• 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
• 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

To strengthen organizational support for the performance of their employees, managers should attend to the other performance factors, such as expectations, equipment, and incentives. They can also:

• Clarify and communicate the organizational mission, develop a work strategy to fulfill the mission, and ensure that the organizational structure—the lines of authority and allocation of resources—supports the strategy (13, 95, 142).
• Involve office staff in efforts to increase adherence to guidelines. Patients of US doctors received better services when, for example, office staff provided information and supportive comments as part of a smoking cessation campaign (24).
• Set up a supportive supervision system that encourages suggestions and problem-solving by staff members at all levels of the organization (11, 22). For example, ASHONPLAFA, a private family planning organization in Honduras, strengthened its supervision system in 1999 and 2000 by combining more support by supervisors—standard setting, planning meetings, feedback and evaluation, field visits, and recognition for good performance—with encouragement for employees to monitor themselves (26).

Strengthening preservice education or conducting in-service training are the main approaches to improving knowledge and skills. Job aids such as checklists or flowcharts also help by providing information or guidance as people work, but training to use job aids is usually necessary (30, 76).

Training in reproductive health care emphasizes transfer of learning to the workplace and the demonstration of competency by trainees (65, 132, 152). Transfer of learning is difficult. In general, participants in training programs use only 10–20% of what they learn on the job because the training was poorly designed or because they receive no support for changing the way they work (150). Trainers, subject matter experts, and PI practitioners are working together to improve the effectiveness of education in reproductive health care.

Strengthening preservice education can have a larger and more lasting effect than in-service training. Preservice education influences more people, and the knowledge and skills learned in professional schools determine the practices of many students throughout their careers. Lessons learned from programs to strengthen preservice education in the Philippines and Turkey, for example, include the importance of recruiting a strong advocate for change in the schools and forging a close relationship between the professional schools and the clinical practice sites (171).

In-service training refreshes knowledge and skills or introduces new information and techniques. In-service training is carried out either on-the-job or away from the workplace. On-the-job training can be informal or structured (61, 150). Among the advantages of structured on-the-job training reported by a PAC program in Kenya, for example, were that the training met each clinic’s specific needs, providers who could best use the training were selected, and there was little disruption of clinic services (168).

Training design includes format, methods, and materials. Training can take place through individual learning, self-assessment, paired learning, peer review, or group learning (74, 105, 150). Among training methods are coaching, mentoring, analyzing case studies, and role-playing (109, 150, 166). Micro-skills training—in which a skill is broken down into its elements and trainees receive lessons on each of the elements—has improved providers’ counseling (170). Combinations of approaches often give the best results (25).

Print manuals are being supplemented by CD-ROM, instruction via the World Wide Web, and coaching by e-mail. For example, PROCOSI, a network of Bolivian health care NGOs, uses CD-ROM and e-mail to train staff members in leadership and management (167).

Transfer of learning to the workplace requires cooperation among supervisors, trainers, trainees, and coworkers. Each has a role to play before, during, and after training. For example, before training, supervisors help select trainees, work with trainers on training objectives, inform trainees about the performance expectations once they are trained, and assign trainees’ work among coworkers. After the training supervisors and trainers should visit trainees on the job to monitor, support, and coach them as they use their new knowledge and skills (132). The goal is a closer link between training and performance (21, 152).