A Step-by-Step Process to Strengthen Performance

Consider the institutional context of the performance problem and get stakeholder agreement. Facilitators examine the mission, goals, strategies, and culture of the organization, and the perspectives of clients and communities. They foster and maintain stakeholder agreement on the objective of the PI process and the plans for addressing the performance problem.

Define desired performance in measurable terms if possible. Desired performance takes into account international or national standards and the perspective of stakeholders. The description of desired performance creates a manageable set of objectives for the process.

Describe actual performance. The description of actual performance is based on observations and interviews of staff members and clients and on reviews of clinic records and other documents.

Measure or describe the performance gap. The difference between desired and actual performance is the performance gap.

Find the root causes of the performance gap. Stakeholders discuss the reasons for the gap and identify the most basic reasons, or root causes. Most root causes can be linked to factors that help people do their work: job expectations; performance feedback (including formal performance appraisals, comments from supervisors, coworkers, or clients, or self-assessments); workspace, supplies, or equipment; incentives; organizational support; and knowledge or skills (see side-bar, Performance Factors). Reproductive health organizations have identified weaknesses in all the performance factors, but most often in knowledge and skills, expectations, and supplies and equipment (128). Linking the root causes of performance gaps to specific factors helps stakeholders generate solutions that address the root causes.

Select interventions. Stakeholders generate ideas for solutions that address the root causes of performance gaps and the related performance factors. These solutions can be drawn from reviews of best practices. Then stakeholders rank and select these interventions according to cost, benefit, or other criteria.

Implement interventions. The staff members or consultants who carry out the solutions need good project management skills—planning, scheduling, budgeting, hiring, supervising, and reporting (49, 159).

Monitor and evaluate performance. Staff members or consultants keep the solutions on track and guide the organizational changes required to support and sustain the solutions, usually with the help of top management. To evaluate performance, they observe actual performance again and remeasure the performance gap to see the effect of the solutions.

The PI process can be used in cycles. The performance observed and evaluated at the end of the first cycle becomes the actual performance of the next cycle.

Benefits of Performance Improvement

Performance Improvement offers a number of advantages for organizations seeking to improve reproductive health services. Performance Improvement is:

Inclusive

• Involves everyone who has a stake in improving performance, including clients and communities. The stakeholders play the central role in Performance Improvement (102, 124).
• Directs staff members to articulate what their job is, what it should be, and how they contribute to the goals of their organization (142).
• Encourages staff members and supervisors to agree on measures of performance (102, 142).
• Encourages organizations and government agencies to pool expertise and work together to analyze and solve performance problems (46, 91, 165).

Logical and systematic

• Begins with discussion among stakeholders to describe the problem and agree on desired performance (102).
• Proceeds step by step from analysis of performance gaps and causes to design and selection of solutions, implementation, and evaluation (102, 124, 159).
• Discourages jumping to conclusions about the causes of performance gaps and possible solutions (48, 94, 142, 159).
• Guides stakeholders to look for causes in all facets of an organization—structure, goals, management, resource allocation, and work processes—and not only in the performance of staff members (1, 94, 142, 159).

Empirical

• Requires observation and research to understand performance problems and measure performance gaps (46, 91, 102, 140).
• Guides stakeholders to solutions based on experience and best practices (162).
• Focuses on results rather than behavior or effort (46).
• Offers an objective, measurable way to evaluate interventions by comparing results with the stakeholders’ original desired performance (46, 91, 102).

Analytical

• Directs stakeholders to look beneath the surface and dig for the root causes of performance problems (102, 124, 159).
• Encourages managers to consider other solutions to performance problems besides training (41, 94, 102, 142).

Empowering

• Encourages staff members to look beyond causes that they can do nothing about, find causes that they can address, and take improvement of services into their own hands (63).

A PI Case Study: The Dominican Social Security Institute

The Dominican Social Security Institute (IDSS) carried out a pilot project using Performance Improvement in 1998 and 1999 to respond to clients’ requests for improved reproductive health services. To describe the performance gaps, facilitators interviewed health center directors, service providers, and managers in the IDSS and conducted focus-group discussions with clients. The facilitators, members of the PRIME project, identified six performance gaps. A group of 26 stakeholders—providers, directors, regional supervisors, and others —met to rank the gaps, analyze causes, and decide what to do.

