Improving Performance to Maximize Access and Quality for Clients Presentation Graphics Notes

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Improving Performance to Maximize Access and Quality Presentation Graphics Notes

Slide 2

This is an introduction to USAID’s Performance Improvement approach, used by a number of cooperating agencies (CAs) in the field. Mention the Performance Improvement Consultative Group (PICG), a consortium of CAs working with USAID to develop and promote PI.

Slide 3

Introduce the session by saying that we all try to do the best job we can, but often obstacles prevent us from performing as well as we would like. Often we decide to just work harder and longer hours but …effort does not always equal performance!

We’ve all seen, or worked with people, who seem terribly busy, but whose output or accomplishments are minimal.

Slide 4

Begin by explaining that the term “performance” refers to the jobs or tasks people do and the results of those tasks. Performance is a function of both behavior and accomplishment. Mention that there are at least two other ways to define performance, including the idea that worthy performance can also be viewed as value/cost (i.e., the value of the performance divided by the cost or the investment the organization makes in the performer).

Give examples as appropriate. Then say, “Let’s think about our own performance.”

Distribute at least 3 post-it notes (“stickies”) or cards to each participant.

Ask participants to think of a specific time when they performed exceptionally well in a job. Ask them to identify three things that helped them to perform well in that situation.

Ask participants to write each of their three responses on a different sticky note or card. Tell participants to hold on to these notes or cards for later use.

Slide 5

Using the next two slides, make a brief presentation on the factors that have been proven to have the most impact on performance. To perform well, people need to have these six conditions addressed. Some details:

Job expectations: knowing what is expected of you

Performance feedback: knowing how you are doing compared with a quality standard

Motivation: internal and external incentives to perform. What happens if a performer performs well? Does his/her life get better? Or worse? Salary isn’t always a major motivator or guarantee of good performance (though USA research says “fair compensation” is important.) Dominican Republic focus group discussions about non-monetary motivation revealed that providers were more interested in participating in decision-making and in receiving feedback on performance.

Knowledge and Skills: Does the worker know how to do her/his job?

Slide 6

Organizational support: the organization’s mission, strategies, goals, and values; communication, management and supervision systems. Does the job fit the organization’s goal? Is the organization able to ensure that all the enabling factors are in place. For example, is gender equity a value?

Environment and tools: having the supplies, equipment and tools needed to do the job

Look at performance factors from a gender perspective.

Job expectations: Are the job expectations the same for others doing the same job?

Organizational support: Are male and female employees:

Treated the same way?

Paid the same for the same work?

Equally represented in all positions in the organization?

Knowledge and Skills: Do males and females have the same access to training and information?

Slide 7

Individual Activity: When you have completed this short presentation, ask the participants to look once again at the things they identified that would help them do their jobs better. Arrange a space?on the wall or on flip chart paper?where each of the six performance factors is written with a blank space under it. Ask participants to get up, walk to the wall and place their cards/stickies under the performance factor into which they would fit each item.

Discussion: Ask participants to walk around reading the posted items. Ask, “How many items do we have under performance factor one, etc. Then ask, “What conclusions might one draw from looking at this?” Compare the number of stickies in various categories.

(See optional slide for an alternate exercise.)

Summary Points:

Many times we apply a specific intervention such as training or IEC without stopping to ask whether or not that intervention will fix the performance problem.

PI uses a systematic approach for finding the root cause(s) of the performance problem. Then, PI implements an intervention that applies only to the root cause(s).

Give a few examples or take examples from the posted items. Encourage discussion.

Slide 8

The following is a definition adapted from the PICG at USAID/Washington DC:

Performance Improvement (PI) 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 step-by step 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. PI is a continuously evolving process that uses the results of monitoring and feedback to learn about progress and make appropriate changes.

