• 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
• To order copies
• CCP Home Page

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

Top-level managers are in a good position to initiate the PI process because they have a comprehensive view of the organization (143). If others initiate the process, however, top managers must at least endorse and support their efforts, and they should participate at key stages, such as defining desired performance.

Managing change—and especially the resistance that often accompanies change—is also a responsibility of management. Resistance may come from employees who fear that they will have to do more work without receiving more pay. Managers need to communicate a strong vision of the organization and an urgency for change. In making the decision to use the PI process, top managers also need to consider the qualifications of facilitators, staff time required, and cost.

Facilitating the PI process requires a thorough understanding of the methodology and good project management skills. In general, facilitators need to communicate well, build trust in the process, inspire people to participate, run meetings, negotiate, forge consensus, and mobilize staff and resources (129). They need to listen well and encourage civil discussion of often contentious issues. Facilitators need tact to dissuade stakeholders from prematurely assigning causes of performance problems and selecting solutions. They also need tact to persuade managers to give up some authority and allow decisions to be made by stakeholders.

One or two people can facilitate a small PI project, but a team may be required for larger projects. If possible, at least two people should facilitate the process so that they can compare insights and observations and share the work. The facilitators may change during the process as the skills needed for specific steps change. In the beginning facilitators are strong listeners, negotiators, and consensus-builders. At the end, to help organization staff members carry out and evaluate the solutions, facilitators may be asked to hire experts in such fields as performance appraisal procedures or performance incentives (129). In a program in Honduras to strengthen family planning and prenatal services, for example, stakeholders found that weak incentives caused a performance gap, and the facilitators selected a motivation and incentives team to address the problem (38).

Managers can appoint staff members or hire consultants to facilitate the PI process. A combination of staff members and consultants may work well in some organizations. On one hand, staff members know their organization and can suggest problems that could be addressed with the PI process (140). Also, stakeholders may prefer to work with people they know and who are always available, rather than with consultants who move on to their next job after a few weeks (154). On the other hand, consultants have expertise that stakeholders respect. They can more easily insist on carrying out each step of the PI process and resist pressure from stakeholders who want to rush through the process (121). They bring knowledge of performance problems at other organizations and solutions that have worked (101).

Moreover, with a fresh perspective, consultants sometimes can see problems that staff members have become accustomed to and no longer notice. As outsiders, consultants generally are less fearful than staff members about describing problems frankly (121), and they do not have relationships with stakeholders that might impede staff members’ work as facilitators.

Time and cost. The time required for the PI process depends mainly on the scale of the performance problem, the availability of stakeholders, and the priority they assign to solving the problem. In general, staff members need one to two weeks to learn to facilitate the process, and they need from one day to several weeks to observe actual performance (88). To strengthen the Zonal Training Centres in Tanzania, for example, the PI facilitators developed checklists and interview guides in meetings over five days, and they collected information on actual performance in four weeks during visits to the centers (135).

In the performance needs assessment, the main cost is time off the job for the stakeholders and staff facilitators. Meetings and observation also often entail travel and per diem costs. The better work, higher efficiency, and improved morale resulting from the PI process, however, can more than make up for the time spent.

Stakeholders often attend several meetings to discuss the performance problem, define desired performance, analyze root causes, and decide what to do. In a program in Yemen working with community midwives, for example, the PI facilitators took about one month to help stakeholders measure the performance gap, analyze root causes, and select solutions (141). In the Tanzania training center project the PI facilitator conducted stakeholder meetings over two months to agree on the performance problem, decide on the staff members whose improved performance could best solve the problem, define desired performance, select indicators and data sources, and design data collection tools. Stakeholders met again following collection and analysis of the data to discuss performance gaps and root causes and to decide what to do (135).

Used only for a performance needs assessment, the shortened PI process can be carried out in one meeting. In Ghana, for example, 22 stakeholders met for a half day to describe performance gaps in infection prevention, determine causes, and recommend solutions. The stakeholders represented the Ministry of Health, the Nursing and Midwives Council, medical schools, regional training centers, USAID, and development organizations working with USAID. Staff members of the ministry and JHPIEGO facilitated the meeting (20).

The time needed to carry out solutions depends on the scale of the project and the resources available. Procedures to communicate expectations or to assess performance in one department usually can be put in place in a few weeks. Writing policies or manuals often takes several months (26). In contrast, training for a national cadre of health care providers may require a year or more (131).

The cost of solutions depends on the root causes being addressed and the scale of the solutions. Strengthening knowledge and skills through training can be expensive, but providing a job aid, such as a chart or checklist, may be as effective and cost much less. Changing a policy, posting job expectations, or establishing an appraisal procedure for staff members need not be expensive. For example, the IDSS in the Dominican Republic set up a system of rating cards and suggestion boxes for clients to comment on their care at a cost about US$1,700 for design, production, training, and distribution to 12 health care facilities in two provinces (63, 119).

Budgeting for a project using the PI process can be carried out in two steps, since the cost of closing performance gaps is not known at the start of the process. The initial budget estimates the cost of measuring the performance gap, finding the root causes, and selecting potential solutions. Stakeholders and the PI facilitators may roughly estimate the cost of the potential solutions at this point, since cost is one criterion used to select solutions. Once stakeholders have selected solutions, PI facilitators and program managers can estimate their costs more precisely and complete the second part of the budget (42).