The stakeholders decided that a gap in considerate treatment of clients had highest priority. To quantify the gap, facilitators developed a questionnaire with 12 indicators of considerate treatment and carried out a baseline survey in which clients and observers rated providers. Clients found that providers did not perform an average of 5 of the 12 indicators, and observers found that providers did not perform an average of 8 of the indicators.

Investigating the root causes, stakeholders decided that providers were not evaluated on their treatment of clients (through job expectations and performance appraisals), were not rewarded for treating clients considerately (incentives), and did not know how to treat clients considerately (knowledge and skills). Stakeholders selected six possible ways to address the root causes and estimated cost-and-benefit ratios for each (91, 120). The stakeholders’ work can be summarized in a Performance Improvement specification form (see Figure 2).

Closing the Gap

To clarify expectations, a 10-member stakeholder committee developed guidelines for considerate treatment. Using findings from focus-group discussions with clients, the committee identified four components of considerate treatment: friendliness, privacy and confidentiality, providing adequate information, and problem-solving.

Approximately 50 providers reviewed and approved the guidelines (91). The IDSS produced a poster of the guidelines to inform both providers and clients about the new expectations for considerate treatment. The guidelines were also used in a training curriculum and on a card for clients to comment on their treatment by providers (55, 63, 91).

To encourage comments from clients, a consultant distributed suggestion boxes and rating cards to each health facility and provided instruction in their use. Also, a letter to clients from the general director of the IDSS—placed next to the suggestion boxes or handed to clients along with the rating cards—described the intent to improve treatment of clients and invited clients to comment (63).

To improve providers’ knowledge and skills, an instructional designer and an expert in reproductive health designed a five- day training-of-trainers workshop and a 21/2-day workshop for providers. The training strengthened expectations by showing providers good and bad examples of counseling. Providers were asked to assess their own counseling in comparison, and they had an opportunity to practice counseling skills (63).

The performance gap decreased significantly in one province, San Cristóbal, where all of the solutions were carried out (see Chapter 9.1). Stakeholders thought that the training had the largest impact on the performance gap but that clients’ comments led to important changes in the way providers viewed clients: Providers understood clients better and were concerned that clients were satisfied with services. One hospital director said that his hospital increased its clientele by almost a factor of four because of improvements inspired by clients’ comments (91).

Assessing Organizational Change

The PI facilitators asked IDSS staff members to assess organizational changes and institutional capacity to support the changes in provider performance. Among the 20 indicators were support for reproductive health from top managers; up-to-date training materials, supplies, and equipment; and community involvement in decisions about reproductive health services. Ranking the 20 indicators from 1 (no capacity) to 4 (full capacity), IDSS staff members concluded that institutional capacity had increased an average of one full point, from 1.3 before the project to 2.3 after the project (91).

Performance Factors

Both the personal qualities an individual brings to the job and the working environment of the organization determine performance. Personal qualities comprise knowledge, skills, capacity, and motives. Environmental factors comprise job expectations, performance feedback, workspace and equipment, and incentives (48).

Facilitators in reproductive health programs in developing countries have linked root causes of performance problems to six performance factors (102):

• Job expectations,
• Performance feedback,
• Workspace, equipment, and supplies,
• Incentives,
• Organizational support, and
• Knowledge and skills.

These factors are similar to the needs of providers identified by the International Planned Parenthood Federation (IPPF), for example, guidance, feedback, infrastructure, supplies, encouragement, and training (58).

The order of the factors indicates how difficult they are to correct. For example, fixing unclear job expectations is usually easier and less costly than training (94, 102, 150, 153). PI practitioners debate the list of performance factors. Capacity—which refers to intelligence, talent, and physical ability (48)—is not included because in developing countries the solution to a capacity problem, telling or encouraging people to leave jobs, is difficult (84, 101). Some practitioners include capacity, however, arguing that it can be taken into account in hiring or in moving people to jobs that suit them better (2, 17).

Incentives, culture, and organizational support are also debated. One prominent PI practitioner leaves incentives off the list, arguing that an employee in a job with all the other factors in place cannot fail to be motivated (142). Another would include cultural practices that affect performance (115). Some leave organizational support off the list, arguing that organizations support performance by attending to the other five performance factors (127).

