Monitors performance using task manager. When spikes show up he investigates. Problems were usually blocking in the database. It's always database issues. Rarely any problems in .net. Because POF doesn't use the .net library it's relatively easy to track down performance problems. When you are using many layers of frameworks finding out where problems are hiding is frustrating and hard.
Makes me blush a bit that we have 1000 - 1100 customer websites (which don't get many hits) spread across 6 CloudLinux servers and the performance is terrible... (not that I have anything to do with those servers!)