Table of Contents
Chapters
- Promoting Dialogue
- Supporting the Client’s Role
- Improving Providers’ Performance
- Make Good CPI a Job Expectation
- Feedback Keeps Performance on Track
- Range of Knowledge and Skills Needed
- Work Environment Supports CPI
- Rewards Offer Motivation
- Match Capacity with Jobs
- Select Approaches to Solve Problems
- Table: Activities to Improve CPI
- Box: Supervisors Can Improve CPI
- Best Practices in Training
- Evaluating the Quality of CPI
- Moving Beyond Family Planning
- Bibliography
This issue was prepared in collaboration with the Maximizing Access and Quality (MAQ) Initiative of the United States Agency for International Development's Office of Population and Reproductive Health. The MAQ Initiative supports research and evidence-based interventions to promote access and quality of reproductive health and family planning services.
Published by the Information & Knowledge for Optimal Health (INFO) Project, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.
Volume XXXI, Number 4,
Fall 2003
Series Q, Number 1
Maximizing Access to Quality
Improving Providers' Performance
Although there is growing appreciation for the client’s role in reproductive health consultations, most efforts to improve CPI continue to focus on the provider. There are obvious ways to affect the provider’s side of the partnership—through training, supervision, policy, management, and funding. Managers today understand that many factors contribute to providers’ performance on the job. They realize that the organizational environment in which providers work is as important as the providers themselves.
Performance Improvement (PI) offers a useful framework for understanding these factors. PI is one of many models developed to analyze and improve performance in business and health care, and reproductive health programs in developing countries are successfully applying it to their operations (87). Experience in developing countries suggests that six factors most influence reproductive health care providers’ behavior on the job (24, 59, 102):
- Job expectations,
- Performance feedback,
- Knowledge and skills,
- Work environment,
- Incentives and motivation, and
- Capacity.
To assure good CPI, program planners and managers must consider all six of these factors and define objectives, allocate resources, and design policies, standards, procedures, and management systems accordingly.
Because each situation is unique, there is no universal solution when poor CPI poses a problem. Before deciding how to improve providers’ performance, program staff should systematically analyze the root causes of any gap between current and desired performance. In the Performance Improvement approach, for example, staff members collect information from records, site visits, interviews, and facilitated discussions in order to define specific problems and identify their causes (87). Knowing the root causes helps managers and staff members decide on effective, feasible, and sustainable ways to resolve problems—and avoids wasting resources on activities that will not help.
Table 1 lists some of the interventions most commonly undertaken to improve the quality of CPI in health care. While some have more obvious links with CPI than others, all help ensure that the organization and its staff value, promote, and practice good CPI (see Table 1).
Make Good CPI a Job Expectation
Good interpersonal communication becomes the norm at a health care facility when all of the staff—from the medical director to the providers to the receptionists—clearly understand their contribution to client-centered services. When staff members do not understand what is expected of them or they receive conflicting messages, the problem may be that official policies, standards, and guidelines do not cover CPI or are outdated.
Policy-makers and program managers need to identify desired communication behaviors in national policies and guidelines, develop standards to define their quality, and help providers and their supervisors operationalize these standards. While local facilities managers can promote good communication practices, it is difficult for them to sustain job expectations without reinforcement from higher levels.
It is equally important to make sure that providers are aware of CPI policies and guidelines and know how to apply them as part of day-to-day service delivery. Simply distributing written copies of guidelines is not enough.
Managers can involve providers in drafting job descriptions and protocols (step-by-step instructions for procedures) that reflect the guidelines. They can regularly remind providers what the policies and guidelines require of them. They can make sure that all training and supervisory activities follow and reinforce the guidelines. And they can develop job aids, such as checklists or cue cards, to remind providers what to do (151).
In Kenya, for example, the Ministry of Health, with the collaboration of JHPIEGO and Family Health International (FHI), disseminated updated reproductive health and family planning guidelines. In addition to holding training workshops, they created a laminated job aid summarizing key points from the guidelines, gave trainees an orientation package to help them update their coworkers, and made supportive supervision visits to reinforce the training. This cascade training approach reached more than 6,000 providers at the central, district, and local levels in 1999 and 2000. It significantly improved the knowledge, practices, and attitudes of providers who attended the workshops and, to a lesser extent, of their coworkers (145).
Certification and accreditation programs, which monitor facilities’ compliance with established standards, provide another way to communicate and reinforce job expectations (50). Accreditation systems for reproductive health services in developing countries, such as Brazil’s PROQUALI Project (64) and West Africa’s Santé Familiale et Prévention du SIDA (SFPS) Gold Circle Initiative (65), typically include CPI standards along with other criteria for quality of care. Communication campaigns designed to promote accredited clinics also help to set norms for providers’ behavior among both providers and clients.
Informal social norms at health care delivery sites may either undercut or reinforce job expectations set by policies and guidelines. In Kenya, for example, counseling skills deteriorated when some providers laughed at newly-trained coworkers for using job aids or for spending a few extra minutes with clients. Even supervisors sometimes criticized providers’ efforts to improve their counseling skills (131).
Whole-site training—in which a facility’s staff decides together on what kinds of instruction are needed—promotes a team approach to service delivery and mutual understanding of staff roles. It can help ensure that all workers at a facility share the same high standards for CPI (19). Encouraging supervisors and staff members to understand the aims of CPI training and actively support coworkers who attend such training also can build positive norms at service delivery facilities (see Adopt Proven Training Methods).