Job expectations. To perform well, employees need to know what is expected of them and how they will be evaluated. Expectations comprise the objective of their job, the tasks they must carry out—with measurable quantities and rates—and where, when, and with whom they must work.

Many employees are unsure about what is expected of them (45, 73, 137). Some may not be able to state the goals of their organization and how their job contributes to the goals or what their responsibilities are (107). Many employees work without formal job descriptions (5, 38, 46), instead learning by watching or talking to colleagues. Some have unclear or imprecise job descriptions.

Performance feedback. Employees need to know how they are doing in comparison with the expectations for their job. Employees find out if they are meeting or falling short of expectations through oral or written information from supervisors, coworkers, or clients.

Personal, cultural, and organizational factors can prevent employees from receiving useful appraisals of their performance. Afraid of offending, supervisors typically praise employees and tell them to “keep up the good work,” without going into specifics. The culture of an organization or national customs sometimes preclude confronting employees directly about performance problems (100, 101, 144). In some Asian and Latin American countries, for example, employees are judged on their personal characteristics such as integrity and loyalty and would be offended by judgments based solely on their performance (144). Some supervisors have trouble giving feedback because they have never done the work of the people they are supervising. Encouraging self-assessment can help in this case (101).

Performance appraisal is a skill that needs to be learned and practiced. Ideally, appraisals should be honest and timely, precise and specific, private, provided with an opportunity for self-evaluation, and delivered without interruption. Employees should receive information about their performance often—weekly or even daily for new employees and once a month for long-term employees (125). For many organizations, however, any systematic performance appraisal would be an improvement. Infrequent feedback and unclear job expectations together are the most common causes of performance problems in US corporations (48, 150).

Workspace, equipment, and supplies. The space in which employees work and the equipment and supplies they need to do their jobs comprise the physical environment. The workspace should be easy and safe to work in. Distractions and inconveniences—for example, noise or inaccessible supplies—require staff to adapt. Some adaptation can be challenging and motivating, but, if employees spend too much time and energy overcoming inconveniences, performance inevitably suffers (71).

Liz Gilbert, Courtesy of the David and Lucile Packard Foundation In the Philippines a clinical staff member uses a microscope in the laboratory. Both the organizational working environment and a worker’s personal qualities determine job performance. Six factors are key: job expectations, feedback, supplies and equipment, incentives, organizational support, and knowledge.

Incentives. Motivation results from both external incentives and a person’s internal motives for doing a job (48). Typical causes of low motivation are poor pay, poor working conditions, and no opportunity for advancement. Lacking incentives, many people do not give full effort. In US surveys of worker productivity, only about 25% of people say that they work as hard as they could. Most say they work at about two-thirds of their potential or only hard enough to hold onto their jobs (14, 40).

Tradition and culture influence the use of incentives. Many organizations reward employees for time on the job rather than for good performance, and the reward is often the opportunity to attend training programs. Also, offering more money as an incentive for individuals may not be effective in countries, such as Denmark and Japan, where work in teams is encouraged by equal pay among team members (144).

Organizational support. To help employees do their best work, managers are responsible for setting up supportive organizational structures, strategies, and work processes. For example, managers create and communicate a clear mission and goals for the organization, provide inspiring and effective leadership, design job roles that align with the organization’s goals, develop clear lines of authority, and encourage open communication up and down the hierarchy (27, 77, 95, 142, 169).

Knowledge and skills. People acquire knowledge and skills for reproductive health care in preservice education and in-service training. They attend professional schools of management, public health, or nursing and midwifery, for example, or they learn on the job.

Employees lack the knowledge or skills to do their jobs well for a variety of reasons. They may have been hired for or promoted into a job they were not trained for. They are unaware of changes in protocols or guidelines, they had poor training in professional schools, or they forgot information or skills from lack of use.

Performance Needs Assessment: Burkina Faso

A district management team (DMT) in Koupéla, Burkina Faso, conducted a five-day workshop that used Performance Improvement to address problems in the team’s support of maternal and neonatal health care. The workshop also prepared DMT members to introduce the PI process to providers at the district health centers. The DMT is responsible for planning, supervising, and reporting on health care activities in the district, including in-service training, provision of equipment, and financial and personnel management. Seven members of the DMT, an instructor at the National School of Midwifery, and a trainer attended the workshop in December 2000.

