1. The
Performance Improvement Approach
An Orientation For Project Team
By Isaac Munene

2. Today’s learning objectives
• Be able to define the Performance Improvement
Approach (PIA)
• Name the 5 performance factors
• Describe the steps in the PI framework
• Thirst for more!!

3. Introductions
• As we go around the room, say:
– Your name
– Your position
– Knowledge or experience with PI

4. Who Wants to Be a Millionaire?
• What is the name of the group of people who
are essential decision makers in the
Performance Improvement process?
Important People
Stakeholders
Presidents
Facilitators

5. Who Wants to Be a Millionaire?
• What is the name of the group of people who
are essential decision makers in the
Performance Improvement process?
Important People
Stakeholders
Presidents
Facilitators

6. Who Wants to Be a Millionaire?
• Which of the following is NOT a performance
factor (conditions necessary for people to
perform well in their jobs)?
Clear Job Expectations
Performance Feedback
Skills and Knowledge
Advocacy

7. Who Wants to Be a Millionaire?
• Which of the following is NOT a performance
factor (conditions necessary for people to
perform well in their jobs)?
Clear Job Expectations
Performance Feedback
Skills and Knowledge
Advocacy

8. Who Wants to Be a Millionaire?
• What term is used to describe the difference
between desired performance and actual
performance in the Performance Improvement
framework?
Performance hole
Performance spiral
Performance gap
Performance differential

9. Who Wants to Be a Millionaire?
• What term is used to describe the difference
between desired performance and actual
performance in the Performance Improvement
framework?
Performance hole
Performance spiral
Performance gap
Performance differential

10. Who Wants to Be a Millionaire?
• What is the name of the process where data is
collected to assess what performance problems
exist and what factors are causing them?
Performance Needs Assessment
Performance Evaluation
Training Evaluation
Performance Factoring

11. Who Wants to Be a Millionaire?
• What is the name of the process where data is
collected to assess what performance problems
exist and what factors are causing them?
Performance Needs Assessment
Performance Evaluation
Training Evaluation
Performance Factoring

12. What is Performance?
 The tasks that people do and the results
of those tasks

13. Effort  Performance

14. What is the Performance
Improvement Approach?
 A step-by-step methodology for finding out
what is needed to ensure good performance,
and delivering it

15. Factors Influencing Performance
 Environment and supplies
 Job expectations
 Performance feedback
 Motivation and incentives
 Skills & knowledge
Organizational Support: Using Performance
Factors

16. Job Expectations
• Do providers know what is
expected of them?
– Guidelines, policies, standards,
procedures, protocols, job
descriptions

17. Performance feedback
Do providers know
how they are doing
compared to set
expectations or
standards?

18. Motivation/Incentives
• Do providers have a reason to
perform as they are asked to
perform?
• Does anyone notice when they
perform well?

19. Physical Environment
The infrastructure, supplies, materials, and
tools necessary to do the job.

20. Knowledge and Skills
• Do providers know
how to do the
required job?
• Are there systems
and interventions to
address how to do a
job

21. Organizational Support
• Does the organization assure that all
the performance factors are in place?
• Through supportive supervision,
communication mechanisms, training,
functioning logistics systems, developing
job descriptions, updating and
disseminating policies, norms, and
protocols…

22. Benefits of PI
• Use systematic approach for finding the root
cause of the performance problem
• Helps avoid making assumptions
• Data driven
• Allowing you to implement the best
intervention that applies only to that root
cause
• Ensures training has maximum impact

23. PI answers these questions
 What performance do we have now? (Actual)
 What performance do we want? (Desired)
 What is the difference? (Gap)
 Why is there a difference? (Root causes)
 What should we do about it? (Interventions)

24. Performance Measures…
• Quality
– Does the performance match the standard?
• Provider should counsel clients on the side effects of
their chosen method during FP counseling.
• Quantity
– Does the performance happen as much or as often as it should?
• Each provider sterilizes 4 sets of instruments at the
beginning of each day.
• The provider should always discuss side effects of the FP
method the client selects (100% of the time).

