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Rational and Steps for Quality Improvement

Presented to Dr. Betty T. Polido Faculty of the College of Nursing Central Philippine University In Partial Fulfillment for the Requirement in the course N 414- F By REGINE MAE SOMONGCAD BRIAN SOMOSIERRA July 10, 2012

1. To be able to understand the steps of
performance improvement. 2. To be able to learn the steps and its rationale. 3. To be able to identify the barriers to successful performance improvement. 4. To be able to apply strategies to build a positive work climate. 5. To be able to discuss approaches for successful negotiation.

Performance refers to the way people do their jobs and the results of their work.

Organizations seeking to solve a performance problem frequently implement a specific intervention, such as training, without fully understanding the nature of the problem or determining whether or not the chosen intervention is likely to succeed. Just as often, professionals with a high level of expertise in a specific intervention area see every problem as an opportunity to ply their trade. As Abraham Maslow once said, To the person who only has a hammer in the toolkit, every problem looks like a nail. In fact, there are a number of methods for improving the performance of organizations, teams and individuals. Organizational development, industrial engineering, training and development, quality assurance, and human resources development address performance gaps in particular ways. Performance Improvement differs from these approaches by using a systematic methodology to find the root causes of a performance problem and then implement an intervention (or fix) that applies to that specific performance deficit.

What is Performance Improvement?

Performance Improvement (PI) is a method for analyzing performance problems and setting up systems to ensure good performance. PI is applied most effectively to groups of workers within the same organization or performing similar jobs. While PI principles are relevant to workers in any field, this publication focuses on primary providers of family planning and reproductive health (FP/RH) care services.

Factors That Affect Performance

Certain factors need to be in place for workers to be able to perform well on their jobs: Clear job expectations Clear and immediate performance feedback Adequate physical environment, including proper tools, supplies and workspace Motivation and incentives to perform as expected Skills and knowledge required for the job.

Rational and Steps for Performance Improvement

Stage 1: Consider Institutional Context The goal of this stage is to have the PI facilitator and team members understand the institutional and cultural context of the organization you are working with. In considering the institutional context it is necessary, from the beginning, to pay attention to the culture within which the work will take place as well as the goals and mission of the institution with which you are working. If at all possible, it is also important to incorporate the perspective of the clients and communities served by the organization, particularly during the implementation stage of PI.


There are no specific steps for this stage. Rather, use the above list as a guide for your information gathering. If your project team is large, you may want to summarize your findings in a meeting and/or written communication.

Stage 2: Obtain and Maintain Stakeholder Agreement

STEP 1: Recognize the opportunity to apply PI Awareness of an opportunity to apply the PI methodology can come through a request for assistance from someone within your organization or from another organization.

STEP 2: Gather preliminary project information Meet with the key decision-makers to gather the preliminary information you need to get started. You may want to approach this meeting with the stated goal of making sure we have all the elements we need to ensure that training is successful. Find out about sources of valuable information, such as existing research, trip reports or documentation of previous attempts to improve performance, and be sure to review those materials before conducting interviews.

STEP 3: Conduct interviews with representative stakeholders Your goal is to identify the major performance issues facing the organization and gather opinions about what might be causing the problems. If a key decision-maker has all the answers, this step may take only one meeting. However, it is best to talk to a representative sample of stakeholders who are familiar with the organization. Ask the key decision-makers to identify other stakeholders you should consult with. You can talk to them one-on-one, in focus groups, meetings or whatever forum suits your style and that of the organization.

STEP 4:Review your findings with the key decision-makers; prepare for Project Agreement Meeting Review your findings with the key decision-makers. Sometimes the interviewees you talked with in Step 3 will disagree on some points. Discuss these disagreements with the key decision-makers and try to reach a consensus before proceeding to the Project Agreement Meeting. Summarize your findings in a handout for use at the meeting. The handout should contain the same headings as the Project Agreement Letter described in Step 6. At the Project Agreement Meeting, when all the stakeholders are gathered together, the goal will be to reach consensus on the project. Decide who will facilitate this important meeting.

STEP 5: Conduct the Project Agreement Meeting Conduct the Project Agreement Meeting. Using the handout you prepared in Step 4, lead the group through a discussion of the summarized findings from the Step 3 interviews.
STEP 6:Prepare the Project Agreement Letter and facilitate necessary approvals Summarize the findings of the Project Agreement Meeting, describing the consensus that was reached. Detail your findings in the Project Agreement Letter. Meet with the key decision-makers and review the letter. When you have a signed Project Agreement Letter, you are ready to define desired performance.