Workshop participants reviewed the PI process and carried out its steps through the analysis of root causes and the generation of solutions. They identified five roles for the DMT, indicators for each role, and desired performance for each indicator. The five areas and sample indicators included:

• Identify problems in maternal and neonatal care. Assemble members of the DMT and any experts needed, present problems, and analyze causes.
• Carry out projects on schedule. Create the schedule of projects, write briefing notes at least two weeks before each project, and deposit funds at least 72 working hours before the project.
• Conduct quarterly supervision visits to the health centers. Hold an introductory meeting with staff of the health center, check that the recommendations of previous supervisory visits have been carried out, discuss problems and solutions with staff and community members, and encourage and thank the staff.
• Write a report summarizing the supervisory visit. Discuss ob-jectives, methodology, activities, results, and recommendations.
• Distribute the report to the regional directorate.

The team described actual performance and identified performance gaps. For example, the team did not write briefing notes two weeks in advance of projects; deposit funds at least 72 hours before a project; conduct supervisory visits four times a year, or even twice a year; invite members of the community to discuss the visit; or write a summary report.

Analyzing the root causes of the performance gaps, the PI team found that many were linked to lack of organizational support. For example, the gap in supervision had several root causes. The few supervisory teams could not visit the large number of health centers every quarter, and the schedule for supervision did not always take into account the availability of supervisors (organizational support); teams could not travel to some centers during the rainy season because roads and vehicles were in bad condition (equipment); supervision was not a priority for the DMT, it was not well organized, and members lacked skills (expectations, skills/knowledge).

To address these root causes, the workshop participants focused on training to improve skills and strengthen expectations. The participants recommended: (1) evaluating the needs of members of the DMT for training in supervision, (2) planning and developing a training program, and (3) following up the members who were trained (66).

Performance Improvement in the Private Sector: India

Stakeholders in Uttar Pradesh, India, used Performance Improvement to find ways to encourage private providers to offer better family planning services and to identify more clients who need family planning services. Indigenous Systems of Medicine (ISM) practitioners use a combination of traditional and modern medicine and provide most curative services in rural areas of Uttar Pradesh (90, 133). They charge clients for medicine and other supplies but not for time spent counseling.

From 1995 to 1999 the State Innovations in Family Planning Services Agency (SIFPSA) and local district organizations trained ISM practitioners to counsel about family planning and to provide oral contraceptives and condoms. Stakeholders felt that despite the training, ISM practitioners were not counseling as many women as they could about family planning.

PI facilitators then carried out a performance needs assessment in 1999. They developed indicators for the quantity and quality of family planning services offered by the practitioners. The main quantitative indicator was the proportion of clients possibly needing family planning services whom the practitioner identifies and counsels. The main qualitative indicator was the adherence of practitioners to an observation checklist, which included items about clinic settings and counseling skills. The PI team found that practitioners counseled less than half of eligible clients. Stakehold-ers set desired performance at a realistic goal: counseling for 75% of eligible clients. The performance gap was the 25% or more of eligible clients whom the practitioners did not identify and counsel.

The main root cause of the performance gap was the loss of income by practitioners when they counseled clients—on average for 10 minutes per visit (incentive). Other root causes were the absence of a reliable source for condoms and oral contraceptives (supplies) and lack of awareness to counsel every eligible client (expectations). Some did not know how to counsel or how to identify eligible clients (knowledge/skills). Communities did not know that the practitioners offered family planning services because practitioners did not promote or market their services (expectations, knowledge, skills).

To solve the counseling problem, stakeholders suggested several initiatives to make selling contraceptives more profitable. They ranked them on a 10-point cost-and-benefit scale. Among the highest ranked solutions were:

1. Make sure during the training program that practitioners know they should provide family planning counseling.
2. Give an initial supply of contraceptives at the end of the training program.
3. Make training more selective to increase the status of ISM practitioners who provide family planning services.
4. Promote services in the community, particularly to elderly women who have great influence on family decisions.
5. Identify wholesalers, distributors, and other sources of contraceptives for the practitioners.
6. Train the ISM practitioners in marketing (90).

Figures for the current percentage of eligible clients being counseled are not available. Quality of care seems to be high: Simulated clients and self-reporting show that 80% of the practitioners are meeting the criteria for good counseling (88, 133).