• Editors' Summary
• Credits

1. Overview
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
• Clarifying Expectations
• Feedback
• Adequate Workspace, Equipment, and Supplies
• Incentives
• Organizational Support
• Knowledge and Skills
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

Implement Interventions

Stakeholders can draw from the worldwide experience of programs and research to solve performance problems. The Performance Improvement literature, the reproductive health literature, and the medical literature suggest ways to address weaknesses in the six performance factors.

Carrying out the solutions to performance problems requires good project management skills. The staff members who carry out the solutions—usually with help from facilitators—plan, schedule, budget, coordinate, and keep people informed. Managers often participate in implementation because they have project management skills and they are ultimately responsible for the outcome of the process. If necessary, managers or facilitators invite individuals or organizations with expertise in the interventions, for example, in training, communication, or logistics, to help with implementation (129). Implementers also plan the evaluation of the solutions and the organizational changes that will help to initiate and sustain the solutions.

Marc Luoma, PRIME Project Indian private health care providers participated in a project to counsel more clients and improve family planning services. Using the PI process, stakeholders found lack of incentives for counseling to be a key problem.

A variety of approaches can help to clarify job expectations—for example, distribution of guidelines with training, accreditation programs, clear job descriptions, posters, prompting providers before a client visit, messages from management, discussions with respected peers, community involvement, and mass media promotion.

Guidelines with training. To clarify job expectations, organizations typically distribute guidelines and expect staff members to read and follow them. Distribution of guidelines alone is usually not enough, however. The materials must be reinforced through training or performance appraisal (24, 52, 59, 91, 118, 149).

One of the few programs that has measured the effectiveness and cost of dissemination of guidelines and training was carried out in 1999 by the Kenya Ministry of Health. Two thousand providers received revised guidelines and training in 1999—274 were trained directly, and about 1,700 were subsequently trained at their clinics by the 274 trainees. Materials to help providers train their coworkers increased scores slightly on 38 indicators at a cost of about US$12 per provider. Adding supervision for 54 providers to reinforce their training increased scores by a factor of nine over training alone at a cost of about US$377 per provider (149).

Accreditation. An accreditation program clarifies expectations by specifying the changes that clinics need to make to satisfy accreditation standards. Such programs are being carried out in Brazil, Egypt, Guatemala, Honduras, Malawi, and other countries (16, 44, 69, 99, 126).

Job descriptions. Written with care, job descriptions specify the contribution that the job makes to organizational goals, the main product or service produced by the job (for example, community-based family planning services), the accomplishments of the job (helping clients choose and use contraceptives), the tasks that the employee must carry out (visiting clients in their homes), and rates or quantities (clients will be visited at least once every month) (102). Such job descriptions also help managers hire or promote employees who can fulfill job expectations (80).

Posters or brochures. Hanging posters where staff members work, or distributing brochures helps to remind staff members what is expected of them (91). The IPPF wall chart listing clients’ rights and providers’ needs, for example, is displayed in the offices of most IPPF affiliates (146).

Prompts for providers. Sheets attached to client files that list tests or procedures to perform have helped British and US doctors improve compliance with guidelines. Also helpful has been giving clients cards listing the services that they should receive, which they give to providers as a prompt during their visit. Doctors comply better when the prompts list instructions specific to a patient rather than general instructions (24, 31, 52, 53).

Messages from top management. In the Dominican Republic a letter from the central office of the IDSS informed the staff of health centers that they were expected to offer five reproductive health services: family planning, maternal and child health care, prevention and treatment of HIV/AIDS and other sexually transmitted infections, breastfeeding promotion, and detection of breast and uterine/cervical cancer and referral for treatment. The letter helped reduce a gap in providers’ knowledge of reproductive health services (63, 91).

Discussions with respected peers. When they discuss proper care in small groups or with individual providers, respected peers can be persuasive (6, 24). Personal visits from peers, known as educational detailing or academic detailing, have helped to improve US physicians’ prescribing practices (117).

Community involvement. A close relationship between health care providers and communities can lead to honest dialogue and better understanding of each other’s expectations and needs (8, 28, 34, 57, 99, 169). For example, in the “Building Bridges for Quality” project in Peru, begun in 1998 and carried out by the Peru Ministry of Health, providers and community groups produced videos portraying their ideal of health care and their impression of the care that is actually provided. Providers toured the communities they serve, community members toured the health center, and together they made plans to improve health services so that providers meet clients’ expectations and clients meet providers’ expectations (8, 57). The communities now feel that providers are more attentive to and respectful of clients, and providers say that community members know more about the health services and ask to be educated about health care (7).

Mass media. Skilled and attentive providers have been portrayed in the mass media to show providers the level of care that they are expected to offer and to show clients the care that they can expect to receive. This approach has been used in several countries, for example, Brazil, Egypt, Ghana, Indonesia, and Nepal (19, 67, 68, 126).