25. Performance Measures…
• Timeliness
– Does the performance happen on time?
• The provider should be ready to see clients by 9:00 a.m.,
every day.
– Does the performance happen as often as it should?
• The provider should do family planning counseling
with all eligible women and couples (100% of the
time).

26. PI Framework
CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
PERFORMANCE
GAP
IMPLEMENT
INTERVENTION
PNA

27. Steps in Performance
Improvement
 Consider the institutional context
 Stakeholder agreement
 Define desired performance
 Determine actual performance
 Identify performance gaps
 Analyze root causes
 Select interventions
 Develop draft action plans
 Implement Interventions
 Monitor and evaluate interventions
Performance
Needs
Assessment

28. Example-FP Providers
• Desired: 100% adherence to client-provider
interaction norms
• Actual: 60% adherence to norms
• Gap: 40% of providers not adhering to norms
• Root causes: unclear expectations,
lack of client provider interaction (CPI)
skills, no feedback
• Interventions: CPI norms training,
feedback from clients

29. Example-2
• Desired: counsel 100% of eligible clients
• Actual: counseling less than 25%
• Gap: 75%
• Root causes: incentives,
supplies
• Interventions: incentive
($), supply chain

30. Let’s break the stages down
one by one

31. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

32. Consider Institutional Context
• The mission of the organization
• The goals of the program
• Strategies in use already
• Culture of the organization and the country
• Client and community perspectives

33. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

34. Obtain and Maintain Stakeholder
Agreement
• Who are stakeholders?
• Gather information from key stakeholders
• Stakeholders meet to agree on desired
outcomes
• Actively participate in identifying goals, prioritizing
performance problems, analyzing root causes and
selecting interventions
• Ownership of process and commitment to making
improvements

35. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

36. Define Desired Performance
Definition:
 What the organization would like to see happening,
 Where do we want to go?
 How do we want things to be?
 i.e. What should the standard of FP services be?
 What are the goals of the FP program?
 What should providers, supervisors, and facilities be doing
to reach goals and objectives?
 Defined by stakeholder consensus using
specific, measurable terms

37. Desired Performance Statements
 Identify the performer
 State accomplishments or behavior within control of
the performer
 Observable
 Measurable
 Specific, can be agreed upon by independent
observers
Example: All FP providers should counsel FP clients on
HIV risk and prevention according to standards.

38. Desired Performance
Statements
Indicators Desired
Levels
Providers counsel FP clients
on side effects of their
selected method.
% of providers who tell clients about
the possible side effects of their
chosen method
90%
Providers promote male
involvement in RH/FP
services.
% of providers who encourage
women to have their spouse join
them for their FP consultation
60%
Community leaders should
talk about the benefits of FP
during community meetings.
% of community leaders who
mention FP during meetings in the
community
50%
Examples of desired performance

39. Practice 1—Define Desired
Performance Statements
 Job: Waiter/waitress in a restaurant
 Describe 2 desired performance statements
for this person
 You have 15 minutes

40. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

41. Methods for assessing actual
performance
 Use existing data!
 Direct observation of performance
 Facility audit
 Provider interview
 Clinic record review
 Focus groups with community members
 Client exit interview
 Household survey
• Self-assessment

42. Actual Performance
Statements
 One for each desired performance statement
 Desired and actual performance are
measured with same indicators

43. Desired Performance
Statements
Actual Performance
Statements
90% of providers counsel FP clients
on side effects of their chosen
FP method
60% of providers counsel FP clients on
side effects of their chosen FP
method
60% of providers encourage women
to have their spouse join them for
their FP consultation
20% of providers encourage women to
have their spouse join them for
their FP consultation
50% of community leaders mention FP
during meetings in the community
0% of community leaders mention FP
during meetings in the community
Examples of actual performance statements

44. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

45. What is a Performance Gap?
Desired Performance — Actual Performance
Desired Performance
For example:
50% - 10% X 100 = 80% Gap
50%
X 100 = GAP