If someone asks about PI’s research roots, emphasize that PI is a common sense approach. Note, however, that PI is based on research in human performance technology that began in the 1940s and 1950s. PI grew out of international corporations whose CEOs demanded that training departments do a better job of improving performance to improve the company’s bottom line. “Human Performance Technology” (HPT) is a term coined in 1972 in Thomas Gilbert's book Human Competence. Since the early 70s, HPT has transformed US industry and business training departments, changing them to human performance improvement organizations. Especially in the 90s, organizations such as the International Society for Performance Improvement (ISPI) have focused efforts on a unified paradigm and a unified profession that uses a single methodology.

Slide 9

Three special aspects of PI

PI is systematic: The PI process is systematic and focuses on measurable performance. If you follow the PI process, it promotes a lack of bias about the problem and the right fix. You are no longer seeing the world through one technical lens. (The next slide expands on this concept.)

PI pays attention to root cause issues: PI uses analysis techniques such as fishbone, the why-why-why technique or the decision tree to help you to get to the basic causes of issues (i.e., those that you can do something about). Examples of analysis techniques are given in subsequent slides.

PI results in targeted interventions: The PI process helps stakeholders think through and select the best interventions that address the root causes to decrease the performance gap. Using PI means not only that you are investing in interventions that are more likely to make a difference, you are also not spending human and financial resources on interventions that aren’t going to make a difference (e.g., training people in procedures or contraceptives that they don’t have supplies for). You are no longer seeing the world with double or triple vision!

Slide 10

An example of why a systematic process is helpful

Training is the most popular intervention when there is a performance problem. This slide illustrates how one intervention—training—is often considered to be the right tool for different causes of performance problems.

A good root cause analysis increases the likelihood that the interventions will have a greater impact—that the right tools will be used.

Slide 11

Results are achieved through a step-by-step process that begins with

Stage 1: Getting stakeholder agreement and beginning to consider the institutional/client/community context issues.

Stage 2 is called a performance needs assessment (PNA) and includes completing the process of defining desired performance, describing actual performance, identifying the performance gap, finding the root cause of the performance gap, and beginning to select interventions. In Stage 2, the PI team and stakeholders decide which performance problems will be addressed—and in which order. This meeting will focus in detail on Stages 1 and 2.

In Stage 3, the PI team and stakeholders complete selection of the interventions, work with experts to design and develop the interventions, ensuring that monitoring and evaluation is built into the process.

In Stage 4, the PI team monitors the implementation process against agreed-upon benchmarks, coordinates additional expertise for the PI team as necessary, assures organizational readiness and manages the change process. Along with the principles of good project management, the PI team, where necessary, will take a lead role in changing plans or making adjustments, talking with key stakeholders and getting new agreements about implementation.

Stage 5: The team measures the change in the performance gap. Where possible, the PI team uses an evaluation method that can be practically integrated into the work place. If possible, linkages between performance and quality and the impact of service delivery are examined.

Slide 12

The goal of Stage 1 is to involve all parties in a transparent and participatory process that results in agreements about:

The PI approach in general

The purpose of the activity

The expected outcomes

Next steps for Stage 2, the performance needs assessment (PNA).

It is not the purpose of Stage 1 to design or get agreements about interventions or solutions to the problems, because these will emerge from the Stage 2 PNA process.

Slide 13

More on Stage 1.

Example: In July 1998 in the Dominican Republic, the coordinators of the reproductive health (RH) program, the Dominican Social Security Institute (IDSS) Health Director and a USAID CA (PRIME) held a series of meetings. The following were identified as initial general areas that needed improvement: quality of care, service coverage and program management. A memo of understanding was signed between the coordinators of the RH program and the CA to work together on the pilot project. After project agreement was reached at the middle management level, the IDSS RH Program/CA team presented the Project to the then IDSS General Director, Dr. Pablo Yermenos, and the IDSS Executive Board, and the agreement was officially approved.

Stage 1 is not a finite stage but an ongoing process, depending on necessity, changing circumstances and a better understanding of performance issues. For example, during the life of the project, the General Director changed twice. The change in General Director required the project team to confirm project agreement to maintain the political good will and support the PI project enjoyed with IDSS upper management.

