There are six main categories of factors that are known to affect the performance of individual employees, teams, organizations, and systems, and therefore the quality of health services. Five categories are divided among organizational and individual/team factors: organizational systems, incentives, tools and physical environment, skills and knowledge, and individual attributes. The sixth category includes factors in the external environment surrounding the organization or facility. These factors help OPQ teams analyze performance and root causes of gaps and strengths throughout the process and are especially useful during Stages 1, 2, 3, and 4.

Performance Factors

These performance factors, described below and summarized in the Factors Influencing Performance Job Aid in the Tools section, are often interrelated or complementary in their impact, and they reflect the fact that effective OPQ requires a systems approach to solving performance or quality problems or creating effective new performance that results in quality health services or systems. Gender cuts across each of these categories of performance factors, highlighting the need for a gender analysis.

Organizational Systems

Organizations—ministries, regulatory bodies, health training institutions, health facilities, nongovernmental organizations (NGOs), and civil society organizations (CSOs)—have unique cultures, policies, and practices that have profound effects on how work gets done and by whom. Organizational leaders and managers, therefore, need to continuously ask, How well do the organizational systems support the desired performance? Key components to consider include:

  • Clear organizational goals, strategic plans, and structures
  • Effective leadership
  • Clear job expectations and authority
  • Supportive supervision systems
  • Clear operational policies and efficient processes
  • Realistic workloads
  • Effective management systems (finance, human resources, logistics/supply chain, and information)
  • Transparent human resources hiring, management, and appraisal systems
  • Clear communication and information channels and access
  • Adequate financial resources


Employees need to be able to answer the question “what’s in it for me” to perform up to quality standards, especially when working conditions are difficult, salaries are low, and there are shortages of health workers or employees. Incentives can encourage employees to work better through connecting clear expectations, feedback, and rewards to improved performance. Successful organizations provide incentives to motivate employees to positively contribute to the organization’s goals and results. The overall question this factor addresses is, Do employees and teams have a reason to perform as they are asked to perform? Elements to consider include:

  • Clear expectations regarding responsibility, accountability, and autonomy
  • Constructive performance feedback
  • Fair compensation and reward systems
  • Recognition for good performance; consequences for poor performance
  • Engaging, meaningful work
  • Professional development and career opportunities

Tools and Physical Environment

This factor focuses on whether employees have the necessary and adequate tools, supplies, and supportive physical environment to do their work well. It also examines whether the organization has the maintenance systems in place to support a well-functioning workplace. The overall question this factor addresses is, Do employees have the physical resources they need to accomplish the job they have to do? Key components to consider include:

  • Equipment, instruments, consumable supplies, drugs, and other commodities
  • Protocols/procedure manuals, job aids, and recordkeeping tools
  • Physical work environment (furniture, workspace, power, water, light, and ventilation)
  • Workplace safety measures
  • Information technology and communication systems, equipment, and connectivity

Knowledge and Skills

This factor—generally the most easily understood—involves a determination of whether or not employees have the necessary knowledge and skills to do the job. It addresses the fundamental question: Do employees and teams know how to do their jobs correctly? For example, do employees/teams have:

  • Basic education for literacy and math
  • Clinical, technical, and professional knowledge and skills
  • Social and communication skills
  • Problem-solving, critical thinking, teamwork, and leadership skills
  • Relevant work experience

Individual Attributes

When considering employees, you can be sure of one thing: no two are exactly alike. Each individual brings different attributes that affect the individual’s and team’s overall performance. The central question is: Do personal attributes of individuals affect their ability to work together and perform their jobs? Personal attributes include:

  • Internal motivation
  • Gender/ethnic/class identity
  • Religious, ethical, and moral values
  • Emotional, intellectual, physical, and creative abilities
  • Previous life and work experience

External Environment

There are many variables external to organizations that affect the ability of the organization, teams, and individuals to perform. Some of these variables are outside the organization’s span of control and can be considered “givens” or parameters within which an organization operates. Others can change over time or be influenced or improved by actions of advocacy groups, professional associations, or community organizations. All should be considered when analyzing root causes of identified performance gaps or strengths. The central question is: Do factors in the external environment impede or support the ability of the organization and employees to perform and achieve their goals? Examples of such factors include:

  • National policies, regulations, standards, and professional scopes of work
  • Licensing or accreditation requirements and processes
  • Societal norms regarding gender, culture, class, religion, and ethnicity
  • Socioeconomic conditions, education levels, and standards of living
  • Market conditions and customer needs and preferences
  • National and local infrastructure: transportation, energy, telecommunications, water, and sanitation
  • Political changes in national and local government