Rick Sullivan
www.jhpiego.org

For years, international development organizations believed that training was the way to improve performance. In reality, to have a lasting impact, training cannot be an isolated event. Instead, we need to employ an integrated process that identifies the most appropriate solution by first defining what desired performance is and then finding out what is inhibiting the achievement of that performance. This process must also assure that quality is sustained through continuous monitoring and evaluation.

At JHPIEGO, we work to improve the quality of reproductive health services by developing a global network of training systems that produce qualified preservice education faculty and inservice trainers, who in turn prepare healthcare providers. While acknowledging this significant contribution, it is important to ask the following questions

• Do these training networks improve the performance of healthcare workers at the service delivery site?
• Is training the best investment for improving performanceCor should other interventions also be considered?

Although training is one way to improve performance, it is rarely the only way. Having successfully developed quality clinical training networks, the next logical areas we need to explore are:

• How can we ensure that training results in improved performance, which in turn produces high quality services?
• What other factors contribute to improved performance, and what can we do to address them?

The Performance Improvement Process used by JHPIEGO and shown in the figure is based on the ISPI model and was adapted to fit our needs by the Performance Improvement Consultative Group (PICG). The PICG consists of representatives of the United States Agency for International Development (USAID) and USAID-funded cooperating agencies.

STEP 1: ANALYZE PERFORMANCE: First, conduct a performance analysis to identify what gaps, if any, exist between actual and desired performance. Focus on the performance of an individual or a group. If desired performance is not already defined, define it by asking

• What is the provider expected to do?
• How well (quality indicators)?
• Under what conditions?
• With what frequency?

Define desired performance with input from national policies and priorities, service delivery guidelines and as much stakeholder involvement as possible including, at a minimum, providers, supervisors and clients.

STEP 2. FIND ROOT CAUSES: Conduct a root cause analysis that asks why the identified performance gaps exist. Gather information from as many stakeholders as possible and identify the causes of poor performance before selecting appropriate interventions. Common causes of poor performance include

STEP 3. SELECT INTERVENTIONS: Next, select and design interventions to address the causes of performance gaps.

Not all interventions can be undertaken at once. Prioritize the selected interventions. Weigh costs and benefits carefully. In determining priority, consider the following criteria

• Appropriateness: Will this intervention contribute to closing the performance gap? Will it be effective in improving the quality of reproductive health services?
• Economics: Is the intervention affordable and sustainable?
• Feasibility: Are systems in place to support this intervention? Can it be successful in a low-resource setting?
• Cultural acceptability: Will the community and clients respond favorably to this intervention and be willing to advocate for it?
• Provider acceptability: Will the healthcare provider or supervisors agree to support the intervention?

STEP 4. IMPLEMENT INTERVENTIONS: During this phase, set interventions in motion and establish monitoring systems. Integrate the concept of change into daily work and carefully manage the direct and indirect impact of that change to maintain organizational effectiveness and achieve performance improvement goals.

STEP 5. MONITOR AND EVALUATE PERFORMANCE: This task is ongoing. Because certain interventions can have an immediate effect on organizational and individual performance, be certain to initiate sound monitoring systems that focus on measurable change in order to obtain early feedback on the results of the intervention. To evaluate the impact of interventions on closing the performance gap, continuously compare formal assessments of actual job performance to desired performance. Obtain information from evaluations and use it to guide further analysis of performance gaps and root causes. Follow leads from the information retrieved to modify the intervention design as needed.

The Performance Improvement Process helps to tell us what factors contribute to desired performance and what can be done to strengthen them. Using this process also helps ensure transfer of training to the workplace, where services are delivered to our ultimate customers: women and families.

Rick Sullivan is the Director of the Learning and Performance Support Office for the JHPIEGO Corporation, an affiliate of Johns Hopkins University,  phone: 410-614-3551, email: rsullivan@jhpiego.org; http://www.jhpiego.org ;http://www.reproline.jhu.edu/english/6read/6pi/pi.htm