Why PI is Important to JHPIEGO | PI Strategy  

Linking MAQ and PI at JHPIEGO

Since 1993, at JHPIEGO we have incorporated MAQ principles as an integral part of our ongoing country programs worldwide. We will continue to draw upon the MAQ Synergy of Interventions to challenge lingering medical barriers; test ways to strengthen adherence to guidelines; promote access to up-to-date, scientific information; strengthen client-provider interaction; and stress the critical role of service delivery guidelines in providing an objective reference point for evaluating FP/RH services. To achieve the objectives listed above in a systematic and rigorous fashion, we will use the steps in the PI process.

Recognizing that quality has been incorporated into global activities that cross regions and that MAQ and PI concepts and interventions are complementary, in February 2000 we created a Performance and Quality Improvement (PQI) Division within the Learning and Performance Support (LPS) Office at JHPIEGO. The PQI Division is seeking ways to provide strengthened field support by linking the MAQ and PI initiatives both conceptually and in the field. The PQI Division will draw upon established MAQ principles and standards to help define desired performance standards. In tandem, the Division will use the PI process to analyze actual performance gaps, uncover root causes of poor performance, and “zero in” on the most appropriate and cost-effective interventions that will promote a “culture of quality.” Whenever appropriate we will use the PI process as a means of achieving the MAQ goal of improved access and quality. We will use the PI process not only to remove or overcome obstacles to improved performance but also to preserve or enhance desired performance that already exists. We will collaborate with other agencies on selected interventions that offer the most promising returns on our mutual investment in improved healthcare. We will incorporate the PI approach during the planning and piloting stages to test the linkages between MAQ and PI in the field.

How Do MAQ and PI Relate?

MAQ (and other quality initiatives) provide tools and interventions that can feed into the PI process. In turn, PI provides a systematic, step-by-step process that can help achieve the MAQ goal of improved access and quality. (See graphic below.)

 

Examples of MAQ/PI Integration in JHPIEGO Training in Reproductive Health (TRH) Programming

• In February 2000, as part of the MAQ Initiative, a MAQ Exchange was held in Ghana. Some of the regional action plans developed at the Exchange identified the need to strengthen supervision systems. In April 2000, a discrete PI activity was held in Ghana. At a strategic meeting, the Ghana PI for Infection Prevention (IP) working group decided that strengthening supervision systems at all levels would be one of its priority strategies. In 2001 we will build on the similarities between these two Ghana activities by integrating (and we hope synergizing) MAQ and PI initiatives. MAQ and PI will co-sponsor a PI for IP assessment, followed by a stakeholders’ meeting that will present the results of the assessment and develop an action plan for strengthening supervisory systems in Ghana.
• To activate the synergies between MAQ and PI, JHPIEGO programming staff are attempting to integrate MAQ and PI (as reflected in the example above) whenever appropriate. As a result, these staff members are receiving many questions from the field. For example, What is the relationship between quality improvement and performance improvement? How does PI relate to MAQ? In November 2000, JHPIEGO hosted a 3-day Performance and Quality Improvement Workshop that helped staff respond to these questions. The workshop oriented JHPIEGO programming staff to performance and quality improvement. And, as part of this workshop, participants explored the relationship between MAQ and PI. In January 2001, this workshop will be repeated at JHPIEGO for programming staff who were unable to attend the November sessions.

PI Embraces MAQ Attributes

In examining the MAQ/PI relationship we have found that PI embraces a number of the MAQ Attributes. For example, the PI process is practical and realistic. PI has been used extensively and successfully in US business and industry, which demand these two attributes. In addition, like MAQ, PI is impact-oriented. PI is geared to produce “the biggest bang for the buck.” Also, with its deliberate intention to select the most appropriate among a range of potential interventions, PI like MAQ prioritizes (puts “first things first”). Like MAQ, PI is collaborative. PI encourages USAID Cooperating Agencies (CAs) and other organizations to pool their talents to achieve the greatest impact. And finally, PI like MAQ is evidence-based. The PI process calls for continuous monitoring and evaluation of performance so that the selected interventions can be validated or modified as needed to assure that healthcare providers and institutions are empowered to deliver high quality services to the client.

Integrated MAQ/Performance Improvement Framework

At JHPIEGO, we would like to build upon the complementary aspects of MAQ and PI. We envision an integrated quality and performance improvement framework that can harmonize MAQ and PI initiatives. (See graphic below.)