STAGE 3: Define Desired Performance

In order to gain consensus on exactly what is desired in terms of performance, you will work with the stakeholder group to state desired performance in results-based, measurable terms. This focus will help every other step of the PI process (including evaluation) become more precise, clear and targeted. Indeed, without a careful definition of desired performance, the rest of the process carries little meaning. To paraphrase the March Hare, if you dont know your destination, any path will do.

STEP 1: Write desired performance statements

Define performance in specific and measurable terms. For the definition to be valid, you must ensure that all key stakeholders have input and/or agree on the performance statements. This process will take time, as individual stakeholders may have opinions that differ, especially when they are forced to be specific.

STEP 2: Attach measures to each desired performance statement

For each statement of desired performance you should arrive at a performance indicator that describes a quality, quantity, time or cost. This step will help the group decide what really matters about the performance in question: Is it how well it is done, how often it happens, on how timely a basis or all three?

STEP 3: Set targets for desired levels of performance

Once you have decided on the measurable indicators for the performance in question, help the group set targets for each indicator. For example, should the performance follow the standard 100% of the time, or is 90% acceptable to start with? Should the providers always arrive by 9:00? Or is it OK to arrive occasionally at 9:15? Remember that the targets you set now may be revised as time goes by. As with ideal performance, setting targets that are unrealistic can be a detractor for performance. Revising targets is a good technique when performance levels are initially very low and you need to set interim goals for performers.

STAGE 4: Describe Actual Performance In the previous stage, the team defined desired performance in specific and measurable terms. Using those same indicators and measures, describe the current, or actual, performance. Possible sources of performance data include clinic records, ministry of health statistics, and previous projects and studies completed in the same area. Many times, however, existing data on current performance will be insufficient, and you will have to collect data on your own.The data gathered for this stage will serve as the baseline for determining the effectiveness of the interventions. After the interventions have been implemented for a designated time period, you will compare performance data to this baseline data to determine whether or how much performance has changed.

STEP 1: Decide on data collection methods

The team must decide which methods to use to collect current performance data linked to the desired performance statements that were written earlier. For each statement of desired performance, determine the best method or combination of methods for gathering reliable, valid data. For example, to gather data on the quality of medical treatment, a combination of client exit interviews and direct observation may be optimal. In another case, simulations may be necessary. As part of data-collection methodology, you will decide on the most adequate sample size and strategy (e.g., systematic cluster) for your project.

STEP 2: Design data collection instruments With the team or a subset of the team, design data collection instruments. The forms should simplify data compilation and be easy to use in the field. Data collection instruments often include interview guides, observation checklists, focus group discussion guides, questionnaires and survey forms.
STEP 3: Identify and equip data collectors Identify the data collectors and prepare them for activity in the field. At times, the data collectors will come from your immediate team or organization. Other times, you will need to hire data collectors. In any case, once the team is identified, they must be equipped with everything they need to collect baseline data. Readying them may include training, supplying vehicles or obtaining lodging in the field.

STEP 4: Compile and analyze data Compile the data that have arrived from the data collectors in the field. For smaller projects, this compilation may be done by hand on tables and check sheets. For larger efforts, statistical analysis software may be used. In either case, the data should be compiled in a way that communicates the current level of performance to the team and to others outside the immediate team. For example, if the desired level of performance is that 90% of eligible clients will receive treatment, what is the actual performance? 40%? 50%? Keep the audience in mind when choosing presentation formats.

STEP 5: Make statements about actual performance Using the Performance Improvement Specification form, take each statement of desired performance and make a corresponding entry that shows the actual (current) performance. Be able to back up the statements with appropriate data presentations (charts, graphs, etc).

STAGE 5:Describe Performance Gaps If the previous two stages are completed thoroughly, and performance statements are given observable and measurable indicators, describing performance gaps becomes a simple arithmetic exercise.For example, consider a case where desired performance states that providers should offer HIV/AIDS counseling to 100% of eligible clients who appear at the clinic, and baseline data show that providers currently counsel only 25% of eligible clients. The statement of the performance gap is that providers do not counsel 75% of eligible clients who appear at the clinic.
STEP 1: Describe the performance gaps Using the same measures as were used to describe desired and actual performance, describe the performance gaps.

