16-17Somongcad R.&Somosiera.ppt2 Complete

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Rational and Steps for QualityImprovementPresented to

Dr. Betty T. Polido

Faculty of the College of NursingCentral Philippine UniversityIn Partial Fulfillment

for the Requirement in the courseN 414- F

ByREGINE MAE SOMONGCAD

BRIAN SOMOSIERRAJuly 10, 2012


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Objectives

1. To be able to determine the steps of performanceimprovement.

2. To be able to identify the steps and its rationale.

3. To be able to discuss the barriers to successfulperformance improvement.

4. To be able to apply strategies to build a positive workclimate.

5. To be able to discuss approaches for successful

negotiation.6. To be able to determine the factors affecting

performance.


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INTRODUCTION

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

Organizations seeking to solve a performance problemfrequently implement a specific intervention, such as training, withoutfully understanding the nature of the problem or determining whetheror not the chosen intervention is likely to succeed. Just as often,professionals with a high level of expertise in a specific interventionarea see every problem as an opportunity to ply their trade. AsAbraham Maslow once said, To the person who only has a hammerin the toolkit, every problem looks like a nail. In fact, there are anumber of methods for improving the performance of organizations,

teams and individuals. Organizational development, industrialengineering, training and development, quality assurance, and humanresources development address performance gaps in particular ways.Performance Improvement differs from these approaches by using asystematic methodology to find the root causes of a performanceproblem and then implement an intervention (or fix) that applies tothat specific performance deficit.


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What is Performance

Improvement?

Performance Improvement (PI) is a method foranalyzing performance problems and setting upsystems to ensure good performance. PI is

applied most effectively to groups of workerswithin the same organization or performingsimilar jobs. While PI principles are relevant toworkers in any field, this publication focuses on

primary providers of family planning andreproductive health (FP/RH) care services.


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Factors That Affect Performance

Certain factors need to be in place for workersto be able to perform well on their jobs:

Clear job expectations

Clear and immediate performance feedback

Adequate physical environment, including propertools, supplies and workspace

Motivation and incentives to perform asexpected

Skills and knowledge required for the job.


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Rational and Steps for

Performance Improvement Stage 1: Consider Institutional Context

The goal of this stage is to have the PI facilitatorand team members understand the institutional andcultural context of the organization you are working

with. In considering the institutional context it isnecessary, from the beginning, to pay attention to theculture within which the work will take place as well asthe goals and mission of the institution with which youare working. If at all possible, it is also important to

incorporate the perspective of the clients andcommunities served by the organization, particularlyduring the implementation stage of PI.


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Steps There are no specific steps for this stage. Rather, use the above list

as a guide for your information gathering. If your project team islarge, you may want to summarize your findings in a meetingand/or written communication.

Stage 2: Obtain and Maintain StakeholderAgreement

STEP 1: Recognize the opportunity to apply PI

Awareness of an opportunity to apply the PI

methodology can come through a request forassistance from someone within yourorganization or from another organization.


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STEP 2: Gather preliminary projectinformation

Meet with the key decision-makers to gatherthe preliminary information you need to getstarted. You may want to approach this meetingwith the stated goal of making sure we have all

the elements we need to ensure that training issuccessful. Find out about sources of valuableinformation, such as existing research, tripreports or documentation of previous attemptsto improve performance, and be sure to reviewthose materials before conducting interviews.


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STEP 3: Conduct interviews withrepresentative stakeholders

Your goal is to identify the majorperformance issues facing the organization andgather opinions about what might be causingthe 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 representativesample of stakeholders who are familiar with theorganization. Ask the key decision-makers toidentify other stakeholders you should consultwith. You can talk to them one-on-one, in focusgroups, meetings or whatever forum suits yourstyle and that of the organization.


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STEP 4:Review your findings with the keydecision-makers; prepare for Project AgreementMeeting

Review your findings with the key decision-makers.Sometimes the interviewees you talked with in Step 3will disagree on some points. Discuss thesedisagreements with the key decision-makers and try toreach a consensus before proceeding to the Project

Agreement Meeting. Summarize your findings in ahandout for use at the meeting. The handout shouldcontain the same headings as the Project AgreementLetter described in Step 6. At the Project AgreementMeeting, when all the stakeholders are gatheredtogether, the goal will be to reach consensus on theproject. Decide who will facilitate this important meeting.


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STEP 5: Conduct the Project Agreement Meeting

Conduct the Project Agreement Meeting. Using thehandout you prepared in Step 4, lead the group through

a discussion of the summarized findings from the Step 3interviews.