Slide 14

In Stage 2, one defines desired performance, describes current (actual) performance, defines the performance gap, prioritizes the performance gaps to work on (the most important first), completes a root cause analysis and begins mapping possible interventions. Performance, both desired and current, should be described in objective and measurable terms. Example: All providers should offer all 5 FP methods available at our clinic. Actual: Only 3 of the 10 providers regularly offer all 5 methods. Give an example of a performance gap—if the desired and actual performance are measurable and observable, the gap is often a matter of simple arithmetic.

The root cause analysis determines what is causing the performance gap. The cause, in turn, suggests an intervention to address. Gap-cause-intervention. Root cause analysis is a very important contribution to the quality process because examining the performance gap using these techniques increases the likelihood that you are fixing the right problem. WHY-WHY-WHY techniques, fishbone, and other cause analysis techniques are an integral part of the PNA process.

PNA maps possible interventions for each cause; however, it focuses on interventions that are most important, most sustainable and least costly. A cost-benefit analysis can help determine cost-effectiveness.

Slide 15

To date, findings from PI work have shown us how challenging it is to define and develop consensus around desired performance. Desired performance needs to be doable, reasonable, timely and measurable. Desired performance also needs to reflect multiple perspectives, including the client’s and the community’s needs.

In Burkina Faso, the PI team was asked to develop the performance of public sector community-based distributors (CBDs). The PNA uncovered widely different viewpoints and expectations about what the community-based FP distributors were to do in their jobs. One of the first interventions (even in Stage 1) was to help the various groups develop consensus about a common expectation regarding the job of a CBD.

To explore desired performance a bit more, let’s take a side trip. Take another sticky, and considering the desired performance in your job, write one statement of desired performance in your own job. You will be sharing this statement with others.

Ask the group to post their statements on a board, then review the examples, using the criteria for desired performance (observable, measurable, etc.)

Slide 16

The Ishikawa diagram, or fishbone diagram, is an example of one technique for graphically organizing ideas by category for root-cause (cause-and-effect) analysis. The fishbone can broaden thinking about potential causes and facilitate further examination of individual causes. Causes are usually brainstormed by a group. A place can be found on the diagram for everyone’s suggestions. The “effect” or performance problem is written on the right. Here, the category labels are performance factors. Note that ”information” is broken out into two items—performance feedback and job expectations. The group should choose the categories of cause that are most relevant to them and can add or drop categories as needed. For each cause ask, “Why does it happen?” and list responses as branches off the major causes. Push the causes back as far as possible.

It is important to remember that the diagram is a structured way of expressing hypotheses about the causes of a performance problem or about why something isn’t happening as desired. It cannot replace empirical testing of these hypotheses. The diagram alone does not tell which is the root cause.

Slide 17

Here is another example of a root cause analysis technique—the decision tree. This slide/overhead shows how the decision tree was used during a performance needs assessment in Ghana.

Slide 18

In Yemen, community midwives participated as stakeholders in Stage 1 activities. Here, a community midwife is presenting the results of small group work to a group of governor-generals, reproductive health directors, central MOH staff and community leaders, representing four governorates.

Yemen: Although the integration of a new cadre, community midwives, was originally viewed as a training issue, the PNA root cause analysis uncovered problems in organizational support pertaining to how the community midwife was being integrated into and accepted by the local health staff and systems.

Slide 19

In Yemen, the Director-General of a governorate (province) participates in the process along with a PI facilitator.

Slide 20

The goal of Stage 3 is to finalize intervention selection and to design and develop interventions that will close the performance gaps identified in Stage 2 (PNA). PI interventions should be:

Results-oriented, or designed to meet measurable needs

Comprehensive, or designed to solve the whole and not part of the problem

Systematic, or integrated into the organization and not stand-alone initiatives

Cost-effective, or designed to ultimately save more than they cost

Slide 21

The MAQ Initiative provides comprehensive illustrations of intervention areas that are important to consider.