STEP 2: Decide whether to work on each gap Depending on your project, the list of gaps may be quite long. It is important to pause and decide as a group whether each gap is worth the effort that will be required to close it. Consider whether the gap is wide or narrow. Take into account whether the gap seriously affects the potential of the organization to reach its goals. Contemplate how the gap affects client outcomes. Finally, weigh the amount of effort necessary to close the gap. Some gaps may not deserve further attention. Efforts to close some gaps may need to be postponed while you work on more serious or urgent gaps. STAGE 6: Find Root Causes Perhaps the most critical step in the PI process is identifying the root causes you will address with appropriate interventions. Root-cause analysis should take place immediately following the review of performance gaps with the same stakeholder group that helped to define desired performance. The outcome should be the identification of a root cause for each gap observed.

STAGE 7: Select and Design Interventions The goal of this stage is to select interventions that will close the performance gaps identified during the previous stages. One or more interventions should address each root cause. All of the interventions in your package should address at least one of the root causes. When you have described the root causes in terms of missing performance factors, certain interventions will naturally suggest themselves. For example, if knowledge and skills are lacking, some kind of training intervention will be appropriate.

STEP 1: Propose and select interventions The aim of this step is to agree on the general interventions, not to design each intervention (which may require additional expertise). The team should describe the proposed interventions in sufficient detail to allow the team leader to approach the stakeholders with a clear explanation of how interventions will address important causes.

STEP 2: Develop a design plan for each intervention If there are multiple interventions, each type of intervention may require a smaller team to work semiindependently. These teams can be formed at the end of the large-group planning meeting.

STEP 4: Develop, field test and produce the final version of the interventions The nature and extent of testing will depend on the stakes involved, the type of intervention, and the time and resources available. For example, you would not pre-test a strategic planning intervention, but if an intervention requires a major production or management effort, or significant costs, then the development team should produce and test a prototype version of the intervention and/or materials before moving to final production and implementation. Testing includes reviews with users, clients and subject-matter experts, or actual trials with members of the target audience in the environment in which the intervention will take place. Testing may reveal major weaknesses in the intervention design or materials and provide the necessary feedback to make revisions before final production. Based on the test data and feedback, revise the workplan as necessary.

STAGE 8: Implement Interventions The goal of this stage is to execute the intervention package designed and developed in the previous stage. The PI facilitator and various colleagues create and manage the implementation team, manage the overall implementation, and oversee organizational change processes. The most important outcome of this stage will be implemented interventions that close the performance gaps. STEP 1: Build the implementation team The first step is to reconfirm the PI team including the PI facilitator and client organization staff. The PI facilitator may be a program manager. The PI team then identifies and contracts with the necessary professionals to implement the interventions. The best place to start locating these team members is with the people who helped develop the interventions. Often, the best team to implement an intervention is the one that designed it. There are, however, occasions when developers may not be the ideal implementers. Examples include:

An instructional designer who is not the best presenter of classroom training A scriptwriter who designed the training video but is not a member of the production company you want to hire to produce the video.

STEP 2: Develop a detailed implementation plan Because implementation projects can become large and include many individuals and organizations with their own responsibilities, the PI team should construct an overall plan detailing the entire implementation structure and the role of each individual. Because PI projects focus on results, it is also important to maintain clarity about the performance expectations of each intervention. STEP 3: Conduct monitoring activities Once the implementation is under way, the role of the PI facilitator (or project manager) switches to monitoring and the performance of interim evaluations. At the milestone points in the implementation plan, the PI facilitator or delegate should assess milestone goals, provide feedback and solve problems. If deadlines slip, the PI facilitator will recalculate the project timeline and inform other implementation team members of any necessary changes in their deadlines.

STAGE 9: Evaluation The goal of this stage is to assess the effects of PI project interventions on provider performance and to judge the extent to which the performance gaps have closed. The evaluation may also examine organizational performance or the capacity of an institution to support and sustain improved provider performance. The evaluation stage is the culmination of a series of evaluative exercises conducted at each stage in the life of the project. The end-of-project evaluation is based on a foundation laid during the definition of desired performance and fed by assessments conducted during intervention selection and implementation.

STEP 1: Implement the evaluation plan

An evaluation plan will: Identify the purpose, users, resources and timelines of the evaluation Select the key evaluation questions and indicators and the best design to measure intended results Sequence evaluation activities (such as completing baseline documentation, conducting participant followups, materials pre-tests, project reviews and special studies) Prepare data collection and data analysis plans, including cost as well as results or program data Plan for communication, dissemination and use of evaluation results Identify the technical competencies needed on the evaluation team(s).

STEP 2: Conduct data collection, analysis and interpretation This step includes: Gathering and organizing data in a systematic way to reduce sources of bias and increase validity Discerning patterns, trends and comparisons from qualitative and quantitative data Linking cost and results data to have a retrospective Cost and Results Analysis (CRA) Involving client and stakeholders in interpreting data Employing standards to arrive at conclusions.

