Marc Luoma, PRIME Project

Table of Contents

• 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
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

• PRIME II revised PI guide: Performance Improvement Stages, Steps and Tools
• ISPI's Performance Express Newsletter
  • PI at JHPIEGO
  • PopReports Issue on PI

• 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

Performance Improvement

Performance Improvement (PI), a process pioneered in industry, is now helping to strengthen reproductive health organizations. PI focuses on meeting the needs of service providers and other staff members. When programs enable and inspire staff to do their best, the quality of care improves.

People need the right knowledge and skills to do a good job, but they also need to know what is expected of them and whether they are meeting expectations. They need to have good working conditions, strong support from their organization, and incentives to perform well.

When people do not perform well, there usually are a number of reasons. The PI approach can help organizations identify and address them all. Performance Improvement is useful in resource-poor settings because it focuses attention on often- neglected causes of performance problems, such as unclear expectations or infrequent feedback, that need not be costly to correct. Performance Improvement is used primarily to solve problems, but it can also help to set up a new job or help staff members take on new tasks or adjust to new standards.

Reproductive health care organizations apply Performance Improvement in a process that is carried out by stakeholders—the staff members, clients, managers, and others who are affected by a performance problem or are interested in solving it. In turn, stakeholders usually need help from facilitators—staff members or consultants who have training or experience with Performance Improvement. The PI process is comprehensive, beginning with research and ending with evaluation of solutions:

1. Consider the institutional context of the performance problem and foster agreement on the objectives of the PI process.
2. Define desired performance.
3. Describe actual performance.
4. Measure or describe the performance gap.
5. Find the root causes of the performance gap and link them to performance factors, such as incentives or knowledge and skills.
6. Select interventions that address the root causes.
7. Implement interventions.
8. Monitor and evaluate performance.

Performance Improvement encourages use of evidence-based “best practices.” In place of trial and error, it offers a systematic approach. Instead of guessing or jumping to conclusions about the reasons for poor performance, managers can use analytical techniques. For the tendency to use familiar solutions, the PI process substitutes closely reasoned links between root causes, performance factors, and solutions.

Beginning with a pilot project in 1998, reproductive health organizations have used the PI process to:

• Respond to demands by clients for improved reproductive health services (Dominican Republic);
• Learn why providers are not following guidelines for infection prevention despite their training (Ghana);
• Perform national needs assessments for reproductive health care, examine organizational performance problems, and decide on priorities (Armenia, Burkina Faso, Nigeria, and Tanzania);
• Establish standards of care and help clinics meet the standards for licensing or accreditation (Guatemala and Honduras);
• Help decentralize health services (Tanzania);
• Identify barriers faced by community midwives (Yemen); and
• Design incentives for private providers to counsel clients better about family planning and to provide services (India).

Performance Improvement is inclusive. It empowers and encourages people to look beyond causes of job problems that they can do little or nothing about and to take into their own hands the task of improving services. Staff members, supervisors, clients, and community members work together to assess needs and find solutions. When necessary, they can seek help from experts in communication, logistics, management, and training.

Performance Improvement promises to be a powerful addition to the quality improvement methods available to reproductive health programs. It can help solve performance problems with well-conceived solutions that lead to more productive and satisfied workers providing better reproductive health care for more satisfied clients.

Note to readers: This report serves two audiences. The first chapter is an overview for managers who will make the decision to use Performance Improvement and need to know the fundamentals, costs, and expected results. The rest of the report details each step of the process, tools, and techniques for readers who may become PI facilitators.