• Editors' Summary
• Credits

1. Overview
• The PI Process
• Applying the PI Process
• Managing the PI Process
• Performance Improvement, Quality Improvement, and MAQ
2. Getting Started
3. Define Desired Performance
4. Describe Actual Performance
5. Measure/Describe Performance Gaps
6. Find the Root Causes
7. Select Interventions
8. Implement Interventions
9. Monitor and Evaluate Performance
10. Managing Change

• Figures
• Tables
• Side-bars
• Bibliography

• PI approach offers many benefits
• Pilot project holds lessons
• Helping people do their best
• Burkina Faso: Assessing needs
• India: PI helps private providers
• Using the “Why Tree” in Ghana

• POPLINE
• Media/Materials Clearinghouse
• Other issues
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Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA

Performance Improvement encourages an understanding of the organization as a system of interdependent functions and people. The system responds to influences from the environment—particularly the needs of its clients—and turns resources into products or services. In a well-run organization there is alignment of structure, goals, and strategies with the processes through which work gets done and the performance of staff members (142).

The focus on job performance is essential. Performance is not behavior or knowledge but rather the results of behavior and knowledge. In most cases performance can be measured (48). Performance problems usually indicate weaknesses in the support that organizations provide to their staff members, rather than problems with staff members themselves (48, 142). Performance Improvement guides organizations in viewing problems systemically and addressing all the areas that enhance performance.

Performance Improvement is inclusive. Everyone participates who is affected by the performance problem or has an interest in solving it. These participants are called stakeholders, and chief among them are the staff members themselves and the clients they serve. Other stakeholders often include top managers of the organization, supervisors of the staff members, community representatives, government officials, and donors. Stakeholders usually need help from facilitators, people who have had training or experience with Performance Improvement.

In reproductive health care PI facilitators use a step-by-step process (see Figure 1). Performance Improvement has a variety of benefits (see side-bar, Benefits of Performance Improvement). Many organizational problems have causes that would not be uncovered without the systematic and comprehensive thinking encouraged by the PI process. The step-by-step process of Performance Improvement helps stakeholders to organize and analyze information before deciding what to do. It discourages guessing about the causes of performance problems or choosing solutions prematurely. Without such a process, managers may unfairly blame staff members for performance problems, suggest an ineffective solution, or suggest one solution when several are necessary (4, 63, 101, 141).

Since 1998 reproductive health care organizations in over a dozen countries have used Performance Improvement to address job-related problems involving service providers, supervisors, support staff, logistics staff, and trainers (see Table 1) (46, 79, 91, 130, 131, 135). The PI process helped these organizations:

• Respond to requests from clients for improved services —and particularly more considerate treatment—in the Dominican Republic. The Dominican Social Security Institute (IDSS) is one of the few organizations that has used the PI process from start to finish to improve reproductive health services (see side-bar, A PI Case Study: The Dominican Social Security Institute).
• Find out why providers in Ghana were not following guidelines for infection prevention despite their training.
• Decentralize health services in Tanzania by strengthening Zonal Training Centres.
• Explore why providers in Kenya, who were trained to offer postabortion care, were not using their skills.
• Perform national needs assessments for reproductive health care, examine organizational performance problems, and decide on priorities in Armenia, Burkina Faso (see side-bar, Performance Needs Assessment: Burkina Faso), Nigeria, and Tanzania.
• Determine qualifications and organizational support for new community-based distributors in Burkina Faso.
• Improve preservice clinical training at schools of midwifery in Ghana.
• Identify barriers to provision of services by community midwives in Yemen.
• Design incentives for private practitioners in India to counsel clients about their needs for family planning and to provide services (see side-bar, Performance Improvement in the Private Sector: India).

The PI process has also encouraged cooperating agencies of the US Agency for International Development (USAID) to collaborate in analyzing performance gaps and root causes and in generating and carrying out solutions in their areas of expertise, for example, communication, logistics, management, and training (46, 91, 120, 135, 136).