Understand basic decisions that happen during implementation Be able to organize and coordinate activities/resources in health service organizations Be able to apply monitoring and supervision as a tool for improvement of health service organizations

1. Implementation
By Yodit Zewdie
Health Services
Management

2. Objectives of the session
2
 By the end of this session, students should:
 Understand basic decisions that happen during
implementation
 Be able to organize and coordinate
activities/resources in health service
organizations
 Be able to apply monitoring and supervision as
a tool for improvement of health service
organizations
2

3. Outline of presentation
3
Definition
Decisions in implementation function
Organizing and co-ordination
Monitoring and redirecting
Supervision
3

4. Definition
4
 Definition:
 Implementation is one of the broad managerial
functions involving the process of putting planned
activities in a specific program or intervention into
action.
 Managers are required to perform three
interrelated activities under this function:
 Organizing and coordinating resources and
activities
 Monitoring the performance and quality of health
services
 Provision of support to subordinates
(supervision, coaching, mentoring, etc)

5. Organizing
5
 Organizing is assigning the tasks developed
during planning to various individuals or groups
within the organization thereby creating a
mechanism to put plans into action.
 It deals with all those activities that result in:
 The formal assignment of tasks and authority
 Coordination of effort
 Differentiation and integration of tasks
 Purpose:
 To make the best use of organizational
resources to achieve organizational goals

6. Organizing Cont…
6
 Benefits of organizing
 Assuring more efficient use of organizational
resources through maximal utilization of
individuals’ skills
 Improving employees understanding of job
duties and responsibilities
 Improving employee morale
 Providing a sense of direction for each of the
organization’s functional areas.

7. Organizing Cont…
7
Organizational Structure

8. Organizational Structure
8
 Organizations are networks of people, with ideas
and resources, working towards common goals.
Two types of organizations
 Formal:A relatively stable set of the organizational
structure and the rules that make up the organization
which arises from the firm’s authority structure.
 Informal:is a network of social interactions among an
organization’s employees (unrelated to the firm’s formal
authority or structure)

9. Organizational Structure Cont…
9
 Organizational structure
 Is the formal decision-making framework by
which job tasks are divided, grouped, and
coordinated
 Usually represented in a chart form called an
Organizational Chart
 An organization chart displays the organizational
structure and shows:
 Job titles
 Lines of authority
 Relationships between
departments/units/processes

10. Organizational Structure Cont…
10
 Reading Assignment
 Read on different types of organizational
structure
 Mechanistic structure
 Organic structure
 Contingency organization

11. Organizational Design
11
 Organizational design refers to the process of
coordinating the structural elements of
organizations in the most appropriate manner.
 It is about the decisions and actions that result in
organizational structure.
 Organizational design is the creation of an
organization's structure, traditionally classified as:
 Functional organization
 Divisional organization
 Matrix structures

12. 1. Functional organization
12
 Authority is determined by the relationships
between group functions and activities.
 Functional structures group similar or related
occupational specialties or processes together.
 Examples of functions
 Finance
 Human Resource Development
 Production/Service Provision
 Advantage:
 Facilitates specialization
 Disadvantage:
 Risk of losing sight of overall organizational
interest while focusing on departmental goals

13. 2. Divisional organization
13
 Corporate divisions operate as relatively
autonomous businesses under the larger
corporate umbrella.
 Divisional structures are made up of self-contained
strategic business units that each produces a
single product.
 A central headquarter, focusing on results,
coordinates and controls the activities, and
provides support services between divisions.
 Divisions accomplish their own division goals.
 Weakness: the tendency to duplicate activities
among divisions is very high.

14. 3. Matrix structures
14
 In a matrix organization, teams are formed and
team members report to two or more managers
which utilize functional and divisional chains of
command simultaneously in the same part of the
organization.
 It is more applicable to:
 Develop a new product
 Ensure the continuing success of a product to
which several departments directly contribute
 Solve a difficult problem requiring the
involvement of different departments

15. Matrix structure cont…
15
 By superimposing a project structure upon the
functional structure, a matrix organization allows
the organization to take advantage of new
opportunities.
 The matrix concept facilitates working on
concurrent projects by creating a dual chain of
command, the project (program, systems, or
product) manager and the functional manager.
 Project managers have authority over activities
geared toward achieving organizational goals
while functional managers have authority over
promotion decisions and performance reviews.