STEP 3: Write a report and communicate evaluation results

This step includes: Writing a report describing the methodology, findings and conclusions Selecting appropriate graphics to communicate summary findings Formulating recommendations based on conclusions and consultations with the client. The report should present findings so an audience can clearly see: Changes in performance How these changes can be attributed to the interventions Cost of the interventions. If the evaluation design warrants, the report should also present the effects (if any) of alternative interventions or the absence of interventions in control areas and discuss differences between those areas and the case area. Cost and Results Analysis (CRA) is especially useful in comparing alternatives and showing which offers the best value. The ultimate goal of evaluation is the use of results to: Demonstrate the validity of a new approach (i.e., what works) Identify areas to be strengthened in future project designs (i.e., what didnt work and what to do differently next time).

When Presented with Organizational Problems All performance gaps can eventually be traced to performers or the absence of performers. During this stage, the objective is to identify who those performer(s) are when an organizational problem is broad and does not readily implicate particular performers. For example, "Infection rates are skyrocketing" or "Postnatal maternal deaths are on the rise." The key to successfully addressing such problems is to understand the situation thoroughly enough to identify all of the performer(s) related to the gaps. As these problems are often complex, solving them may require additional investigation upfront before the traditional PI process can begin.

STEP 1: Understand the problem

The key stakeholder(s) will have opinions of what the problem is and these opinions will be important to the success of the process (whether or not they are correct). You will need to conduct an interview, or several interviews, to answer the following questions: What is the problem? What is the desired outcome? What would the situation look life if there was no problem? What are possible causes? (Note: care should be taken not to accept any of these causes as 'truth' until further investigation is done.) What does the client see as possible solutions? What potential constraints are there? (political, financial, etc.) Is the problem worth solving? Discuss with the client, making comparisons if possible with similar organizations or benchmarks. Who will be involved in the PI process from the organization? Identify local individuals to join the PI team.

STEP 2: Understand the organization

Now that you have asked your clients their opinions of the situation, it's time to explore the organization with your own eyes. The objective is to see how things work, start to fill in the picture and locate possible problematic areas. Don't stop when you've found one problem the whole process should be understood and mapped out. By the end of this step, you should be able to answer the following questions: What are the overall goals of the organization? How is the organization structured? What does it look like? Which components (or units) of the organization affect the problem area? What are the processes and functions of these components? How do they go about their work? What are the products or accomplishments that correspond to each process? How do the components/processes/functions relate? Where do they interact or intersect? Can you identify possible problem areas already?

STEP 3: What should the situation look like? What should the organization, systems, processes look like (think in terms of "what is possible")? This is an opportunity to use your experience and guide the discussion. As an outsider to the situation, it will be important for you to help the client see 'the whole picture'. Don't limit yourself too soon a great deal might be possible if you have the backing and cooperation of key stakeholders. At the very least, this step will allow you to discuss issues such as alignment of objectives and performance indicators with the client.

STEP 4: Identify the gaps and the performers on which to focus the PI process

With the PI Team, develop a set of preliminary findings and conclusions, and report to the client and other key stakeholders. Questions to be answered include: Where are the major gaps? Do gaps correspond to pieces that are missing from the organizational structure (e.g., a new area/performance will be required to close a gap)? Can you identify the performers who are responsible for the gaps? Process Steps (These can be done with a larger stakeholder meeting or with smaller meetings with key stakeholders). Present maps of desired and current status of organization/processes. Identify and prioritize gap areas. Develop/propose a working plan to address most critical area(s) first. Prepare MOE with conclusions, recommendations.

Lessons Learned
Performance development steps have proven effective and now widely use, there has been increased interest and experience in applying these same approaches. Recognizing that successful performance improvement processes require adoption and tailoring in given situation, interesting patterns of challenges and opportunities particularly to health service delivery. For instance, the growing practices of integration and intersectoral collaboration have reinforced expectations to broader range of stakeholders will be involved in decision making and planning process.

Bibliography Books
Moore, K., et al. (1992). Principles and vales of continuous Improvement healthcare. Paper presented at Management Conference, St. Lukes Episcopal Hospital , Huston Texas: p. 156-159 Cavaleri Steven A., Fearon David S. (2006). Inside Knowledge: Rediscovering the Source of Performance Improvement. The McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York,NY,10020: p. 678-679

Electronic Resources
http://www.intrahealth.org/sst/stage0.html (07-7-2012) www.intrahealth.org (07-7-2012) http://www.insightperformance.com/ (2012)