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Since its inception, the MAQ Initiative has worked to establish internationally recognized, scientific and evidence-based standards. These standards provide the background and context within which the performance improvement (PI) process can be activated by USAID. While MAQ provides key concepts that can be used to establish, define and standardize quality, PI provides a process that can be used to implement MAQ practices and strengthen MAQ principles. The MAQ Initiative has set standards for desired performance in family planning and reproductive health that are continuously updated, monitored and expanded to keep pace with current best practices. In essence, MAQ sets the stage upon which performance improvement can be enacted.

Get and Maintain Stakeholder Agreement: Use the MAQ Initiative as a wakeup call to advocate for improved quality and access through improved performance of organizations, systems, providers, communities and clients. Use the MAQ Initiative to summon key stakeholders to the table and then garner and sustain their support. For example, the MAQ Exchange can be used as a forum of interchange among USAID missions, their country counterparts and USAID/Washington to gain the consensus that is needed to promote and activate performance and quality improvement initiatives. Use MAQ both as an advocacy tool to get stakeholders to recognize the need for guidelines and as a policy tool— an international, state-of-the-art healthcare yardstick—against which national guidelines can be measured.

Consider the Context

Consider the specific context (e.g., the mission, goals and strategies of the organization or institution) in which you will apply the PI process to achieve the MAQ goal of improved access and quality. Be aware of the cultural context (e.g., belief systems, social norms, level of economic development). And be sure to examine client, provider and community perspectives.

Step 1: Analyze Performance

Define desired performance: Use evidence-based international guidance (e.g., the World Health Organization’s Medical Eligibility Criteria for Contraceptive Use, the MAQ Technical Guidance and Competence Working Group’s Recommendations for Updating Selected Practices in Contraceptive Use)and country-specific policy documents(e.g., national service delivery guidelines) to help define desired performance at the global and national levels. Then, at the site level, adapt these guidelines as precise performance tools (e.g., up-to-date job aids and accurate job descriptions) that reflect specific performance expectations that are negotiated or developed between the worker and supervisor. For performance areas in which standards do not exist, guidance documents and tools that define desired performance may need to be developed.

Describe actual performance and identify gaps: MAQ brings to the table a set of clearly defined interventions that can be used to narrow gaps found between desired and actual performance.

• Use the MAQ Synergy of Interventions to focus on specific areas in which a gap may exist.
• Use the PI process to analyze performance factors and pinpoint the gap between actual and desired performance within a specific in-country context.

Step 2: Find Root Causes: Why does the performance gap exist? Use the PI process to determine causes of poor performance.

Step 3: Select Interventions: What can be done to close the performance gap?

• Use the MAQ Synergy of Interventions as a menu of specific, field-tested solutions from which to choose.
• Match MAQ and other interventions to address causes of poor performance.

MAQ Interventions	Common Causes of Poor Performance
Standards/guidelines, indicators/certification, job aids, organization of work	Unclear job expectations
Supportive supervision	Lack of performance feedback
Provider rewards/environment	Poor motivation
Leadership, problem solving	Weak management or leadership
Training	Deficient knowledge and skills
Supplies/logistics	Inadequate facilities, equipment or supplies
Client engagement, community engagement	Lack of client/community sense of ownership and action to improve quality

• Use the PI process to select the most appropriate, timely and cost-effective intervention(s) from among many potential remedies. Select those interventions that are strongly and directly related to the root causes (i.e., interventions that will alleviate the root causes and close the performance gap). Be sure that the interventions selected are ones that will actually address the root causes of the problem. Do not select an intervention simply because the implementing organization is comfortable with it.
• If the organization itself cannot address the interventions that match the root causes, step outside the box to look for and team with partners and collaborators who can.

Step 4: Implement Interventions: Use MAQ and other materials (e.g., MAQ Exchange modules, MAQ Papers) to provide approaches and tools for selected interventions. Use the momentum inherent in the PI process as a catalyst for implementing selected MAQ interventions.

Step 5: Monitor and Evaluate Performance: Throughout the process, use lists of quality indicators (e.g., Quick Investigation of Quality/QIQ) to measure the impact of MAQ/PI interventions. Adjust interventions, as needed, based on evaluation results.

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