New roles and responsibilities. New approaches have broadened and improved the supervisor's role in quality management. In conventional supervision systems the supervisor plays the role of inspector, using checklists to assess staff performance (11, 26). Checklists can focus supervisors' attention on quality issues, help them identify specific areas of weakness, and prompt them to give immediate feedback to staff (184, 296).

The supervisor's role can go beyond inspection, however, to include supporting and guiding front-line workers. Supervisors can reduce subordinates' fears and develop more trusting relationships. They can help the staff solve problems, coach and motivate workers, provide liaison with upper management, and serve as advocates—for example, helping to obtain needed supplies, training, or infrastructure (15, 26). Thinking of subordinates as internal clients fosters a more productive approach to supervision (98) (see Chapter 3.6, Providers as Internal Clients).

The concepts of facilitative supervision and team supervision, which have been championed by AVSC International and Family Planning Management Development, respectively, apply these new supervisory approaches (15, 25, 26) (see box, Resources for Quality Control). Both link periodic visits by a supervisor with continuous self-improvement efforts by clinic staff. These approaches require supervisory visits lasting days rather than hours, but the extra time allows supervisors to improve the quality of care, not just rate it (25). Where limited resources preclude this type of external supervision, a staff member at the site may assume supervisory functions.

During a visit to a facility, the supervisor not only carries out the usual monitoring tasks—reviewing records, touring the facility, observing consultations, and interviewing clients—but also leads a staff meeting to discuss areas that need improvement and to develop recommendations. In Honduras, for example, the supervisor and staff make a written commitment, or compromiso, that spells out who will correct problems and when action will be taken (26).

To take on more supportive roles, supervisors need the full support of top management (331). Organizations should find ways to reward supervisors who take their responsibilities for quality improvement seriously (11, 124, 334). Training is crucial to teach supervisors the necessary problem-solving, listening, and coaching skills (25).