Slide 22

The goal of Stage 4 is to execute the intervention package designed and developed in Stage 3. The team creates and manages the implementation process (which might include consultants and subcontractors), manages the overall implementation and oversees organizational change processes.

Slide 23

The goal of Stage 5 is to assess the effects of the interventions on provider performance and to judge whether they “narrowed” the performance gap, and if so, to what extent. Additionally, the evaluation may examine organizational performance, or the capacity of an institution to support provider performance, and linkages between performance results and FP/RH service quality and access issues for clients.

The evaluation process actually starts in Stage 2. Remember, PI starts “with the end in mind.” A measurable performance gap is identified. So, monitoring and evaluation activities are already being implemented and planned as interventions are being designed.

PI projects focus on performance. We initially described performance as the tasks that people do and the results of performing those tasks. In international RH, the results of performance can mean not only the change in the performance gap but also the impact that change has on the quality of service, client behavior and community activity.

Slide 24

In the Dominican Republic, a PI team was asked to investigate a situation in which clients were not returning to clinics of the Dominican Social Security Institute (IDSS). Focus groups and observations confirmed that clients were not being treated in a manner that they expected. So, many clients were not returning to the clinics. Instead they were going to secondary-level care facilities, which were overloaded.

Desired Performance: Stakeholders decided that they wanted providers to adhere to a set of norms for how to treat clients.

Actual Performance: Baseline data confirmed that providers were acting according to the norms only 60% of the time.

Gap: The difference between desired and actual level of adherence to client-provider interaction (CPI) norms was 40%.

Root Causes: Investigation with providers uncovered the following facts: providers didn't understand that they were expected to act in accordance with the norms, received no feedback on their performance, and lacked some knowledge and skills about how to treat clients.

Interventions: To fix the root causes, sites gave information on how providers were to treat clients, including a letter from the Director of the IDSS, pamphlets and wall posters. Providers were trained in the CPI skills they lacked. Finally, a simple system of giving feedback from clients to providers (on feedback cards) was implemented. (The feedback system remains in effect, over a year after the end of outside technical assistance.)

Slide 25

The quality of CPI (as measured by direct observation of providers in consultation with clients) increased by 62% in the province where the full intervention package was implemented.

The full intervention package includes CPI norms development and dissemination, client feedback, and training and logistics (not related to CPI)

Basic interventions exclude training

Results show that the participatory training in communication techniques, clear expectations for adherence to CPI norms, reporting/explaining PNA results (client opinions on services), and modeling and practicing good CPI behaviors was a necessary intervention for acquiring these good results.

A follow-up evaluation has been conducted and data are currently being analyzed. This evaluation will give us more information on adherence to CPI norms a year after intervention implementation.

Slide 26

This slide/overhead shows an example of the PI process in India.

Original project: 5,000 trained, only 1,200 actually doing any counseling. The original request was for additional training in counseling.

Slide 27

This slide/overhead shows an example of the PI process in Ghana.

Desired performance: Regional Resource Teams (RRTs) were to supervise providers in PAC skills, do the supervision according to national standards, and do one supervision visit per provider per quarter.

Actual performance: Although the RRTs did supervision according to standard, they did fewer than one visit per year, per provider.

Main root causes: RRTs didn’t know how many supervision visits they were supposed to do. They also lacked money for hiring transport and/or paying for fuel, if they had existing transport.

Interventions: The one visit per quarter expectation was added to RRT job descriptions, and added to the pre-service training. Because small amounts of money were available from donors for items such as transport and fuel, RRTs were taught how to write the (1-page) proposals to receive the funds.

Slide 29

Clarifying job expectations included the establishment and dissemination of minimum standards for quality performance.

Facility improvements included developing a logistics system and some management and facility changes.

Motivation was increased by institutionalizing an accreditation system to motivate, support and reinforce continuous learning and sustained performance.

