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Job Aids Symposium Introduces Powerful Ways to Improve Health Worker Performance

by Cynthia F. Young, Senior Staff Writer


Edward Kelley, Senior QA Advisor, introduced the morning keynote presentations.

The Quality Assurance Project and the Child Survival Collaborations and Resources (CORE) Group hosted a Job Aids Symposium at the International Trade Center in Washington, D.C., on May 24, 2001. The event, which was attended by more than 70 participants, introduced the growing use of job aids as a promising way to improve healthcare provider performance in developing countries.

The day-long event, with morning keynote presentations and afternoon breakout sessions, shared success stories, views, and evidence about the state-of-the-art in job aids and identified future developments that could make job aids more useful for child survival and international health. Participants also examined actual job aids that had been developed and tested in the field in a Job Aids Display area.

"We are trying to get out of old habits and look at new ways to improve performance," said Edward Kelley, PhD, Senior QA Advisor, who introduced the morning session.

Bart Burkhalter, Associate QA Project Director, Operations Research (left); James Heiby, Medical Officer, USAID; and Tony Moore, President, Moore Performance Improvement, Inc.

The traditional way of improving health worker performance in developing nations is through training. Growing evidence suggests, however, that these resource-intensive interventions may not always be sufficient and that well-developed job aids can be a powerful way of improving performance.

"Job aids are one of the fundamental strategies for improving healthcare performance," said James R. Heiby, MD, MPH, Medical Officer in the U.S. Agency for International Development Global Bureau’s Office of Health and Nutrition and QA Project Manager.

 "Yet, for them to work, the use of job aids needs to be actively supported by the health system," he noted. "Sometimes, managers assume that simply distributing the job aids is all that is needed. Job aids are not something a manager just pulls off a shelf and expects a healthcare worker to use. Health workers need the active support of management to use job aids appropriately."

The display tables featured a wide array of job aids.

Job aids also need to be created with care, he added. "Everyone understands that you need a high level of technical expertise to produce a good job aid. Yet what is not widely appreciated is that you also need expertise in the state-of-the-art in developing job aids. Both are necessary."

"The need for well-developed job aids is growing," he concluded, "and this is just the beginning."

Tony Moore, president of Moore Performance Improvement, Inc., who has developed job aids for the space shuttle, the U.S. Coast Guard, Southwestern Bell, and Johnson & Johnson, explained how job aids can be used across industries with dramatic, measurable results. Moore presented examples of incredible gains in productivity and quality, sometimes as high as 300 percent, with the use of job aids. While he advocates the use of data to monitor performance, detailed analyses in such cases only confirm the obvious. "You get such incredible changes in critical job measurements after using job aids that there is no need to do statistical analysis," Moore said. "It hits you right between the eyes."

"Job aids are used on the job while performing the task," he noted. "It tells you when to and when not to take action, and tells how to do it. Job aids are like having a coach who won’t ... humiliate you, a gentle guide."

Job aids help improve skills and knowledge of both health workers and patients.

Yet, he added, there are some caveats. First, job aids are designed to address one cause of poor performance: information and use of information gaps. They cannot solve environmental or motivational problems. "Psycho-social barriers also are a big issue for doctors and nurses," Moore added. "They don’t like sitting in front of patients and following a job aid. They feel it destroys their credibility."

However, this is a mistaken perception on the part of healthcare workers, he noted. While conducting research in Zambia, Moore came upon a surprising attitude among patients. He asked patients, "How much would it bother you if your doctor followed a manual?" The patients replied that, in fact, they would prefer it. They had faith in the manual, they said.

Leading practitioners in the field also shared their successes at the symposium. Paula Tavrow, PhD, QA Project Deputy Director of Operations Research, spoke about the successful use of job aids to improve malaria treatment in Kenya and malaria diagnosis in Malawi. In Kenya, the QA Project developed job aids for shopkeepers that explained the new malaria guidelines to them in Kiswahili. These job aids were then distributed by wholesale vendors. Outlets receiving the job aids were significantly more likely to provide correct anti-malarial treatment and information to mystery shoppers. In Malawi, improvements made to the instructional inserts accompanying rapid malaria diagnostic kits led to dramatically better use of the kits.

Federico R. Leon, PhD, of the Population Council, discussed his work to improve family planning counseling in Peru. He helped create job aids to assist healthcare providers to provide the most effective family planning counseling. They created method cards for counselors and method pamphlets for clients to take home. "The job aids help counselors to better administer the information exchanged with clients and represent a bridge, rather than an obstacle, in the relationship with them," he said.

Wendy Edson, PhD, Senior QA Advisor, Operations Research, discussed how job aids helped to improve caretaker adherence with antibiotic regimens to treat pneumonia in children in Niger. Increasing compliance with antibiotic therapy is a strategy to curb the development of antimicrobial resistance. For this intervention, the QA Project developed a package of job aids for caretakers and healthcare workers. The package included a counseling card with information from the Integrated Management of Childhood Illness manual, a medication envelope containing dosage information, a poster depicting good interpersonal communication, and a short training course introducing the job aids and reviewing inter-personal communication.

Linda Bruce, Senior Program Officer in the Program for Appropriate Technology in Health (PATH), discussed the role of using a Clean Delivery Kit, a pre-packaged kit of essential hygiene and cord-cutting supplies and pictorial instructions, in delivery of a baby. She also discussed the Vaccine Vial Monitor, which contains heat and time-sensitive labels on vaccine bottles that change color when the vaccine can no longer be used. This vaccine vial monitor is accompanied by a simple companion job aid that describes the action needed based on the color of the label.

Adrienne Kols, a consultant to the Johns Hopkins University Center for Communication Programs, talked about using job aids to improve client-provider communication in Indonesia. In this case, job aids were used as a form of self-assessment to help healthcare workers consolidate and apply their skills. "Self-assessment can be an effective tool in reinforcing training," Kols said. "We also learned the importance of keeping the job aids simple."

She also discussed their Smart Patient client education project to increase clients’ participation in family planning. In Indonesia, women are often shy and reluctant to ask questions: the project developed a job aid that encouraged women to express their opinions. "The contribution of the job aids helped legitimize clients’ right to speak out."

Afternoon breakout sessions addressed job aids for non-literate populations, job aids to improve clinical services, scaling up job aids efforts, and electronic job aids. QA Project staff were aided by facilitators from CORE and collaborating agency communities, each of whom had unique experiences with job aids that they presented. These colleagues included Sameh Saleeb of Africare, Anwar Aqil of Catholic Relief Services, and Susan Krenn of the Center for Communication Programs, among others. At the end of the day, Moore led a short, roll-up-your-sleeves course on how to develop job aids, covering topics from content and type size to layout.

The symposium proceedings, including presentations and electronic versions of many of the job aids displayed, will be compiled on a CD-ROM. When it becomes available, information will be posted on this website. (posted June 29, 2001)

Job Aids Symposium Materials

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.