TOOLS: Performance Improvement Specification — Job Aid

This job aid provides step-by-step information for completing the Performance Improvement Specification form. As you complete the steps described below, you will define desired and actual performance, identify the root causes of performance gaps (the difference between desired and actual performance), consider appropriate interventions to close the gaps, and rank the interventions on a cost benefit scale.

Steps 1 & 2: Define Desired and Actual Performance

First Things First: Specify the problem in terms of performance

People will often present you with problems like “clients are not returning to the clinic.” While that is certainly a problem, it is stated in general terms that do not reflect anyone’s performance. Your job is to “drill down” until you uncover the performance that is the root cause of the problem. Once you’ve done that, you can define desired performance and the actual performance.

The “why-why-why” technique is useful to gain specificity and uncover the performance in the problem. When presented with a problem, keep asking “why?” until there are no more answers. (Those of you with small children will be especially familiar with this technique.)

Example of the why-why-why technique
A: People aren’t coming back to our clinic.
B: Why aren’t they coming back?
A: Well, I’m not sure. I hear some complaints about the time it takes.
B: Why are people complaining about the amount of time?
A: I guess they think it takes too long.
B: Why do they think it takes too long?
A: Maybe they think a four-hour wait is too long, and maybe they are right.
B: Why do people have to wait four hours?
A: Well, the providers can only do so much, but they only see about one person per hour.
B: Why do they only see one person per hour?
A: Well, they have a lot to do with each client.
B: Are there any other reasons? (“why” else?)
A: Well, they have a lot of down time between clients.
B: Why do they have a lot of down time?
A: Hm, they have some paperwork, and they take long breaks.
B: Ah ha!

The interviewer turns a hard-to-solve problem (people not coming back) into a performance problem (long breaks) that can be attacked. The interviewer should then go back and start at the beginning again to see if other problems need to be identified. In this case, you would say, “Are there any other reasons people are not coming back?”

Specify the performance in question

When defining desired and actual performance, your role is to describe the performance in observable, measurable indicators. We will use these indicators later to determine project success. Good performance indicators:

Poor Example Problem/With Example Better Example
The provider should show they care about the client. Ambiguous—there are many ways to show that one cares. The provider lets the client finish all explanations and does not interrupt.
The provider should spend adequate time with each client. Adequate is open to many interpretations. The provider spends at least 20 minutes with each client.
The provider should know the client-provider interaction (CPI) protocol. Not observable: we cannot see what someone knows, only what they do. The provider follows the five steps of the CPI protocol with every client.
The provider respects the privacy of each client. Not observable and ambiguous. The provider should meet with every client in a place that allows conversations that cannot be overheard by anyone else.
The provider sees at least five clients every day. Not under the control of the provider—what if only three come to the clinic? The provider takes no longer than 15 minutes of break/documentation time between clients when clients are in the waiting room.
There should be adequate supplies in the clinic. Not the behavior or accomplishment of the provider. This might be a cause of a performance problem, but it is not a description of desired performance. When available, the provider should give each OC client a two-cycle supply.
The providers have inadequate community support. Not the behavior or accomplishment of the provider. This might be a cause of a performance problem, but it is not a description of performance. Providers have explicit mechanisms to solicit feedback about performance from community members; the provider acts on feedback and communicates results.
The providers do not offer integrated RH services. Ambiguous—no clear definition of integrated. Or, if there is a definition, it should be used instead. The providers offer the five minimum services listed in the clinic policy manual or refer clients when the service is unavailable at their site.

Step 3: Define Performance Gaps

Once you have described performance in observable and measurable terms, stating the gap is often a simple matter of arithmetic—just subtract the desired from the actual. Some examples appear in the table below.

Desired Performance Actual Performance Gap
All providers should offer all five FP methods available at our clinic. Only 3 of the 10 providers regularly offer all five methods. 70 percent (7 out of 10) do not offer all five methods.
Providers should spend 8 to 10 minutes consulting with clients regarding their reason(s) for coming to the clinic (and reviewing the resolution of prior health concerns as noted on the client’s chart) before starting procedures. Eight of 10 providers spend an average of less than five minutes with clients discussing current and past health concerns (some frequently do not consult the client’s chart) prior to beginning procedures. 80 percent of providers are not performing at the desired level.

Step 4: Determine Root Causes of Gaps

Determining the root cause is an essential step of any PI investigation. Selecting the right intervention is completely dependent on finding the root cause of the performance gap. Remember the relationship between performance and interventions:


We should only select interventions that will fix the cause of the gap. If we select an intervention that does not fix the root cause of the gap, there will be no positive change in performance. For example, consider what happens if we offer training when lack of skills and knowledge are not the cause of a performance gap.

There are many effective root-cause analysis tools, including the why-why-why technique described here and the Diagnosing Performance Problems table also included in this section.

Root Cause Analysis Tool: Why-Why-Why Technique

The why-why-why technique was described earlier as a means of getting clients to describe problems in relation to performance. The same technique can be used to explore the root causes of gaps. When exploring the root cause(s) of a gap, interviewers must keep asking why until they have exhausted the possible causes for the gap. Since there may be more than one reason, it is necessary to examine all the possibilities and consider which are most responsible for the gap.

State the Root Cause in Terms of the Related Performance Factor

After you have determined a root cause, you should be able to state the performance factor to which the root cause is related. The goal is to state the root cause as specifically as possible. Examples of root causes and the related performance factors are shown below.

Step 5: Propose Interventions

When you have found the root cause of the performance problem, and you have stated it in terms of its factor, the intervention will become obvious. The table below provides some possible interventions.

Performance Root Cause Possible Intervention
Lack of Information—no clear job expectations

Let performers know what is expected of them:

  • Job descriptions
  • Written protocols
  • Norms for the job
  • Clear verbal statement of expectations
Lack of information—no clear immediate performance feedback

Provide clear feedback on work performance, as soon as possible after the performance, for example:

  • Regularly post client satisfaction data
  • Provide information about adherence to a CPI checklist
  • Verbally tell a provider how they are doing compared to what is expected of them
Poor work environment or tools

Provide the tools, environment and supplies necessary to do the job, for example:

  • Enough light
  • Private space to do counseling
Lack of incentives for doing good work

Provide incentives contingent upon performing up to standard, for example:

  • Verbal “good job” for good performance
  • Access to training or other development activity
  • Employee-of-the-week award
  • Public recognition in newsletter, newspaper
  • Notation on employment record
Lack of organizational support

Provide organizational support, which may require any of the following:

  • Supportive supervision that makes sure all the other performance factors are in place
  • Rewriting mission statements
  • Restructuring of the organization
  • Restructuring of the reporting relationship
Lack of skills and knowledge

Provide training/learning activities/opportunities, for example:

  • Job aids
  • Instructional manuals
  • Self-study modules
  • On-the-job training
  • Peer training
  • Workshops
  • Classroom training