Improving Performance to Maximize Access and Quality for Clients

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Improving Performance to Maximize Access and
Quality for Clients
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Session Goals

• Participants will explore
• Performance improvement (PI) approach, framework
  and factors influencing performance
• How PI works
• Benefits of using PI

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E ? P

• Effort is not the same thing as Performance

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What is Performance?

• The tasks that people do and the results

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What Factors Influence Performance

• Clear job expectations
• Clear and immediate performance feedback
• Motivationtransparent incentives to perform as
  expected
• Knowledge and Skillsjob-based information and
  technical competencies

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What Factors Influence Performancecontinued

• Organizational Supportstrategic direction, job
  roles and responsibilities, supportive
  supervision system
• EnvironmentAdequate and proper tools, supplies
  and workspace

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Performance FactorsIndividual Activity

• For items that would help you do your job
  betteridentify performance factor for each
• Post each card/post-it in appropriate box on the
  wall
• Read all posted items
• What conclusions can you draw?

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Performance Improvement

• A process for achieving desired institutional and
  individual results
• Goal the provision of high quality, sustainable
  health services for clients
• Source USAID Performance Improvement
  Consultative Group (PICG)

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How is PI Different From Other Quality
Approaches?

• PI
• Is a systematic process
• Analyzes measurable gaps between desired and
  actual performance
• Targets interventions to root causes of
  performance gaps to achieve desired institutional
  and individual results

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If all you have is a hammereverything looks
like a nail.
Lack of tools and equipment
Lack of knowledge and skills
Training
Lack of motivation and incentives
Lack of data and information
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Performance Improvement Framework
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
Get and Maintain Stakeholder Agreement
Define
Consider
Desired
institutional
Performance
Context
Select
Find Root
mission,
Interventions
Implement
Causes
goals,
What can be done
Gap
Why does the
Interventions
to close the
performance
strategies,
performance
gap exist?
gap?
culture and
Describe
client and
Actual
community
Performance
perspectives
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Performance Improvement Framework
Stage 1
Get and Maintain Stakeholder Agreement
Define
Consider
Desired
institutional
Performance
Context
Select
Find Root
mission,
Interventions
Implement
Causes
Gap
goals,
What can be done
Why does the
Interventions
to close the
performance
strategies,
performance
gap exist?
gap?
culture and
Describe
client and
Actual
community
Performance
perspectives
Monitor and Evaluate Performance
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Stage 1 Obtain and Maintain Stakeholder Agreement

• Stakeholder(s) initiate the PI process by asking
  for help with problem(s) or requesting a specific
  intervention
• You gather information from key stakeholders
• Stakeholders meet to agree on desired outcomes

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Performance Improvement Framework
Stage 2
Get and Maintain Stakeholder Agreement
Define
Consider
Desired
institutional
Performance
Context
Find Root
mission,
Implement
Causes
goals,
Gap
Why does the
Interventions
to close the
performance
strategies,
gap exist?
culture and
Describe
client and
Actual
community
Performance
perspectives
Monitor and Evaluate Performance
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Examples of Desired Performance

• Do FP counseling with 100 of eligible clients
• Supervise providers according to standard, one
  visit per quarter
• Practice infection prevention, according to
  standard, 100 of the time

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Why? Tree Root Cause Analysis
Supervisors were not making supervision visits
Didnt know how many were expected
No transport
Why?
No funds
No one told them
Not in job description
Not part of their training
Why?
Why?
Didnt ask for funds
Have no job description
No ones job to tell them
Why?
Why?
Dont know how to write proposal
Have no supervisor
No one made one
Example Ghana, 2000
Why?
Not in their training
No support system for them
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Performance Improvement Framework
Stage 3
Get and Maintain Stakeholder Agreement
Define
Consider
Desired
institutional
Performance
Context
Find Root
mission,
Implement
Causes
Gap
goals,
Why does the
Interventions
to close the
performance
strategies,
gap exist?
culture and
Describe
client and
Actual
community
Performance
perspectives
Monitor and Evaluate Performance
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Stages 2-3 Guidance from MAQ in Selecting and
Developing Interventions
Leadership
Client Engagement
Problem Solving
Community Engagement
Indicators/Certification
Provider Rewards/Environment

Supportive Supervision
Standards/Guidelines
Supplies/Logistics

Organization of Work
Job Aids
Training
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Performance Improvement Framework
Stage 4
Get and Maintain Stakeholder Agreement
Define
Consider
Desired
institutional
Performance
Context
Select
Find Root
mission,
Interventions
Causes
Gap
goals,
What can be done
Why does the
to close the
performance
strategies,
performance
gap exist?
gap?
culture and
Describe
client and
Actual
community
Performance
perspectives
Monitor and Evaluate Performance
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Performance Improvement Framework
Stage 5
Get and Maintain Stakeholder Agreement
Define
Consider
Desired
institutional
Performance
Context
Select
Find Root
mission,
Interventions
Implement
Causes
Gap
goals,
What can be done
Why does the
Interventions
to close the
performance
strategies,
performance
gap exist?
gap?
culture and
Describe
client and
Actual
community
Performance
perspectives
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PI Example Improving Client-Provider
InteractionDominican Republic

