• 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

A number of studies and programs have tested ways to provide people with information about their job performance. To encourage more frequent performance appraisal, organizations have worked with supervisors to present quantitative feedback, encouraged comments from clients, or encouraged providers to assess themselves and their coworkers.

Quantitative feedback. Organizations have trained supervisors to evaluate staff members with checklists and to provide detailed and quantitative appraisals (15, 22). For example, a program in Burkina Faso, carried out in 1994 by the Programme Elargi de Vaccination (Expanded Program on Immunization) and the Ministry of Health, used quantitative feedback to promote vaccinations against measles. Six months after a workshop to train health workers in communication skills, supervisors visited clinics and observed the health workers, pointed out weaknesses, and helped with solutions. Supervisors prepared bar charts on transparencies that, when laid on top of each other, allowed a health worker to compare her current performance with her previous performance and the averages for coworkers and a control group. The health workers appreciated the quantitative feedback and they were motivated to improve skills that had declined since their training, such as providing information to mothers about caring for children with measles, arranging return visits for vaccinations, and responding to questions (15).

Observation, presentation, and discussion. A program in Niger introduced Integrated Management of Childhood Illness (IMCI) in 1997 and 1998 by training providers and then observing and discussing their performance with them. Observers presented their appraisals to providers in a workshop. Providers then discussed the appraisals in small groups with the help of a facilitator. After being appraised, providers were better at some of the tasks, such as recognizing symptoms of severe illness and malnutrition and finding out about vaccination history, but the improvements were not sustained after eight months. Also, counseling skills declined despite the feedback. The cost of the appraisal system was US$108 per provider. Adding an average of 11 days of training had a larger and more comprehensive impact on skills, but cost a total of about US$430 per provider (72).

Surya B. Shrestha for JHU/CCP In Nepal health workers listen to a distance education series broadcast on radio. The main approaches to improving knowledge and skills are in-service training and preservice education. Job aids such as checklists or flowcharts also can offer guidance.

Comments from clients. In the Dominican Republic the IDSS set up suggestion boxes and offered comment cards asking clients to rate their care on friendliness, privacy and confidentiality, communication, and problem-solving (see Figure 5). Each week the responses were collected, and the directors of the health centers discussed them in staff meetings or with any providers whom clients mentioned by name. Stakeholders said that the comments influenced providers to take better care of clients and, as a result, clients were more satisfied with services, and providers were happier in their work (91). The system was not sustained, however, because of administrative problems (119).

In Peru, Max Salud, a private, nonprofit health care organization, set up a system in 1998 and 1999 with six ways of collecting comments from clients: 10-minute exit interviews in the waiting room or just outside the clinic; follow-up visits to clients at home; focus-group discussions that were tape recorded with clients’ permission; household interviews of people who had stopped using services; suggestion boxes; and community meetings. Among the lessons learned were that clients were overly polite during exit interviews but more willing to be critical when they were interviewed at home. Also, comments from clients should be distributed to providers as soon as possible so that they can respond quickly, and comments should be collected frequently because clients’ expectations change. The study found that suggestion boxes were the least costly method of collecting clients’ comments (145).

Self-assessment. A study in Indonesia conducted by the State Ministry of Population/National Family Planning Coordinating Board (BKKBN) evaluated the effect of self-assessment and peer review on counseling skills following a training workshop. Providers used self-assessment forms to evaluate their counseling skills daily for 16 weeks. They also assessed the clients’ behavior and their influence on clients. Also some providers met weekly in groups of three or four to discuss their performance.

The assessments helped the providers remember what they learned in the workshop, clarify performance standards, and recognize and work on weaknesses. Four months after the training, providers who had training reinforced with self-assessment had better counseling skills than a control group. For example, they gave more information and built better rapport with clients, and their clients talked more and were more satisfied with the counseling. Discussion with peers further enhanced counseling skills but did not increase clients’ satisfaction (74).