16. Matrix structure cont…
16
 Advantage:
 Matrix organizations are particularly appealing to
firms that want to speed up the decision-making
process.
 Weaknesses:
 It may not allow development of long-term working
relationships.
 Using multiple managers for one employee may
result in confusion as to manager evaluation and
accountability.
 The matrix system may elevate the conflict
between product and functional interests.

17. Matrix structure cont…
17
Health
Institution
Head
Laboratory Nursing
Physician
Consultation
Malaria
Control
Project
HIV
Control
Project
TB
Control
Project

18. Departmentalization
18
 After reviewing plans, usually the first step in
the organizing process is
departmentalization.
 Once jobs have been classified through work
specialization, they are grouped so that
common tasks can be coordinated.
 Departmentalization is the basis on which
work or individuals are grouped into
manageable units.

19. Departmentalization cont…
19
 Methods for grouping work activities
 Departmentalization by function
 Departmentalization by product
 Departmentalization by geographical regions
 Departmentalization by process
 Departmentalization by customer

20. Departmentalization by
function
20
 Organizes by the functions to be performed
 Functions reflect the nature of the work.
 The advantage of this type of grouping is
obtaining efficiencies from consolidating similar
specialties and people with common skills,
knowledge and orientations together in common
units.

21. Departmentalization by
product
21
 Assembles all functions needed to make and
market a particular product/service under one
executive.
 For instance, a pharmaceutical company’s
stores can be structured around product
groups such as:
 Vaccines
 Antibiotics
 Vitamins
 Hormones
 Others

22. Departmentalization by geographical regions
22
Groups jobs on the basis of territory or geography

23. process
23
 Groups jobs on the basis of product or customer flow.
 A patient preparing for an operation would first engage in
preliminary diagnostic tests, then go through the admitting
process, undergo a procedure in surgery, receive post
operative care, be discharged and perhaps receive out-
patient attention.
 This approach tries to bring different activities in a process to
be performed under the sight of a process owner.
 BRR in the current Ethiopian health system is trying to
establish this type of organization at all levels.
 An example for a hospital service:
 Registration
 Consultation
 Investigation
 Treatment

24. Departmentalization by customer
24
 Groups jobs on the basis of a common set of
needs or problems of specific customers.
 For instance, a hospital may group its
patients as:
 Emergency patients
 Stable patients
 Follow up cases

25. An example from a business firm
25

26. Organizing Cont…
26
 What can be read from an organizational chart?
 Responsibilities of individuals
 Formal reporting relationships, level of hierarchy,
or chain of command/ communication
 How individuals are grouped into sections or
departments
 Span of control
 Decentralization and centralization
 What organizational chart doesn’t show
 human factors (motivation, dissatisfaction)
 Relationship among individual organizational
members

27. How to design organizational chart?
27
 Review activities planned to achieve
objectives (Plan document)
 Group similar activities
 Identify the proper personnel for each activity
 Create a network of relationships among
each activity
 Create a chain of command among each
level

28. Organizational structure cont…
28
 Changes in an organizational structure may
occur as a result of:
 Changes in government policy regulations and
system
 Changes in the organizational objectives
 Expansion and contraction of the organization
 Change of the management body
 Inefficiency which may be due to:
 Improper decision
 Conflicts
 Poor relationship

29. Some important terms in Organizing (reading
assignment)
29
 Work Specialization
 Chain of Command
 Authority, Responsibility, and Accountability
 Delegation
 Span of Management
 Tall vs. Flat Structure
 Centralization, Decentralization, and Formalization

30. Work Specialization
30
 The degree to which organizational tasks are sub-
divided into individual jobs
 Also called division of labor
 With too much specialization, employees are
isolated and do only a single, tiny, boring job.
 Solution:
 Enlarge jobs to provide greater challenges
 Assign workers to tasks that are rotated
 With too little specialization, employees may not
develop the appropriate skills.

31. Chain of Command
31
 An unbroken line of authority that links all
individuals in the organization and specifies who
reports to whom.
 Two important concepts
 Unity of Command - one employee is held
accountable to only one supervisor (sometimes
not applicable – in mixed structure)
 Scalar principle - clearly defined line of authority
in the organization that includes all employees

32. Authority, Responsibility, and
Accountability
32
 Authority - formal and legitimate right of a
manager to make decisions, issue orders, and
allocate resources to achieve organizationally
desired outcomes.
 Responsibility - duty to perform, the task or
activity an employee has been assigned
 Accountability - the fact that the people with
authority and responsibility are subject to
reporting and justifying task outcomes to
those above them in the chain of command

