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An Introduction toAn Introduction toPerformance Improvement Performance Improvement

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Performance ImprovementPerformance Improvement

What is it?

How can we apply it?

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What is Performance Improvement?What is Performance Improvement?

A step-by-step methodology for finding out what is needed to ensure good performance, and delivering it.

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Performance Improvement: Performance Improvement: A Definition for Reproductive HealthA Definition for Reproductive Health

Performance Improvement is a process for achieving desired institutional and individual results. The goal of Performance Improvement is the provision of high quality, sustainable health services.

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……Why a Performance Improvement Why a Performance Improvement Process?Process?

• Training alone will not ensure performance• Results-orientation embedded in the process• Better return on investment (ROI)• If doing training, assure it has the maximum impact

– Sharper training objectives fixing root causes

– All enabling factors in place or known

• Provides a process for CA collaboration

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PI/HPT HistoryPI/HPT History

• Harvard basic psych. research, 40’s-60’s• Tom Gilbert, Human Competence, 1972• Transformation of US industry training departments• NSPI/ISPI• ASTD—Mission is now performance

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Performance Improvement Asks…Performance Improvement Asks…

• What performance do we want?• What performance have we got now?• What are the causes of the performance gap?• Which solution gives us the greatest return on our

investment?

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Factors Influencing PerformanceFactors Influencing Performance

• Job expectations• Performance feedback• Environment and tools• Motivation• Organizational support• Skills & knowledge

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GET and MAINTAIN STAKEHOLDER AGREEMENT

CONSIDER INSTITUTIONAL

CONTEXT

MISSION

GOALS

STRATEGIES

CULTURE

CLIENT andCOMMUNITY

PERSPECTIVES

DESCRIBE ACTUAL

PERFORMANCE

DEFINE DESIRED

PERFORMANCE

FIND ROOT CAUSES

Why does the performance

gap exist?

SELECT INTERVENTIONSWhat can be done

to close the performance gap?

MONITOR AND EVALUATE PERFORMANCE

GAPGAP

The Performance Improvement The Performance Improvement ProcessProcess

IMPLEMENT INTERVENTIONS

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Use the Performance Improvement Use the Performance Improvement Process to Guide Program Development Process to Guide Program Development

Work with stakeholders to:• Define desired performance• Conduct a performance gap analysis • Conduct a root cause analysis• Identify the most cost-effective interventions to

close the performance gap• Implement interventions as appropriate• Evaluate the impact of interventions on

performance

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Example Interventions for Example Interventions for Job ExpectationsJob Expectations

• Policies and guidelines• Job descriptions• Written protocols• Norms for the job• Clear verbal statement of expectations

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Example Interventions for FeedbackExample Interventions for Feedback

• Regularly posting client satisfaction data• Providing information about adherence to a CPI

checklist• Verbally telling a provider how they’re doing,

compared to what’s expected of them

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Example Interventions for Example Interventions for Environmental FactorsEnvironmental Factors

• Supplies• Tools• Space for private counseling

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Example Interventions for Example Interventions for MotivationMotivation

• RECOGNITION for performing up to standard• Verbal “good job” for good performance• Access to training or other development activity• Employee of the week award• Public recognition in newsletter, newspaper• Notation on employment record

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Example Interventions for Example Interventions for Organizational SupportOrganizational Support

• SUPERVISION SYSTEMS that assure all performance factors are in place

• Work rescheduling (removing competing tasks)

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Example Interventions forExample Interventions forSkills and KnowledgeSkills and Knowledge

• Group based learning • On the job training • Experiential learning • Self study • Distance learning• Job aids

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Performance and Quality ImprovementPerformance and Quality Improvement

PERFORMANCE

IMPROVEMENT

• Roots in behavioral sciences• Focus on performer• How do we get the

performance we want?• More focused - looks at set of

performance factors

QUALITY

IMPROVEMENT• Roots in engineering,

statistics and management• Focus on customers• How do we do the right

things right?• Broad, all encompassing

Some DifferencesSome Differences

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PI Application ExamplesPI Application Examples

