• 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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• 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

The PI facilitators also ask for information about the performance factors that will help in the root cause analysis (see Chapter 6). Typical questions include (102):

• Job expectations: Can you explain what is expected of you? Have you been given a job description? How do you find out what is expected of you?
• Feedback: How do you know when you are meeting job expectations? Do you get feedback orally and/or in writing? How often? From whom?
• Workspace, equipment, supplies: Do you have all the equipment or supplies you need to do your work? Have you requested material and supplies that you have not received? Do you have all the space you need, particularly private space? Is equipment maintained?
• Incentives: What happens if you do an outstanding job on a particular day? In your area how are decisions made about promotions, invitations to external training, or other opportunities? How can recognition for good performance be improved?
• Organizational support: How does the structure of the organization help your work or make it more difficult? How are the goals and strategies of the organization communicated to you? How are important decisions made and communicated to you? Are you getting enough help and guidance from your supervisor?
• Knowledge and skills: How much of your training do you use on the job? Would on-the-job reminders help you with certain tasks? Would you do a better job if you knew you would receive an extraordinary reward or recognition?

These questions may yield a long list of causes from which stakeholders select the few vital root causes.

To encourage truthfulness, PI facilitators can question staff members and supervisors, or nurses and doctors, in separate groups. When answering questions about expectations or performance assessments, staff members may not feel free to criticize supervisors if they are in the room (165).

Observation of staff members at work is an indispensable source of information about actual performance. Observers need to be unobtrusive to avoid disturbing staff members, some of whom may never have been observed before (75).

To obtain a complete impression of actual performance, observers pay attention to the operation of the clinic or office as a whole (the organizational level of performance) and to the work of individual staff members. In the Nigeria needs assessment, for example, observers noted problems at the clinics in planning and goal setting, supervision, record keeping, and equipment and supplies. Problems among providers were in interpersonal skills, use of service statistics, and adherence to infection prevention procedures (46).

Checklists help observers attend to all the performance indicators. Checklists of clinic operation may cover equipment and supplies, the presence of guidelines, the quality of clinic records, information provided in counseling, and the attitude of providers and other staff members.

Observation has limitations. Some staff members feel anxious or threatened when they are observed and thus do not perform as usual. Obtaining permission from staff members and discussing the PI process and the project before the observation can help to reduce anxiety. Staff members are reassured if they have worked with someone on the observation team. In the training program in Tanzania, for example, the PI facilitators included a senior staff member from the human resources division of the Ministry of Health, who had met the staff of the Zonal Training Centres (165). Also helpful for observers is dressing like clinic staff to be inconspicuous (16), staying long enough that staff members become accustomed to being observed (106), and explaining to staff members that they are not being rated and that the observation will not affect their salaries.

Using simulated, or mystery, clients to collect information avoids some of these observation problems but can create other problems (60, 81, 93). Simulated clients need to be keen observers with a good memory and the ability to play a role. Training people to pose as clients can be time-consuming, sometimes requiring several weeks (93, 96). Also, using simulated clients raises ethical problems of deceiving providers and breaking down trust between staff members and management (93, 106).

Observer bias or disagreement may also be a problem. Two observers may differ in their interpretation of the same behavior (78, 81, 106). In a study in Peru simulated clients were inconsistent in overall ratings of providers but were more reliable at observing specific behaviors and recording them on checklists after their appointments (81). Training in observation methods and memory aids, or else using tape recorders can improve the accuracy of information (93, 106).