33. Delegation
33
 Delegation is the process managers use to
transfer authority and responsibility to
positions below them in the hierarchy
 Organizations today tend to encourage
delegation from highest to lowest possible
levels
 Can improve flexibility to meet customers
needs and adaptation to competitive
environments

34. Span of Management
34
 Is the size of subordinates/supervisees working under a
manager
 Larger span of management is required when:
 Work performed by subordinates is stable and routine.
 Subordinates perform similar work tasks.
 Subordinates are concentrated in a single location.
 Subordinates are highly trained and need little direction in
performing tasks.
 Rules and procedures defining task activities are available.
 Support systems and personnel are available for the
managers.
 Little time is required in non supervisory activities such as
coordination with other departments or planning.
 Managers' personal preferences and styles favor a large
span.

35. Tall vs. Flat Structure
35
 Tall - A management structure characterized by an
overall narrow span of management and a relatively
large number of hierarchical levels.
 Tight control
 Delays decision making
 Flat - A management structure characterized by a
wide span of control and relatively few hierarchical
levels.
 Loose control
 Facilitates delegation
 Facilitates timely decision making

36. Centralization, Decentralization, and
Formalization
36
 Centralization
 The location of decision making authority
near top organizational levels.
 Decentralization
 The location of decision making authority
near lower organizational levels.
 Formalization
 Availing written documentation used to
direct and control employees.

37. 37
Exercise

38. Coordination
38
 Is bringing activities into proper relation with
each other.
 Makes rule that everything that needs to be
done is done and no two individuals are trying to
do the same work (i.e., avoiding gaps and
overlaps).
 A process by which team leaders achieve
integrated pattern of group and individual
efforts.

39. Monitoring and Redirecting
39
 Monitoring: is a continuous, systematic and critical review of a
program or any of its components with the aim of checking
progress towards achievement of targets and taking timely
corrective actions.
 It is an ongoing collection and analysis of information to see if:
 Required resources are being availed and utilized
 Key activities are being carried out as planned
 Planned changes are happening at the target population
level
 Is important to:
 Identify problems
 Take corrective actions
 Assess trends
 Is the base for effective evaluation and it guarantees
efficiency.

40. Purpose of monitoring
40
 The main purpose of monitoring is to maintain work
standard by:
 Measuring performance and identify deficiencies
in set standards
 Tracing the cause of work deficiencies
(technical, administrative, personal or
organizational)
 Monitoring
 Helps to take early and timely correction if
deficiencies are encountered
 Provides guidance about how projects/programs
can be modified
 Identifies issues for evaluation or research

41. Steps in monitoring
41
1. Determine what to monitor – Key areas and purpose
2. Determine how to monitor
 Monitoring Plan, formats, data collection, sampling
techniques, reporting
3. Have standards to see if activities are completed as
planned (time frame specified, budget spent, quality
of care standards, management and work process)
4. Measure performance and compare with the
standard
5. Identify performance gaps
6. Investigate performance gaps to identify root causes
7. Look for potential solutions, prioritize and implement
corrective measures

42. Information sources for monitoring
42
 Information sources for monitoring include
but are not limited to:
 Reports and records
 On job supervision
 Checklists to observe performance
 Meeting and discussion with the staff
 Community/client surveys
 Complaints

43. Different Monitoring Activities
43
 Monitoring of inputs
 Monitoring of process
 Monitoring of outputs
 Monitoring of outcomes and impacts

44. Monitoring activities cont…
44
 Monitoring of inputs ensures that
 Staff is available (in accordance with the
assignment)
 Space, equipments, furniture and consumables
are available
 Resource consumption and costs are within
planned limits
 The required information is available
 Community groups or individuals are mobilized
as expected

45. Monitoring activities cont…
45
 Monitoring of process ensures that the
 Expected activities performed in accordance with
quality standards
 Meetings are held as planned
 Communication takes place as necessary
 Decisions are timely and appropriate
 Trainings are conducted as scheduled
 Conflicts are controlled

46. Monitoring activities cont…
46
 Monitoring of outputs ensures that the
The number/amount of products and
services are in line with planned targets
Number of children receiving vaccines
Number of patients treated

47. Monitoring activities cont…
47
 Monitoring of outcomes and impacts
ensures that the
 Expected program effects are being
achieved at the target population level
 Knowledge of people on Tuberculosis
 Prevalence of HIV
 Incidence of malaria

48. Supervision
48
 Supervision is a process of guiding, helping,
training, and encouraging staff to improve
their performance in order to provide high-
quality health services.
 It is the overall range of measures to ensure
that personnel and their organization carry out
their activities effectively and become more
competent at work.
 It helps to maintain and improve the quality of
health care

