• Editors' Summary
• Credits

1. Overview
2. Getting Started
3. Define Desired Performance
• Performance Indicators
• Stakeholders
• Examples of 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

Define Desired Performance

When stakeholders define desired performance, they are describing the type of reproductive health services they would like. The PI facilitators select indicators of desired performance based on international or national standards and guidelines and information gathered in meetings or interviews with staff members, exemplary performers, clients, community groups, and other stakeholders.

Defining desired performance is one of the most useful steps of the PI process but also one of the most difficult and contentious steps. Many organizations can benefit from a systematic and thoughtful discussion of the desired performance of their staff members. Such discussion should involve all stakeholders in selecting clear objectives that, if possible, are measurable (101).

Defining desired performance gives some staff members their first opportunity to discuss what their job should be and how they contribute to their organization (36). The difficult part is persuading stakeholders to use observable and measurable indicators of performance. The facilitator usually needs to help with tactful questioning and clear examples of desired performance (63).

For jobs that involve clinical procedures with universally accepted standards, there is little room for debate on desired performance. For other jobs, however, stakeholders often disagree vehemently on desired performance, arguing, for example, that standards are being set too high or that achieving them will take too much time. Some stakeholders prefer realistic goals, while others favor ideal goals. Both approaches pose risks. Setting ideal goals can inspire staff members to try harder than they would with a realistic target, or else the higher target can be demoralizing because it seems unreachable. The choice between idealistic and realistic measures, or a mix of the two, is part of the consensus among stakeholders.

In the program working with private practitioners in India, for example, stakeholders first set desired performance at counseling 100% of women who might need family planning—women between the ages of 15 and 49 who were not using contraception. But when the PI facilitators found that providers actually were counseling fewer than half of such women, stakeholders decreased desired performance to counseling 75% of the women (88).

Self-assessment guides, such as those from the COPE process developed by EngenderHealth, can help define both desired and actual performance. Checklists for self-assessment cover all aspects of services, for example, quality of care, staffing, recordkeeping, and counseling (32–34, 92).

Indicators are objective measures of performance. They describe accomplishments that are observable, measurable, and under the control of the staff members whose performance is being measured. Desired performance, actual performance, and the performance gap should be defined with the same indicators.

Indicators are a key component of the PI process because they determine the amount and type of information that the PI facilitators must collect. Too many indicators, or indicators that require information that is difficult to find, will waste the facilitators’ time. For example, facilitators have found that some indicators require time-consuming travel and interviews, and they have replaced them with indicators that can be found more easily in clinic records (165). The PI facilitators consult with stakeholders to select an initial set of indicators. These may change as the facilitators collect more information.

Indicators for clinical skills, such as IUD insertion or infection prevention, are generally taken from international or national standards. For example, several indicators that a provider is prepared to insert an IUD are: washes hands with soap and clean water for at least 15 seconds, tells the woman what will happen and encourages questions, and conducts a pelvic exam (16, 103).

Studying the guidelines followed by other health care facilities or organizations, a practice known as benchmarking, is also useful for defining desired performance (98). Reviews of evidence-based best practices in reproductive health care, such as the WHO Reproductive Health Library distributed annually on diskette and CD-ROM, are also helpful (51, 116). Contact information for the library and for sources of information about the PI process, such as the International Society for Performance Improvement and the USAID-sponsored Performance Improvement Consultative Group, can be found on the Internet at http://www.populationreports.org/j52/j52boxes.stm#resources.