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, youare ready to define desired performance.


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STAGE 3: Define Desired Performance

In order to gain consensus on exactly what is

desired in terms of performance, you will work with thestakeholder group to state desired performance inresults-based, measurable terms. This focus will helpevery other step of the PI process (including evaluation)become more precise, clear and targeted. Indeed,without a careful definition of desired performance, therest of the process carries little meaning. To paraphrasethe March Hare, if you dont know your destination, anypath will do.


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STEP 1: Write desired performance statements

Define performance in specific and measurable terms. For thedefinition to be valid, you must ensure that all key stakeholders

have input and/or agree on the performance statements. Thisprocess 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 desiredperformance statement

For each statement of desired performance youshould arrive at a performance indicator that describes aquality, quantity, time or cost. This step will help the

group decide what really matters about the performancein question: Is it how well it is done, how often ithappens, on how timely a basis or all three?


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STEP 3: Set targets for desired levels ofperformance

Once you have decided on the measurable indicatorsfor the performance in question, help the group settargets for each indicator. For example, should theperformance follow the standard 100% of the time, or is90% acceptable to start with? Should the providersalways arrive by 9:00? Or is it OK to arrive occasionallyat 9:15? Remember that the targets you set now may berevised 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 whenperformance levels are initially very low and you need toset interim goals for performers.


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STAGE 4: Describe Actual Performance

In the previous stage, the team defined desiredperformance in specific and measurable terms. Using

those same indicators and measures, describe thecurrent, or actual, performance. Possible sources ofperformance data include clinic records, ministry ofhealth statistics, and previous projects and studiescompleted 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 datagathered for this stage will serve as the baseline fordetermining the effectiveness of the interventions. Afterthe interventions have been implemented for adesignated time period, you will compare performancedata to this baseline data to determine whether or howmuch performance has changed.


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STEP 1: Decide on data collection methods

The team must decide which methods to use to

collect current performance data linked to the desiredperformance statements that were written earlier. Foreach statement of desired performance, determine thebest method or combination of methods for gatheringreliable, valid data. For example, to gather data on the

quality of medical treatment, a combination of client exitinterviews and direct observation may be optimal. Inanother case, simulations may be necessary. As part ofdata-collection methodology, you will decide on the most

adequate sample size and strategy (e.g., systematiccluster) for your project.


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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. Datacollection 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 willcome from your immediate team or organization. Othertimes, you will need to hire data collectors. In any case,once the team is identified, they must be equipped witheverything they need to collect baseline data. Readyingthem may include training, supplying vehicles orobtaining lodging in the field.


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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 byhand on tables and check sheets. For larger efforts, statistical

analysis software may be used. In either case, the data should becompiled in a way that communicates the current level ofperformance to the team and to others outside the immediate team.For example, if the desired level of performance is that 90% ofeligible clients will receive treatment, what is the actualperformance? 40%? 50%? Keep the audience in mind whenchoosing presentation formats.

STEP 5: Make statements about actual performance Using the Performance Improvement Specification

form, take each statement of desired performance andmake a corresponding entry that shows the actual(current) performance. Be able to back up thestatements with appropriate data presentations (charts,graphs, etc).


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STAGE 5:Describe Performance Gaps If the previous two stages are completed

thoroughly, and performance statements are given

observable and measurable indicators, describingperformance gaps becomes a simple arithmeticexercise.For example, consider a case where desiredperformance states that providers should offer HIV/AIDScounseling to 100% of eligible clients who appear at theclinic, and baseline data show that providers currentlycounsel only 25% of eligible clients. The statement ofthe performance gap is that providers do not counsel75% 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 theperformance gaps.


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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 isworth the effort that will be required to close it. Consider whether

the gap is wide or narrow. Take into account whether the gapseriously affects the potential of the organization to reach its goals.Contemplate how the gap affects client outcomes. Finally, weigh theamount of effort necessary to close the gap. Some gaps may notdeserve further attention. Efforts to close some gaps may need tobe 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 thereview of performance gaps with the same stakeholder group thathelped to define desired performance. The outcome should be the

identification of a root cause for each gap observed.


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STAGE 7: Select and Design Interventions

The goal of this stage is to select interventions thatwill close the performance gaps identified during the

previous stages. One or more interventions shouldaddress each root cause. All of the interventions in yourpackage should address at least one of the root causes.When you have described the root causes in terms ofmissing performance factors, certain interventions will

naturally suggest themselves. For example, if knowledgeand skills are lacking, some kind of training interventionwill be appropriate.


