1. Supervision Training: some lessons from Kenya Dr Pamela Lynam / Nancy Koskei JHPIEGO-Johns Hopkins University Chris Rakuom – DSRS-Ministry of Health

2. Background 1999 Supervision training needs assessment found: There is little training for supervision What there is, is theoretical and difficult to apply Supervisors do not have the time to spend 2- 6 weeks (or longer) in training Poor logistics and planning make “traveling supervision” very difficult to apply Few good practical tools for supervisors Few or no supervision reference materials to help them do a better job

3. Methodology JHPIEGO developed a supervision training approach that addressed these needs Pre-tested in one district (Busia) Revised the package and incorporated lessons learned Used the package to train 28 on site supervisors from MCH/FP clinic in district hospitals and health centers Introduced the Performance and Quality Improvement process during the training to solve actual problems supervisors were facing

5. GET and MAINTAIN STAKEHOLDER AGREEMENT CONSIDER INSTITUTIONAL CONTEXT MISSION GOALS STRATEGIES CULTURE CLIENT and COMMUNITY PERSPECTIVES DESCRIBE ACTUAL PERFORMANCE DEFINE DESIRED PERFORMANCE FIND ROOT CAUSES Why does the performance gap exist? SELECT INTERVENTIONS What can be done to close the performance gap? IMPLEMENT INTERVENTIONS GAP The Performance and Quality Improvement Process MONITOR AND EVALUATE PERFORMANCE

6. Methodology contd. Reinforced the course with Mailings for encouragement and also to get feedback on implementation, challenges and constraints Distribution of further tools intermittently Followup meeting for participants to share experiences Supportive supervision to each participant for encouragement, answering questions, modeling, etc.

7. Components of the training Overview of supervision Working with people Defining desired performance Assessing performance Finding root causes Selecting and implementing interventions Monitoring and evaluating performance

8. Results Improved Infection Prevention practices e.g.: Improvised hand washing containers where no running water Purchased containers for decontamination An improvised hand washing container in one of the health facilities – MCH/FP Department The supervisor at Ikanga Health Centre with containers for mixing jik

9. Results contd. Standards Developed: Performance standards set and posted on the wall

11. Results contd. Community feedback on services: Suggestion boxes introduced Client Exit Interviews done by staff Suggestion Box at Ikutha Health Centre introduced by the supervisor (pictured right) as a way of getting feedback from the community

12. Results contd. Meetings improved  Invitation & agenda posted on the notice board  Minutes filed Meeting Agenda at Ekwanda Health Centre

13. Results contd. Privacy improved: Curtains purchased and put up Curtains bought to provide privacy in one of the health facilities – MCH/FP Clinic

14. Results contd. Shared visions with other stakeholders (staff and community ) led to: Opening of a maternity facility The community had complained that “…the facility has been here for many years but none of our children were born here…. We need….” Reduced client waiting time

15. Results contd. Staff Motivation : Supervisors developed new ways to motivate staff, e.g.: Introducing tea provided by the clinic (a Kenya tradition!) One started a lunch club Days off made more equitable by reorganizing the duty rosters

16. Results contd..  Supervisors enthusiastic about the materials and tools, e.g.:  Supervisory skills  Infection Prevention manual  Laminated Supervisors guide  Laminated hand washing tools

17. FHI Evaluation Examples of results:

18. What next? Since the evaluation, the program has continued to evolve: Trained further cadres: Health Inspectors Hospital Matrons DPHNs Employed more self assessment Used a cross-cutting quality issue (infection prevention)

19. Lessons learned A short course with reinforcements can be effective (vaccination analogy) Some great changes can be made with little outside input Both on-site and “traveling” supervisors need access to training

20. Recommendations Evaluate the further part of the program (training of Health Inspectors and Hospital Matrons) Use this approach to train other cadres: MOHs Med Sups DRH staff Provincial T&S team Health Administrators

21. Recommendations contd. Enable the Ministry of Health to provide this course to all staff who have been promoted or assigned supervisory duties. The Health Inspectors, who have been trained in supervision, can continue providing support supervision to the on- site supervisors. Include a practicum day for visits to the clinic for participants to have “hands on” before implementation.

22. Quotes from the field “This course really changed our supervisor a great deal....” “…she is ready always to give feedback and assist every time....” “He regularly provides feedback on performance …like last year we were awarded a certificate to MCH/FP department staff for good performance.” “He is a very good in-charge who listens to problems of staff.... This happened after the course.” Some of the quotes from providers as they filled the supervisory skills ratings questionnaire were:

23. Thank you!