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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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0
10
20
30
40
50
60
70
80
90
100
Baseline 9 months 12 months 24 months
Results Pilot ClinicsResults Pilot Clinics
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Performance Improvement: Performance Improvement: Problem SolvingProblem Solving
0
20
40
60
80
100
Total
RH Car
e
Infe
ctio
n Pre
ventio
n
Counselin
g
Infra
-stru
cture
Man
agem
ent
Baseline 12 Months