• Editors' Summary
• Credits

1. Overview
2. Getting Started
3. Define Desired Performance
4. Describe Actual Performance
• Probing the Performance Factors
• Observation
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

Describe Actual Performance

The description of actual performance is needed to define the performance gap. The sources of information for describing actual performance comprise:

• Clinic records;
• Interviews or meetings with stakeholders, particularly the staff members whose performance is being analyzed, supervisors, and clients; and
• Observation of staff members.

Before investigating actual performance, PI facilitators review existing surveys, operations research, or clinic observation studies. These sources may save some time in gathering information, but they rarely have all the information needed to assess actual performance or the performance factors (88, 141).

A flowchart can help the PI facilitators to understand actual performance and to visualize desired performance as well. With information supplied by the staff member, the flowchart maps a job as a series of tasks and decision points, and it can reveal the reasons for problems. Long waiting times for clients, for example, may result from tasks that could be carried out at another point in the process or that may be unnecessary (70). In logistics, flowcharts have helped identify redundant tasks, wasted time, decisions that required more people than necessary, or decisions made without reference to standards or best practices (36).

Clinic records contain information such as number of clients who have received services, the outcome of their visits, and orders for equipment and supplies. The PI facilitators should know how the data were collected and how current and reliable they are. To respect the confidentiality of clients, clinic records should be reviewed by PI facilitators who are staff members rather than by consultants (102).

The PI facilitators should review records before conducting interviews or meetings with stakeholders. Knowing what the records contain, facilitators can formulate useful questions and avoid asking for information that they could obtain from the records. Asking stakeholders about some information in the records, however, can verify its accuracy. If records are incomplete or inaccurate, stakeholder interviews can supply missing information.

In interviews and meetings PI facilitators ask staff members to assess their actual performance with questions such as: What do you do during a normal work day? What services do you provide? Roughly how much time do you spend on your main tasks?

Staff members may present an inaccurate impression of their performance, making it sound better or worse than it is. In a clinic accreditation project in Brazil, for example, staff at some clinics said everything was fine, while staff at other clinics said the opposite. Role playing or showing a videotape to demonstrate good and poor performance can help providers assess themselves objectively (16).

The PI facilitators can check providers’ perceptions by observing them and by interviewing clients and community members. In the Nigeria needs assessment, for example, questions for clients in focus groups included: How would you describe the clinic environment? Your meeting with the family planning provider? If you had a friend interested in family planning, would you recommend that he/she go to this facility? Why or why not? Community members can answer similar questions based on their impression from talking to friends, relatives, or neighbors who have used the clinic (46). The PI facilitators should also ask family planning clients if they felt that providers had given them enough information to choose a contraceptive method with confidence.

Information from clients is not always reliable, however. Some clients are reluctant to criticize staff members who have higher status, or clients think that criticism would be impolite. Interviewing clients where they live rather than at the clinic can reduce this courtesy bias (145).

Interviews with staff members may uncover obstacles to the PI process itself. Providers who have not been paid in months, for example, have rejected efforts to improve their performance (4, 16).

Abdul Rashid Memon, Population Council In Pakistan a health worker interviews a group of women as part of a family planning research project. Clients and community members are important participants in the Performance Improvement process. Asking them what they expect and whether they are satisfied with services helps define desired perfomance and describe actual performance.