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Marc Luoma, PRIME II Director of Performance Improvement;
William H. Jansen II, PhD, PRIME II Project Executive Director;
and James McCaffery, PhD, Project Leadership Group, PRIME II Project

We read with interest the Spring 2001 issue of QA Brief, which framed a comparison of the quality assurance (QA) and performance improvement (PI) approaches. We applaud the effort to identify the similar and distinguishing features of the two. It is important for our colleagues in the fields of international and reproductive health to understand how and when each approach can be used to its full potential.

We would like to add our views on how PI is currently practiced in the field, especially by the PRIME II Project. In doing so, we hope to give the readership of the QA Brief additional views of PI so that they can be aware of the full potential that PI represents.

Focus

The opening editorial of the issue states that “PI begins with a focus on the limitations of staff training….” Our PI work, which is consistent with the framework adopted by the PI Consultative Group, begins with the identification of desired performance and its impact. The focus from the beginning is on the results that should be achieved.

Sustainability

The earlier QA Brief article states that “PI is usually led by a specialized practitioner while QA and QI have always been intended to be managed by the health program itself.” This statement, and the discussion following, could lead the reader to conclude that the PI approach is less likely to be sustained or continue to have an impact in the healthcare settings where it is applied. Sustainability in PI is a planned outcome of PRIME II work. In fact, both approaches use facilitation to move the process along. In the course of implementing a variety of PI initiatives in the PRIME II Project, we have found that field staff can and do learn the PI process quickly. We also see that healthcare organizations do continue to use the PI approach and its tools after the completion of external technical assistance. Our experience indicates that by making capacity building a specific part of any technical assistance in PI, the ability to build a “leave-behind” capability in PI is greatly enhanced.

Teamwork

Another statement indicates that QA “contrasts with PI, which does not emphasize the use of teams.” In the way that the PI approach is practiced in the PRIME II Project, the formalized stakeholder buy-in process demands the participation of rather large teams. Indeed, wide participation in defining desired performance and conducting cause analyses has been pointed out in several published evaluations of our PI projects as strength of the approach. Although counterparts are sometimes interested in reducing the number of individuals participating in the stakeholder process, we feel that teams are a requirement for wider impact on the service delivery system and to achieve lasting changes in provider performance. All stages of the PI process are carried out by teams that vary in size depending on the amount of input needed to realize the performance improvement objective. Using teams at different stages also helps to ensure that we are working toward the goal of building PI capacity at the local level.

Standards

The article also states that QA/QI’s emphasis on standards is “more systematic and comprehensive” than what is normally done in PI. Perhaps the nature of the wide stakeholder involvement in defining desired performance has obscured the common use of clinical or quality standards in the PI process. In PRIME II’s PI literature and our normal practice of PI, international (typically from the World Health Organization) and national standards or service delivery guidelines serve as a critical reference in determining desired performance of service providers. We believe that PI’s use of standards, while possibly different from QI/QA, is still systematic and comprehensive.

Potential for Success

A concluding comment in the  article says, “QI/QA’s more comprehensive and systematic process for developing, communicating, and implementing standards around those or similar factors appears more likely to achieve success, and successes are sustained longer if staff retain, refer to, and follow standards.” Both approaches and projects strive to improve health worker compliance with standards. The similarities of the approaches and the variations in the way they are applied in any one particular setting make it unlikely that one could infer that one approach is likely to be more successful than another. Much work remains to be done on making standards clear to providers so standards can serve as performance expectations. The PI approach in the PRIME II Project is being actively used in this endeavor to put standards into practice. Our experience to date is already providing us with impact within service delivery settings and among service providers that we classify as “successes.”

Continuing the Dialogue

The commendable effort to illuminate similarities and differences among the various approaches and tools available for improving quality in healthcare will be best served by broadening the dialogue among projects, USAID cooperating agencies, and others. Indeed, PRIME II already is working with EngenderHealth to develop more definitive comparisons between COPE (client-oriented, provider-efficient services) and PI to better advise practitioners and healthcare managers in the field about the tools available to them to help address quality of care issues. We are pleased the PRIME II and the Quality Assurance Projects are planning a continuing dialogue that will result in a new joint publication that should provide a more complete comparison of the PI and QI/QA approaches. We look forward with eager anticipation to this joint publication and urge the readership of QA Brief to do so as well.

Go to Performance Improvement

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¹ Editor’s Note:  The previous issue of the QA Brief presented an article titled “Quality Assurance and Performance Improvement” by Thada Bornstein. We are pleased to publish a perspective on that article, by staff of the PRIME II Project, which compares quality assurance/quality improvement (QA/QI) and performance improvement (PI).

PRIME II is a partnership combining leading global health care organizations dedicated to improving the quality and accessibility of family planning and reproductive health care services throughout the world. Funded by the United States Agency for International Development, PRIME II focuses on strengthening the performance of primary care providers as they work to improve services in their communities.

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