• 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
9. Monitor and Evaluate Performance
• Did the Project Close Performance Gaps?
• Did Provinces Differ?
• Did Facilities Differ?
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
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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

The differences between San Cristóbal and La Romana indicate the relative strengths of the solutions to the performance problems. In La Romana the performance gaps for considerate treatment of clients either increased or did not change significantly, and the gap in providers’ knowledge of reproductive health services increased at the first follow-up survey. Compared with the decrease in performance gaps in San Cristóbal, the results in La Romana indicate that providers lacked knowledge and skills—not only clear expectations and feedback—and needed training and follow-up, which were not offered in La Romana (37, 101). Also, managers may not have communicated the new expectations clearly and forcefully enough to decrease performance gaps in La Romana (37).

Higher expectations of clients may also explain the increase in the performance gap in treatment of clients at the first follow-up survey. Responding to the posters describing the quality of reproductive health services, clients may have expected better quality of care than providers in La Romana could deliver (63).

The results from La Vega, the control province, indicate the overall effectiveness of the pilot project. The small changes in the performance gaps in La Vega show that the improved performance in San Cristóbal was the result of the pilot project rather than a general improvement in performance in all provinces.

The facilities differed significantly in their response to the pilot project. The doctors’ offices improved performance most. For example, the performance gap for considerate treatment of clients, as rated by clients, decreased significantly in doctors’ offices between baseline and the first evaluation survey from 5.8 to 5.1 (12%) on the 12-point scale. At hospitals and clinics, in contrast, the gap increased (120).

Bureaucracy and staff turnover may explain the differences between the facilities. Procedures at hospitals and other large institutions are difficult to change, particularly as a result of short-term projects. The organizational changes required to improve performance take more time in a large institution than in an office (37). Also, staff turnover at hospitals probably prevented improved performance because new staff would not have participated in the project (120).