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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 insufficient detail to allow the team leader to approach thestakeholders 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 ofintervention may require a smaller team to work semi-

independently. These teams can be formed at the end ofthe large-group planning meeting.


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STEP 4: Develop, field test and produce the finalversion of the interventions

The nature and extent of testing will depend on the

stakes involved, the type of intervention, and the timeand resources available. For example, you would notpre-test a strategic planning intervention, but if anintervention requires a major production or managementeffort, or significant costs, then the development teamshould produce and test a prototype version of the

intervention and/or materials before moving to finalproduction and implementation. Testing includes reviewswith users, clients and subject-matter experts, or actualtrials with members of the target audience in theenvironment in which the intervention will take place.

Testing may reveal major weaknesses in the interventiondesign or materials and provide the necessary feedbackto make revisions before final production. Based on thetest data and feedback, revise the workplan asnecessary.


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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 colleaguescreate and manage the implementation team, manage the overallimplementation, and oversee organizational change processes. The most

important outcome of this stage will be implemented interventions thatclose 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 professionalsto implement the interventions. The best place to start locating these teammembers 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 idealimplementers. Examples include:

An instructional designer who is not the best presenter of classroomtraining

A scriptwriter who designed the training video but is not a member of theproduction company you want to hire to produce the video.


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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 PIprojects focus on results, it is also important to maintain clarityabout 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 theperformance of interim evaluations. At the milestone points in theimplementation plan, the PI facilitator or delegate should assessmilestone goals, provide feedback and solve problems. If deadlinesslip, the PI facilitator will recalculate the project timeline and informother implementation team members of any necessary changes intheir deadlines.


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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 haveclosed. The evaluation may also examine organizationalperformance or the capacity of an institution to supportand sustain improved provider performance.

The evaluation stage is the culmination of a series ofevaluative exercises conducted at each stage in the lifeof the project. The end-of-project evaluation is based ona foundation laid during the definition of desiredperformance and fed by assessments conducted duringintervention selection and implementation.


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STEP 1: Implement the evaluation plan

An evaluation plan will:

Identify the purpose, users, resources and timelines ofthe evaluation

Select the key evaluation questions and indicators andthe best design to measure intended results

Sequence evaluation activities (such as completing

baseline documentation, conducting participant follow-ups, materials pre-tests, project reviews and specialstudies)

Prepare data collection and data analysis plans, includingcost as well as results or program data

Plan for communication, dissemination and use ofevaluation results

Identify the technical competencies needed on theevaluation team(s).


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STEP 2: Conduct data collection, analysis andinterpretation

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.


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STEP 3: Write a report and communicate evaluation results

This step includes:

Writing a report describing the methodology, findings andconclusions 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 ofinterventions 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).


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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 doesnot readily implicate particular performers. For example,"Infection rates are skyrocketing" or "Postnatal maternaldeaths are on the rise." The key to successfullyaddressing such problems is to understand the situation

thoroughly enough to identify all of the performer(s)related to the gaps. As these problems are oftencomplex, solving them may require additionalinvestigation upfront before the traditional PI processcan begin.


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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 ofthe process (whether or not they are correct). You will needto conduct an interview, or several interviews, to answer thefollowing 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 investigationis 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 orbenchmarks.

Who will be involved in the PI process from the organization?Identify local individuals to join the PI team.


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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 andlocate possible problematic areas. Don't stop when you've foundone problem the whole process should be understood andmapped out. By the end of this step, you should be able to answerthe 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?


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STEP 3: What should the situation look like?

What should the organization, systems, processes looklike (think in terms of "what is possible")? This is anopportunity to use your experience and guide thediscussion. As an outsider to the situation, it will beimportant for you to help the client see 'the wholepicture'. Don't limit yourself too soon a great deal

might be possible if you have the backing andcooperation of key stakeholders. At the very least, thisstep will allow you to discuss issues such as alignment ofobjectives and performance indicators with the client.


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STEP 4: Identify the gaps and the performers on which tofocus 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 berequired 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.


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Lessons LearnedPerformance development steps have proven

effective and now widely use, there has been increasedinterest and experience in applying these sameapproaches. Recognizing that successful performanceimprovement processes require adoption and tailoring ingiven situation, interesting patterns of challenges and

opportunities particularly to health service delivery. Forinstance, the growing practices of integration andintersectoral collaboration have reinforced expectationsto broader range of stakeholders will be involved in

decision making and planning process.


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Bibliography

Books

Moore, K., et al. (1992). Principles and vales of continuousImprovement 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, NewYork,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)


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END

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