Health Centre Supervision Checklist

Abstract

• Name: Health Centre Supervision Checklist
• Purpose: The supervision checklist was designed to serve as a job aid for supervisors to measure performance in public sector health centers in Zambia.
• Type of Design: Checklist; descriptive and cross sectional.
• Sample Size: N/A
• Where Used: Zambia (not officially adopted by the Ministry of Health but is being used by some District Health Management Teams).

To survey tool

Basic Information

Name: Health Centre Supervision Checklist

Origin: Developed by BASICS consultant, Gilbert Burnham, and BASICS/Zambia Child Health Advisor, Abdikamal Alisalad.

Source: BASICS Zambia Child Health Project

Basic Description: The Health Centre Supervision Checklist is job aid for district level supervisors. It is a comprehensive checklist which is split into two main parts: Core Health Facility Activities and Specialized Health Centre Activities. The checklist is comprised of 91 questions, some with multiple elements.

Country Applications: Zambia

Languages Available: English

Technical Scope: Assessing and improving health worker performance

Purpose: The supervision checklist was designed to serve as a job aid for supervisors to measure performance while conducting comprehensive supervision visits at public sector health centers.

Type of Methods: Qualitative

Design: Descriptive and cross sectional.

Frequency of Administration: Monthly, quarterly, or as often as supervision visits are conducted.

Key users of Information

Both the District Health Management Team and staff being supervised benefit from the use of information generated by this tool. It provides a common framework for both groups, and establishes clear performance standards for health workers.

Objectives and Scope of Tool

The supervision checklist is intended to be used regularly by supervisors in order to systematically evaluate various elements of the health center, services provided, and the performance of health workers. It serves as a guide to performance standards and allows supervisors to identify areas where health workers require additional assistance such as in problem-solving, and technical skills. The areas assessed with the checklist include:

Part I - Core Health Facility Activities

1. Facilities, grounds and buildings
2. Records, reports and wall charts
3. Review of outpatient register for the past month
4. Review of the antenatal register for the past month
5. Review of the tuberculosis treatment register for the past month
6. Financial records
7. Services Provided
8. Personnel
9. Equipment, supplies and stationary
10. Vaccine supply and cold storage
11. Drugs and contraceptives
12. Malaria/child health (including UCI, diarrhea, pneumonia, nutrition, and malaria)

Part II - Specialized Health Center Activities

1. Community partnership/health communication
2. Environmental health
3. Observation of family planning service delivery
4. Health centres with a maternity facility

Key Monitoring Needs and Evaluation Questions Tool Seeks to Address

The tool primarily aims to answer questions about health facility and health worker performance, as well as questions related to community partnerships and environmental conditions in the community. The tool does not dictate the frequency of health worker performance monitoring. Supervision visits are determined by the District Health Management Team based on the number of health centers to be covered and the extent of human and other resources available for supervision. Results from application of the tool may indicate the need to increase the frequency of supervisory visits.

Key Indicators

The tool focus primarily on quality of care indicators and includes a limited number of indicators on problem-solving skills. Supervisors are expected to received training in problem-solving in preparation for applying this tool.

Research Design

Standard Protocol:

Type of Design: Checklist

Units of Observation and Analysis: Health centers and health workers within health centers.

Sample Size: Not pre-determined.

Target Population: Supervisors and health workers.

Lessons from Experience:
This tool was developed from a draft checklist designed by Bob Pond. It was further developed by BASICS' consultant, Gilbert Burnham, and BASICS/Zambia Child Survival Advisor, Abdikamal Alisalad, with extensive input from representatives of the Central Board of Health in Zambia. District Health Management Team members informed additional revisions through a series of workshops and field applications.

Training

Standard Protocol:
A training workshop in the use of this tool was held in Lusaka in February 1997. The workshop had the following aims and objectives:

Aims:

• Help health managers understand how to conduct effective supervision.
• Develop a checklist which will serve as part of the supervision process.
• Start the process which will be a model for a national supervision program.

Objectives:

By the end of the workshop participants will be able to:

• Conduct an effective supervision visit.
• Explain the difference between support and inspection in supervision.
• Assess the quality of services through:

An interview with the clinic in charge or other health workers;

The direct observation of facilities, records and drugs, equipment, and supplies; and

Observation of health worker providing care to children and adults.

• Discuss problems identified with health workers and use a problem solving approach to address them.
• Identify the need for on-the-spot training.
• Discuss how the community can be involved in the supervision process.
• Establish a one-year supervision action plan for the participants' districts.

Lessons from Experience:
The supervision workshop provided participants from four districts in Lusaka with basic supervision skills as demonstrated at the conclusion of the workshop. Participants received an outline of the supervisory process and multiple copies of the final checklist.

Implementation

Standard Protocol:

Interviewers: District Health Management Team members.

Administration Requirements: The checklist is used as part of the standard supervision schedule. No special administrative actions are required.

Supervision and Data Quality Assurance Requirements: The quality of supervision visits is not generally monitored. At the time of writing, most districts had not received any training in the use of this check list. Other supervision checklists were also being tested in Zambia, including one developed by the Quality Assurance division of the Central Board of Health.

Transportation Requirements: No special transportation is required. But transport is needed for DHMTs to reach the health centers on a regular basis.

Translation and Language Issues: The checklist is available in English. Members of the DHMTs used local dialects during supervision visits, guided by the English checklist.