• Desired 100 adherence to CPI norms

Interventions Feedback, CPI Norms, Training, Logi
stics
Main root causes Lack of knowledge and skills,
lack of information
Gap 40 of providers not following CPI norms
Actual 60 adherence to CPI norms
Dominican Social Security Institute (IDSS)
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Helping Providers Meet Client Expectations
Provider Adherence to

CPI Norms
Dominican Republic
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Interim Results
50
49
43
39
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Baseline
Interim results
No

Basic

All
interventions
interventions
interventions
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PI Example Supporting SupervisorsGhana

• Desired Supervise providers according to
  standard, 1/quarter

Interventions Clear job descriptions, coaching
on proposal writing
Main root causes Unclear expectations, no
transport
Gap 3 supervisions/year not done
Actual Supervised
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PI ExampleImproving IP PracticesBrazil

• Desired Practice appropriate infection
  prevention (IP) 100 of the time

Interventions Motivation intervention centered
around performance feedback and strengthened
management/ policies
Gap 78 of the time, IP practices are not
adequate
Main root cause Lack of incentive for practicing
IP
Actual Practicing appropriate IP 22 of the time
PROQUALI
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Interventions Clear Job Expectations, Improved
Facilities, Institutional Accreditation Sytem
Desired Performance
Interventions Selected
Actual Performance

• Quality criteria developed in
• Reproductive healthcare
• Infection prevention
• Counseling resources and practices
• Physical resources and supplies
• Management systems

• Clarification of job expectations
• Training
• Facility improvements
• Rewards programs

Only 5-30 of all criteria met
At the end of the 18-month project, 4 of the 5
clinics achieved 95-98 of the established
performance criteria.
The PROQUALI Project, Brazil
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Institutions Can Achieve and Maintain Quality
Accreditation Criteria
PROQUALI, Brazil Results in Pilot Clinics
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Performance Problems Can Be CorrectedOver Time
PROQUALI, Brazil PI Problem Solving
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PI User Perceptions

• Clear, step-by-step approach
• Highly participatory method
• Focuses on all possible barriers
• Focuses possible interventions on most important
  problems
• Potential for PI use in many other areas
• (Burkina Faso, Dominican Republic, India,
  Kenya, Yemen)

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More User Perceptions of PI

• Performance Improvement works at the
  organizational level as well as at the individual
  worker level
• IDSS Activity, PRIME Project

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How We Benefit from a Performance Improvement
Process

• Step-by-step diagnostic processes are important
• Systems frameworks that combine intervention
  strategies work best
• PI considers all causes of performance problems
• Results-orientation is embedded in the process
• Better return received on financial and human
  investment
• If doing training, assures it has the maximum
  impact
• Provides a process for CA collaboration

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Optional Slides
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Exercise
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Fishbone Technique
SKILLS AND KNOWLEDGE
MOTIVATION
PERFORMANCE FEEDBACK
Incorrect collection time
Staff careless in storage
Staff not well trained
Lack of motivation system
No funds
Material scanty
Wrong blood-coagulant ratio
EFFECTStaff performingunnecessaryrepeat lab
tests
Not enough collected
Staff not trained
No feedback
Poor disposable equipment
No job descriptions
Poor quality
Not properly selected
No written guidelines
No procedures fororder description
No funds
No supervision system
Damaged equipment
No procedures for collection
Poor maintenance
Unskilled personnel
JOB EXPECTATIONS
No funds
ENVIRONMENT AND TOOLS
ORGANIZATIONAL SUPPORT
Using Fishbone Technique inRoot-Cause Analysis
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PI Example Motivating Providersto Give FP
CounselingIndia

• Desired Counsel 100 of eligible clients

Interventions Motivation Actions that help ISM
providers sell contraceptives
Gap 75 of eligible clients receive no FP
counseling
Main root cause Lack of incentives to counsel
Actual Counseled 25 of eligible clients
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Root Cause Exploration Ghana
Infection Prevention (IP) Practices
Stakeholders
Group 2
Group 1
Group 3

• Job expectations
• Performance feedback

• Knowledge/skills
• Motivation

• Facilities/Equipment/Supplies
• Management/Leadership
• Community perception

• 6 Identified Interventions
• Adapt IP protocols to cut across all service
  areas
• Strengthen supervision system
• Incorporate IP into existing supervision system
• Sensitize health providers and community to IP
  practices
• Operationalize IP course into structured IST
  system
• Standardize bleach used in all facilities

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PI in the Dominican RepublicParticipant
Impressions

• About the PNA
• This is the first time weve considered other
  things, like feedback.

Dra Clavel Sanchez, IDSS
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PI in the Dominican RepublicParticipant
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 RepublicParticipant
Impressions
The big impact for us has been the humanization
of servicesthe better treatment of our clients.
Dr. Juan Octavio Ceballos, Minister of Health,
SESPAS