46. Desired Performance
Statements
Actual Performance
Statements
Performance
Gaps
90% of providers counsel
FP clients on side effects of
their chosen FP method
60% of providers counsel
FP clients on side effects of
their chosen FP method
33% of providers do NOT
counsel FP clients on side
effects of their chosen FP
method
60% of providers
encourage women to have
their spouse join them for
their FP consultation
20% of providers
encourage women to have
their spouse join them for
their FP consultation
67% of providers do NOT
encourage women to have
their spouse join them for
their FP consultation
50% of community leaders
mention FP during
meetings in the community
0% of community leaders
mention FP during meetings
in community
100% of community
leaders do NOT mention
FP during meetings in the
community
Examples of Performance Gaps

47. Prioritize Performance Gaps
• Cannot work on every performance gap at once
– Resources are limited
– Need to focus the efforts for greater success
• How to prioritize gaps?
Largest gaps
Critical area of performance
• Can select via democratic voting process or other method
• Place in priority order (i.e. highest number of votes to
lowest number)

48. Practice 2—Performance Gaps
• For each desired performance statement
discuss and agree on actual performance
based on your experience eating out
• Determine the size of the gap for each
performance statement
• You have 3 minutes.

49. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

50. Root Cause Analysis—Multiple Whys
Why?
Why?
Why?

51. Root Cause Analysis Technique
 For each gap, ask “why is this happening?”
 For each answer, ask “why” again?
 Record all responses as they come up
 Keep asking “why?” until there are no more reasons
 Stop when you say “I don’t know”
 The root cause is the lowest-level cause that something can
be done about.

52. Gap: Supervisors are not making appropriate number of supervision visits
Root Cause Analysis Example
Did not know how many visits were expected No transport
No one told themHave no job
description No funds
No one developed a
Job description
No one’s job
to tell them Did not request funds
Did not know how to complete
the funding request form
Were not trained
Have no supervisor
No support system for them
Not in their
training
Example: Ghana,
2000
Why? Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
Why?
I don’t
know
I don’t
know
I don’t know I don’t know
Why?
Why?
Why? Why?

53. Practice 3—Root Cause Analysis
• Discuss and select the priority performance
gap that is most important to work on first
• Use the multiple whys technique to uncover
the root cause (s) for that 1 gap
• You have 15 minutes.

54. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

55. Steps to select interventions (1)
• Define intervention criteria
• Make a list of criteria for judging possible
interventions, some examples include:
• Affordable
• Feasible (considering resources)
• Time bound (i.e. completed within 1 year)
• Culturally appropriate

56. Steps to select interventions (2)
• Brainstorm possible interventions
– Generate as many possibilities as you can
• Prioritize and select interventions
– Compare each intervention to criteria list
– Cross out those that do not meet the criteria
• Select the best intervention to fix the root cause—aim
for 1 intervention per root cause
• Develop action plan for each intervention:
– Activities/steps/tasks
– Person responsible
– Timeframe

57. Intervention and Action Plan Format
Performance
Gap
Root
Cause
Intervention Activity/
Steps
Person
Respon-
sible
Time-
frame
Clinical
officers,
midwives, and
nurses are not
performing
IUCD insertion
Lack of
knowledge
and skills
Training of
health workers
Identify
training
sites
Identify
trainees
Identify
supplies
Conduct
training
District
director
District
Nurse
District
health team
District
trainers
30-03-05
30-03-05
30-04-05
30-04-05

58. Design Interventions
• Form and convene a design and development
team
– Involve potential implementers
• Develop a workplan for the design and
development team
• Design and develop interventions
• Field test where appropriate
• Identify input, process and output indicators

59. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

60. Implement Interventions
• Develop an implementation plan and a
monitoring and evaluation plan
• Identify and mobilize resources
• Carry out interventions
• Foster and document organizational change
process

61. CONSIDER
INSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT AND
COMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIRED
PERFORMANCE
FIND ROOT
CAUSES
WHY DOES THE
PERFORMANCE
GAP EXIST?
SELECT
INTERVENTIONS
WHAT CAN BE DONE
TO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUAL
PERFORMANCE
IMPLEMENT
INTERVENTION

62. Monitor & evaluate performance
• Monitor the implementation and make adjustments as
necessary
• Repeat the baseline data collection exercise using the same
indicators and instruments
• Compare baseline to final results
– Make statements about the extent to which the gaps closed
• Where goals were met, celebrate!
• Where goals were not met, analyze and cycle through PI
process again

63. What questions or comments do
you have?