Technical Resource Requirements: DHMTs should receive training in the use of the checklist. However, in some cases the checklist was simply sent out to a number of the Districts. In addition to introducing the checklist, the training workshop was particularly useful for conducting training on supervision in general and introducing a problem-solving approach.

Lessons from Experience:
Excerpts from a trip report of July 30, 1998: "District Support for IMCI: Presentations made at a special meeting of the IMCI Advisory Group follow:

Kitwe

District supervisors in Kitwe find the supervisory checklist useful and frequently refer to it during their supervisory visits. However, they would like to modify it as follows:

1. Some staff feel that with 91 items it is too long.

2. The District Director, who is trained in IMCI, feels that the section on IMCI should be even longer. For example, he suggested that the checklist include items for more carefully assessing counseling and the appropriateness of the health worker's classification and treatment of illness.

3. Little has been done thus far to inform health center staff about the checklist. Some district staff have received a copy but no training. Health center staff have not received copies of the checklist.

4. The checklist has been used to guide the supervisor's observations. Then the supervisor speaks briefly with individual health workers providing advice on how to improve care. Some staff say that it makes them a bit nervous to have supervisors observe their work. Others say that it is helpful, since the supervisors are not finding faults and do provide encouragement and support. Sometimes there are no patients, or at least sick children, when the supervisor visits a health center, and it is impossible to observe case management.

5. In general, supervisors discuss their findings with the clinic In-charge at the end of the visit. Then the In-charge discusses the findings with the staff at a staff meeting the following week. A written report may be given to the clinic In-charge, but reporting mechanisms have not be standardized.

6. Quality assurance (QA) coaches in Kitwe remain focused on the physical setting and have not yet included problem solving methods into their visits.

Kafue

1. Three district staff visit each of the 13 health centers in the district every two to three months. They guide their supervision visits using the integrated checklist. District staff have found the checklist helpful since it is integrated, touches on all key areas, adds consistency to the supervision visit and is supportive, not punitive. Health workers appear to be a bit nervous the first time they are observed in their work, but eventually they relax.

2. Some respondents noted difficulties relating to the increased length of the visit when using the checklist. However, some health center staff appreciated a longer time with the supervisor. The risk in small health centers is that the supervision visit disrupts patient care. However, it is necessary for supervisors to observe sick child care directly. Kafue staff also felt that if either the supervisor or health worker has not been trained in IMCI, then it is difficult to gauge performance in IMCI.

3. When no patients were treated during supervision visits, records were reviewed. However, there was great variation in record-keeping.

4. Feedback is provided directly by supervisors to health workers and also from the group of supervisors to the health center staff as a whole. Minutes of the group meeting are kept, and these notes eventually form the content of the supervisors' report. The report consists of major issues and findings from observations of health workers are often omitted. The checklist is not included since it is re-used at each health center as a memory aid.

5. Quality assurance coaches are active in this district and have had some successes using the problem solving approach. However, the QA coaches feel that district coaches must visit more frequently or train a member of the clinic staff as QA facilitators.

6. Recommendations from the districts for strengthening technical supervision follow:

• Supervision should be supportive and problem-solving should be emphasized.
• Supervision of clinical care should be an integral part of routine supervision.
• Supervisory visits should be regular, at least one hour, and should not disrupt patient care in the health center (perhaps focus on one area each visit for small clinics).
• District supervisors should be trained in IMCI.
• IMCI-trained supervisors should observe case management and discuss the findings with health workers, as should IMCI-trained health center In-charges and clinical care specialists.
• The checklist should be further developed to include more elements of clinical care and it should be reviewed every year or two to update it.
• The checklist should be distributed and discussed with health center In-charges.
• Records review is a reasonable alternative when observation of clinical care is not possible. However, health workers should be trained in the minimum standards for record-keeping.

Analysis

Standard Protocol:
Data Entry Techniques or Tricks: The checklist is filled out in hard copy during each supervision visit.

Analytical Requirements: Analysis is conducted on-the-spot, based on the findings of the visit.

Time and Labor Requirements: Theoretically, no additional time is required since the checklist is simply a tool, or memory aid, for supervisors to use during their routine visits. If use of the checklist is refined, however, it could serve as a time-saver since supervisors will know what issues to focus on in subsequent visits, and which issues may not require special attention if performance has been adequate.

Lessons from Experience:
At times it is difficult for the supervisor to provide a balanced analysis of health worker performance because they themselves do not have the requisite skills. For example, if a supervisor who has not been trained in IMCI observes an IMCI-trained health worker, there is no guarantee that they are assessing the accuracy of the case management visit adequately. The analysis may therefore be skewed. It is important that all supervisors are trained in IMCI in order to be able to appropriately supervise case management of sick children and ensure that standards of practice are being met.

Reporting

Standard Protocol:
There is no protocol for reporting on findings from use of the checklist. Each supervisor reports findings from the supervision visit in their own way.

Dissemination of Results

Standard Protocol:
This tool is not intended to produce district wide reports.

Manuals and Guidelines

Checklist available. No other instructions are available except the trip report noted above.

Link to and Complementarity with Other Tools: Attempts have been made to finalize either the HMIS or the BASICS supervision checklist, but at the time of this writing it is not clear whether either has been vetted by the Zambian health authorities.

The method has not been validated, although more and more districts are using the checklist even without the benefit of training.

Contact Person
Rene Salgado
BASICS Project
1600 Wilson Blvd.
Arlington, VA 22209
703-312-6800