After key indicators and associated targets are selected, the second component of performance measurement and management is instituting a measurement/monitoring system to track progress towards targets. Performance management depends on data and information systems to identify deficits and strengths.
Managers must have access to performance measurement data, have the capacity to interpret data, and be able to set action plans based on gaps identified in the data. Staff should be involved throughout the process; they should be aware of targets, receive updates on performance data, and be engaged in data interpretation and development of action plans.
Another important consideration when assessing measurement and monitoring systems is the frequency with which data are collected, analyzed, and shared. Facility managers must consider how long it will take to collect a sufficient quantity of data to make meaningful conclusions and balance that with any reporting requirements or internal improvement processes.
When implementing performance measurement systems, stakeholders should be aware of how individual provider performance is measured and communicated. Data on provider performance can complement facility-level performance data; with both, stakeholders can understand how individual providers contribute to successes or areas for growth within a facility. However, provider performance management should be designed such that feedback is actionable and encourages improvement – sometimes with incentives – rather than purely punitive. If providers feel that performance measurement is futile and/or only used to punish them, they will not be motivated to improve and actively collaborate with managers to identify areas for growth. More information is included in the provider motivation module.
Systems for individual-level provider performance management should incorporate provider perceptions and involve collaboration between providers and managers to develop actionable improvement plans. Some examples of questions that managers may ask providers to catalyze performance review and improvement include:
- Please describe results or responsibilities you delivered that contributed to better results for your team and/or organization?
- Please describe results or responsibilities you fell short of achieving? What could have been done to achieve better results?
- What part of the organization’s mission do you demonstrate well?
- What part of the organization’s mission do you struggle to demonstrate?
- How do you want to grow in this team, and what steps are required to get there?
Staff supervision is a form of applied, individual-level performance measurement and management. However, not all supervision is equally effective. There has been inconclusive evidence of the effects of supervision in LMIC. A systematic review in 2011 found small improvements in provider practice and provider knowledge in some studies, but the data did not provide substantial evidence to support any conclusions.7 This was echoed in another systematic review on support and performance improvement for PHC workers in LMIC. This review identified supervision as one of five approaches to performance improvement. The others included mentoring, tools and aids, quality improvement methods, and coaching.8 Although supervision was the most studied of the five approaches, the types of supervision and results were heterogeneous. The authors concluded that while supervision did seem promising, more research was needed on how supervision is delivered to determine the effect.
By contrast, supportive supervision – whereby supervisory practices focus on problem solving and strengthening relations between staff rather than high-level problem solving – has been found to improve quality of care and job satisfaction in Sub-Saharan Africa.9 While traditional supervision often focuses on inspection and line management, resulting in punitive or corrective action and negatively affecting provider motivation and satisfaction, supportive supervision instead aims to build pathways to improvement through active collaboration between providers and supervisors.9 However, it is important to note that supportive supervision may only be effective if providers have a baseline level of support such as adequate drugs and supplies, human resources, workload, incentives, and career development. A systematic review of supportive supervision in Sub-Saharan Africa found that supportive supervision had the greatest positive impact when the following components were also in place:9
- Two-way communication between provider and supervisor, including real-time feedback
- Non-judgmental approach, actively listening, and humility
- Cordial relationships and consensus to work together
It is important to note that supervisors cannot be expected to immediately understand how to provide supportive supervision. Supervisors should be trained on how to coach, mentor, communicate, and conduct performance planning. Additionally, supervisors can be taught adult learning and training techniques to improve their skills.10