Refining Performance Improvement Tools and Methods

This 6-page paper explores the application of performance improvement methods and tools to health services work in resource-poor settings around the world. It explores an area of evaluation and means of sharing knowledge that may get shortchanged in settings that cannot afford dedicated staff with sufficient time, expertise, and means of collecting, analysing, and sharing data for improved performance. Despite these and other challenges often associated with applying performance improvement methodologies, the authors argue that these methodologies "offer the possibility of achieving substantial gains in the quality and access of health services in low-resource settings".

The authors explain that "The qualities of adaptability and stakeholder participation are the hallmark of the performance improvement framework, and they are reflected in many of the best tools for implementing performance improvement interventions in developing countries." Examples of tools described here are the framework developed by USAID's Performance Improvement Consultative Group; DELIVER's process mapping technique; the Management and Organizational Sustainability Tool (MOST); and the Performance Factors Questionnaire (PFQ) designed by the PRIME II project and applied in the area of reproductive heath and family planning in countries such as Ghana, Bangladesh, Armenia, and Nigeria.

Communication is a central strategic component of many of the methods highlighted here. For instance, the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs' "paired performance" method uses in-depth interviews, group discussion, and observation in recognition of the fact that "Improved performance in interpersonal communication requires two people, not one". As part of this process, "[s]hort indepth interviews are conducted with individual providers and clients. Twelve open-ended questions are asked to elicit individuals' perspectives on the presence or absence of six performance factors. While staying true to the fundamental elements of human performance technology, terminology used in discussing performance factors is adapted to be appropriate for providers in their work capacity - as well as their clients. In this context, the six factors are role expectations, performance feedback, physical environment and communication aids, motivation, social and organizational support, and skills and knowledge. At the end of each interview, respondents rank their perception of the influence of each factor had on their ability to communicate effectively in the process of the health consultation. Analysis of the data produces common themes and trends that are then shared with 'peer' groups of providers and clients for validation."

This resource also features a section highlighting lessons learned through experiences with applying these tools in the field. To cite only one, maintaining effective engagement of a range of stakeholders in the performance improvement process - on an ongoing basis rather than in stages - has been found to be crucial. In this regard, "the buy-in and support of the community and local government authorities is key in finding locally appropriate solutions and resources to address performance challenges." Discussion of specific recommendations, including the suggested shape of a rapid needs assessment toolkit, follows. This toolkit might include:

• An agenda for a performance needs assessment planning meeting (and other stakeholder meetings)
• A sheet of tips to help determine reasonable sample size
• A survey questionnaire
• Ways to collect data in a quick and cost-effective manner
• Criteria for prioritising among performance factors.

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