Slide 30

This slide represents the composite data of the 5 pilot clinics. At baseline, the clinics averaged 12 percent of the necessary criteria for accreditation. By 9 months, the clinics averaged approximately 73% of the criteria. And, within 12 months, all but 1 (4 out of 5) of the clinics were accredited. Interestingly, with very little support or technical assistance, the clinics maintained their accreditation status 12 months later (24 months from start) in a reaccreditation exercise.

Slide 31

This slide represents one clinic’s attempt to become accredited. As is illustrated, the clinic continually struggled with the criteria in the infra-structure and management areas. Even after 12 months, the clinic still did not reach the necessary levels within these two areas and was, therefore, not accredited. Interestingly however, recent data collected in a re-accreditation exercise has demonstrated the achievement of all necessary criteria for accreditation.

Slide 32

These results come from qualitative process evaluations of PI work in 5 countries.

Slide 33

PI can work as effectively at the organizational level as it does at the provider level. In the year 2000, the Executive Council of the Dominican Social Security Institute (IDSS) used PI to identify and resolve its performance problems related to the field of reproductive health. The IDSS substantially redesigned its organizational structure to improve its RH performance. This new alignment particularly affects the RH Program, which increases in status within the Institute from a Special Project to the Division of Reproductive Health responding directly to the Health Directorate. The PNA revealed a significant disconnect between the widespread need for improved RH services among the IDSS’ target population and its relatively low priority in the organization. The RH coordinators developed a series of awareness-raising interventions for senior-level managers to demonstrate the importance of an integrated RH approach, along with the target population’s real need for these RH services. This unmet need is especially poignant given the shift over the last decade within the population served by IDSS from an agrarian base with almost an exclusive male population to an industrial workforce with a majority of female members. IDSS had never adapted its clinical and preventive services to match this dramatic shift until the PI process clarified the situation. With the increased RH awareness and strong leadership support, IDSS is committed to becoming an organization responsive to client needs and rights.

The organizational shift places RH at the forefront where it can provide the greatest impact for the Dominican working population. The RH Division will receive high institutional support, increased funding and additional human resources to allow increased control of the quality and access of the RH services it offers.

Slide 34

Systematic: The PI process prevents us from jumping to conclusions about the problem and the solution, investing people’s time and money in the wrong solution or trying to fix every perceived weakness without understanding which issues are the root causes. The PI process also ensures that clients and communities have a say in the definition of desired performance and that stakeholders, like providers, participate in identifying the root cause.

We need a step-by-step process to keep us focused. Systematic diagnostic processes promote looking at all the potential causes and interventions from a neutral perspective. (Chochrane Collaboration results)

Results: The process ensures that we start with the end in mind (desired performance).

Slide 36

A group of stakeholders came together to discuss some of the root causes of identified poor infection prevention practices. The stakeholders were divided into 3 groups. Each group was given 2 to 3 performance factors and asked to brainstorm about the contribution these factors make to good IP practices. The groups were also asked to consider things that weren’t happening that could cause poor performance. Based on the results of this exercise, the groups were asked to identify possible interventions that might resolve the performance issues and then prioritize the interventions that would be most important. The groups came up with many interventions, but prioritized 6.

IST = In-service training

Slide 40

Alternate exercise

Draw the chart shown above on flip chart paper and hang the chart on the wall. Hand out one large post-it note (sticky) per person. Describe the performance factors in each box. (See previous speaker notes that describe the six factors that influence performance.)

Then, ask this question: “Improvement in which one of the following six areas would enable you to do your job better?” Ask people to write down the number of one area and post it on the chart.

After everyone has posted his/her number, point out that, usually, most items are placed in the top row (which is organizational), and fewer are placed in the bottom row (which is personal). Also point out that the chart is directional (clockwise): the factors that cause an improvement are in order from most frequent cause (information and resources) to least frequent cause (training).

Indicate that you are now moving from performance to discuss more specifically, USAID/PICG’s performance improvement approach?what it is and how to do it.

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