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GET and MAINTAIN STAKEHOLDER AGREEMENT

CONSIDER INSTITUTIONAL

CONTEXT

Private ISM doctors

Can’t charge for counseling,

only for products

Taught to counsel, then give away free government

supplies

COUNSEL 25% OF ELIGIBLE

CLIENTS

COUNSEL 100% OF ELIGIBLE

CLIENTS

NO MOTIVATION TO DO

COUNSELING(NO $)

INTRODUCE SALE

OF CSM SUPPLIES

IMPLEMENTATION IN PROGRESS…

75%75%

INTRODUCE CSM INTO SUPPLY CHAIN, TRAIN

ON MARKETING, PRICING

PI in India:PI in India:PNA - India ISM examplePNA - India ISM example

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PI in India:PI in India: Main Intervention - MotivationMain Intervention - Motivation

Selling CSM supplies (for a profit):• Include sales, pricing and marketing training• District-level implementing agencies will

establish/strengthen supply chain• Simplify recordkeeping• Improve post-test, follow-up checklist

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GET and MAINTAIN STAKEHOLDER AGREEMENT

CONSIDER INSTITUTIONAL

CONTEXT

Social Security System (IDSS) clinics

Low usage rates

Contraceptives in short supply

LOW SATISFACTION, LOW NORMS ADHERENCE

HIGH CLIENT SATISFACTION, ADHERENCE TO

CPI NORMS

LACK OF CLEAR EXPECTATIONS,

LACK OF FEEDBACK

MAKE CPI EXPECTATIONS

CLEAR, PROVIDE FEEDBACK FROM

CLIENTS

SIGNIFICANT INCREASES IN CPI NORM ADHERENCE AND CLIENT SATISFACTION

GAPGAP

LETTERS FROM IDSS DR. TO

HOSPITAL DRS.,CPI POSTERS,

CLIENT FB CARDS

PI in the Dominican Republic:PI in the Dominican Republic: PNA - DR IDSS examplePNA - DR IDSS example

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Gaps Found• Poor treatment

of clients• No protocols• Inconsistent

services• No RH materials• No support from

leadership• Contraceptive

stock-outs

PI in the Dominican Republic:PI in the Dominican Republic: Focusing on ImpactFocusing on Impact

Gaps Chosen• Treatment of

clients• Integrated RH

awareness• Contraceptive

supplies

Main Interventions• Client feedback• CPI Norms• Training• Logistics (FPLM)

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About the PNA:

“This is the first time we’ve considered other things, like feedback.”

PI in the Dominican Republic:PI in the Dominican Republic:Participant ImpressionsParticipant Impressions

—

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PI in the Dominican Republic:PI in the Dominican Republic:Participant ImpressionsParticipant Impressions

About the feedback system:

“We learn things that people would never say in person. This is responsible for many improvements.”

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PI in the Dominican Republic:PI in the Dominican Republic:Participant ImpressionsParticipant Impressions

“The big impact for us has been the humanization of services—the better treatment of our clients.”

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PI in the Dominican Republic:PI in the Dominican Republic:Participant ImpressionsParticipant Impressions

“The quality of service from providers has gone up. No longer do they see clients as a set of symptoms— they see them as people.”

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Quality criteriadeveloped in:

• Reproductive Healthcare

• Infection Prevention

• Counseling resources and practices

• Physical resources and supplies

• Management systems

PI in Brazil:PI in Brazil: The PROQUALI ProjectThe PROQUALI Project

Desired Performance

Actual Performance

Only 5%-30% of all criteria met in PNA

Interventions Selected

• Clarification of job expectations

• Training

• Facility improvements

• Rewards programs

At the end of the 18 month project, 4 of the 5 clinics achieved 95%-98% of the established performance criteria.

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Baseline 9 months 12 months 24 months

Results Pilot ClinicsResults Pilot Clinics

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Performance Improvement: Performance Improvement: Problem SolvingProblem Solving

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100

Total

RH Car

e

Infe

ctio

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ventio

n

Counselin

g

Infra

-stru

cture

Man

agem

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Baseline 12 Months