that they are able to help others and provide information to them.”

Advice from Aswan on Supervision 1. There needs to be commitment to quality from local managers. External supervision can initiate the process of performance improvement, but to continue and to sustain, local supervision is needed. 2. Local supervisors know exactly the climate of work, the exact needs of the community concerns and the resources available. 3. Local supervisors can help the units to make their priorities – they can facilitate and solve many problems with the service providers.

Aswan Governorate Health and Service Results, Maternal Mortality Rate – Infant Mortality Rate (less than one year) – ANC average visits – Family Planning Coverage – 55, 735 to % increase in new FP users

Conclusion It would be useful to explore how adding a leadership approach to service delivery teams and supervisors can improve commitment, teamwork and the attainment of service and health improvements.