49. Styles of supervision
49
 Supervision could be conducted in three
different styles each having their own
strengths and weaknesses.
Autocratic
Democratic
Anarchic

50. Styles of supervision cont…
50
 Autocratic – characterized by the supervisors
approach “Do what I say!”
 Communication is usually one way – the
supervisor speaks and supervisee are expected
to listen
 Improvement actions are forwarded as orders
rather than agreed upon recommendations
 When applied to the health sector, it is
humiliating and dries up workers initiatives.
 Workers feel insecure

51. Styles of supervision cont…
51
 Democratic – characterized by the supervisors
approach “Let us agree on what we are going to do”
 Two way communication and participation of
supervisee in problem assessment and
improvement planning are its characteristics
 Helps people to grow, become responsible, and
show initiatives
 Recent recommendations for different health
systems with the name “Supportive/Facilitative
Supervision”

52. Styles of supervision cont…
52
 Anarchic – characterized by the supervisors
approach “Do what you like”
 Applicable to supervisees who are highly
skilled and responsible regarding their work.
 The choice of style should depend on the:
 Kind of work – complexity, difficulty, the need
for quick decision
 Kind of staff – Skill, reliability, experience, their
willingness to accept responsibility

53. schedule
53
 Decide how often it should be done and to which
area it is most needed
 In health systems practicing integrated supervision,
different departments/working units should be
involved in deciding how frequently and when to do
supervision
 Frequency of visits will depend on
 Nature of programs for supervision
 Level of expertise among supervisee
 Stage of the program development
 Availability of transport, personnel and other
resources

54. Preparation for supportive supervision
54
Reading assignment
 For better results, supervision should be
preceded by adequate preparation both by the
supervisor and supervisees.
 Preparations by supervisor
 Preparations by supervisee

55. Preparation by Supervisor
55
 Before each visit, the supervisor should:
 Review reports from previous supervisions
 Review routine reports for the reporting period prior to the
supervision to see performance gaps.
 Discuss with relevant experts on observed performance gaps
and actions to be taken
 Collect helpful publications, materials, and supplies for the
health facility.
 Prepare updates and/or refresher training to present during the
visit.
 Prepare a supervision checklist to be used during field work
 Arrange the necessary transport and logistics for the
supervision visit.
 Communicate with supervisee on the actual date of supervision
visit

56. Preparation by Supervisee
56
 In preparation for supervision, supervisees should:
 Review the previous supervisory report and
associated action plan developed during the last
supervision
 Review reports sent to the supervisor after the
previous supervision
 Review actions taken following recommendations
from previous supervision
 Conduct self-assessment on performances related
to areas for supervision
 Make sure that all relevant experts will be available
for the supervisory visit.

57. Conducting supervision
57
 Conducting supportive supervision involves the
application of different techniques with the
purpose of:
 Identifying gaps as compared to performance
and quality standards
 Motivating workers and creating common
vision for improvement
 Taking actions to build on strengths and correct
identified problems
 The supportive attitude of supervisors determines
the results achieved from supervision.
 Supervisors must always remember that
supervision is a helping process.

58. Steps in supportive supervision for health care
facilities
58
 Supervision to health care providing facilities
involves the following steps:
1. Introduction to the Process of Supervision Visit
2. Interview Appropriate Staff at Supervisee Level
3. Quality of Clinical Care Review
4. Review of performance reports
5. Referral System Review
6. Administration Review

59. Steps cont…
59
7. Community Involvement Review
8. Local Priority Health Issues and Related
Problems
9. Discussions and Problem Solving
10.Providing Constructive Feedback
 On site verbal feedback
 On site written feedback
 Immediate verbal feedback to other levels

60. Supervisory competences
60
 Technical competence in the field
 Supervisors must have solid technical knowledge
for the duties they are to perform and must know
how and where to gain access to additional
support.
 Quality improvement skills
 Team leading capacity
 joint problem solving, with full staff participation
and using simple, practical tools, will foster the
quality-improvement process
 Communication skills
 Supportive attitude and facilitative styles of
communication

61. Causes of Poor
Implementation
61
 Changes in priorities or policies from those
originally agreed
 A resistance to changes inherent in the plan
 Lack of necessary resources (personnel, funds,
relevant resources, poor timing of inputs)
 Lack of clear guidelines
 lack of appropriate organizational structure
 lack of appropriate managerial skills
 Unforeseen circumstances

62. 62
Questions???

63. 63
Thank you