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Considerations for Developing a Performance Improvement Strategy

The concept of performance improvement is not a new one, and most organizations working internationally in reproductive health already apply some elements of performance improvement. Traditionally, USAID-supported cooperating agencies (CAs) have implemented interventions in areas such as service delivery; management; logistics; training; and information, education and communication. The objective has been that, within a given country, a number of CAs simultaneously working with country partners would be implementing interventions at individual, organizational and community levels, eventually resulting in provision of quality services to clients. Success in achieving this objective clearly depends on the extent of collaboration and coordination among the CAs and country partners. A performance improvement approach can help to strengthen these partnerships.

Based on the review of the literature presented in this paper, there are a number of ideas that organizations may wish to consider as they develop a performance improvement strategy:

• The strategy must be based on a proven framework which is recognized by other partners.
• There must be strong collaboration with partners and key stakeholders throughout the entire process. In order to maximize effectiveness, organizations can no longer work in isolation hoping that their interventions will have the desired effects.
• There must be a strong quality component to any performance improvement strategy.
• There must be common performance analysis and root cause analysis tools and instruments that all partners are able to use.
• The focus should be on the causes of poor performance at individual, organizational and community levels that will have the greatest impact on performance and theprovision of quality services. In many cases it will not be possible to address all of the causes of poor performance, and decisions regarding priorities will have to be made.

• Each organization must develop expertise in designing and implementing a specific set of interventions. An organization may need to develop expertise in new interventions.

• When training is an intervention, there must be a component for the transfer of training to ensure a link from training to the work site. The transfer of training should involve the worker's supervisor and manager whenever possible.

JHPIEGO's Performance Improvement Process

The definition of performance improvement that JHPIEGO will use is based on one developed by representatives from several USAID cooperating agencies (Performance Improvement Consultative Group 2000):

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. Results are achieved through a process that considers the institutional context, describes desired performance, identifies gaps between desired and actual performance, identifies root causes, selects interventions to close the gaps and measures changes in performance.

The Performance Improvement Process, based on the framework shown in Figure 1, helps to tell us what factors contribute to desired performance and what can be done to strengthen them. Using this process also helps ensure transfer of training to the workplace, where services are delivered to our ultimate customers: women and families. This process is consistent with the literature review in this paper and comprises the five steps described below.

Source: The Performance Improvement definition and framework are products of a collaborative effort among members of the Performance Improvement Consultative Group. This group consists of representatives of USAID-funded Cooperating Agencies.

• Analyze performance: First, conduct a performance analysis to identify what gaps, if any, exist between actual and desired performance. Focus on the performance of an individual or a group.

  If desired performance is not already defined, define it by asking:

  • What is the provider expected to do?
  • How well (quality indicators)?
  • Under what conditions?
  • With what frequency?
• Define desired performance—performance while considering the institutional context—with input from national policies and priorities, service delivery guidelines and as much stakeholder involvement as possible including, at a minimum, providers, supervisors and clients.

• Find root causes: Conduct a root cause analysis that asks why the identified performance gaps exist. Gather information from as many stakeholders as possible and identify the causes of poor performance before selecting appropriate interventions. Common causes of poor performance include:

  • Unclear job expectations
  • Lack of performance feedback
  • Poor motivation
  • Weak management or leadership
  • Deficient knowledge and skills
  • Inadequate facilities, equipment or supplies
  • Lack of client and community focus

• Select interventions: Next, select and design interventions to address the causes of performance gaps.
  
  Not all interventions can be undertaken at once. Prioritize the selected interventions. Weigh costs and benefits carefully. In determining priority, consider the following criteria:

  • Appropriateness: Will this intervention contribute to closing the performance gap? Will it be effective in improving the quality of reproductive health services?
  • Economics: Is the intervention affordable and sustainable?
  • Feasibility: Are systems in place to support this intervention? Can it be successful in a low-resource setting?
  • Cultural acceptability: Will the community and clients respond favorably to this intervention and be willing to advocate for it?
  • Provider acceptability: Will the healthcare provider or supervisors agree to support the intervention?
• Implement interventions: During this phase, set interventions in motion and establish monitoring systems. Integrate the concept of change into daily work and carefully manage the direct and indirect impact of that change to maintain organizational effectiveness and achieve performance improvement goals.
• Monitor and evaluate performance: This task is ongoing. Because certain interventions can have an immediate effect on organizational and individual performance, be certain to initiate sound monitoring systems that focus on measurable change in order to obtain early feedback on the results of the intervention. To evaluate the impact of interventions on closing the performance gap, continuously compare formal assessments of actual job performance to desired performance. Obtain information from evaluations and use it to guide further analysis of performance gaps and root causes. Follow leads from the information retrieved to modify the intervention design as needed.

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