Title: Improving Performance to Maximize Access and Quality for Clients
1Improving Performance to Maximize Access and
Quality for Clients
2Session Goals
- Participants will explore
- Performance improvement (PI) approach, framework
and factors influencing performance - How PI works
- Benefits of using PI
3E ? P
- Effort is not the same thing as Performance
4What is Performance?
- The tasks that people do and the results
5What 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
6What Factors Influence Performancecontinued
- Organizational Supportstrategic direction, job
roles and responsibilities, supportive
supervision system - EnvironmentAdequate and proper tools, supplies
and workspace
7Performance 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?
8Performance 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)
9How is PI Different From Other Quality
Approaches?
- A systematic process to analyze measurable gaps
between desired and actual performance and target
interventions to root causes of performance gaps
to achieve desired institutional and individual
results
10If 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
11Performance 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
12Performance 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
13Stage 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
14Performance Improvement Framework
Stage 2
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
Monitor and Evaluate Performance
15Examples 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
16Using Fishbone Techniquein Root-Cause Analysis
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
17Why? 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
Why?
Not in their training
No support system for them
Example Ghana, 2000
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20Performance Improvement Framework
Stage 3
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
21Stages 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
22Performance 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
23Performance 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
24PI in the Dominican Republic PNADR IDSS Example
- Desired 100 adherence to CPI norms
Interventions Feedback, CPI Norms, Training, Log
istics
Interventions Feedback, CPI Norms, Training, Logi
stics
Gap 40 of providers not following CPI norms
Main root causes lack of KS, lack of information
Main root causes Lack of knowledge and skills,
lack of information
Gap 40 of providers not following CPI norms
al 60 adherence to CPI norms
Actual 60 adherence to CPI norms
25PI in the Dominican RepublicInterim Results
Provider Adherence to
CPI Norms
55
50
49
43
39
34
Baseline
Interim results
No
Basic
All
interventions
interventions
interventions
26PI Example Indigenous Systems of Medicine (ISM)
Practitioners, India
- 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
27PI Example Regional Resource Team Members
(RRTs), Ghana
- 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 lt1/year
28PI Example PROQUALI, Brazil
- 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
29PI in Brazil The PROQUALI Project
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.
30PROQUALI Brazil Results Pilot Clinics
31PROQUALI Brazil Performance ImprovementProblem
Solving
32PI Users 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)
33More User Perceptions of PI
- Performance Improvement works at the
organizational level as well as at the individual
worker level - IDSS Activity, PRIME Project
34How 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
35Optional Slides
36Root Cause Exploration Ghana
Infection Prevention 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
37PI in the Dominican RepublicParticipant
Impressions
- About the PNA
- This is the first time weve considered other
things, like feedback.
Dra Clavel Sanchez, IDSS
38PI 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.
39PI 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
40Exercise