QI vs. PI

Although both QI and PI take a systems view, a noticeable difference between them is that PI places more emphasis upon human performance while QI focuses on processes. Both assert the need for data.

The QA Project recommends a flexible stance in deciding how to perform the analysis step, i.e., whether to conduct a root-cause analysis, whereas PI holds firmly that root-cause analysis should be performed. When root-cause analysis is conducted in QI, hypotheses are produced using a variety of techniques, such as generating possible causes and organizing them on a fishbone (Ishikawa) diagram, or using the Tree Diagram technique ("Five Why's"), narrowing down the most likely causes, and developing simple data collection tools to verify which one is the actual root cause. Descriptions of root-cause analysis in PI often exclude the verification step.

Rapid approaches employ solutions from a list of known change strategies that have a history of results in reducing errors and rework.

The QA Project advocates not performing root-cause analysis when the cause is obvious (this usually applies when the individual approach is used), or when the problem solvers are sufficiently knowledgeable about the process to make educated guesses as to the cause (often used by teams using the rapid or process improvement approach). These approaches yield a quicker result, but require a level of QI expertise to know when they should be applied. Rapid approaches employ solutions from a list of known change strategies that have a history of results in reducing errors and rework.

Another significant difference between PI and QI is that PI is usually led by a specialized practitioner, while QA and QI have always been intended to be managed by the health program staff itself. This approach supports the institutionalization of quality in many of the countries where the QA Project works and is exemplified in the autonomous and continuous character of QI teams, which are central to the sustainability of QI. QI teams are usually self-directed groups of facility-based health workers.

The teams are developed and supported by coaches who provide them with both formal and just-in-time training in QI—the process, tools, and techniques—and on team process matters such as: the functions and roles of team members; communication skills (e.g., active listening, giving and receiving feedback); decision making; planning, conducting, and documenting team meetings; and presenting team results to managers.

Teams use the QI process to decide what they want to improve, and are thus empowered to improve their work conditions and outcomes, often making systemic transformations to their work environment. This contrasts with PI, which does not emphasize the use of teams. QI team members are selected for their expert knowledge of the process being improved or other special skills. This combination of knowledge and skills gives the team the expertise that enables them to deal with complex systems and processes. Often a QI team is wholly responsible for the process they are improving (process improvement teams). Such teams can continually seek opportunities for improvement, and design, test, and implement solutions without requiring higher authority to initiate the effort.

On the other hand, PI is often initiated at a client's request and directed by a PI practitioner. While teams are formed to design and implement interventions, there is less indication that, after the original performance problem is improved, self-directed facility-level teams continue to initiate PI activities independently as part of their regular way of doing business. However, many CAs are now conducting PI training to develop the capacity of field staff and host country counterparts to use PI independently of headquarters.

QA recognizes that standards must be in place and met for these inputs, processes, and outcomes in order to maximize the potential for desired health outcomes.

Because of its roots in human resources (HR) and training, PI is more inclined than QI to consider HR-related causes and solutions, for example, clear job expectations, performance feedback, motivation, and incentives. And QI is more predisposed toward looking at processes and systems, a focus that generates a broader array of interventions. One example of such complex interventions is an accreditation system that may incorporate both internal and external monitoring and improvement. Another is the systematic monitoring of Health Management Information Systems (HMIS) data to generate opportunities for continuous QI.

However, there is increasing evidence of common ground between QI and PI: QA/QI is developing and testing so-called "HR"-type interventions, such as supervisory feedback and health worker motivation, while PI is identifying systemic causes such as lack of systematic monitoring and evaluation.

Many system-wide intervention mechanisms (e.g., licensure, accreditation, regulation, and certification) that are tailored to healthcare and employed by QI have not yet been adopted in the current practice of PI.⁶ Accreditation can take any of several forms: focused accreditation (focused on a single service) and facilitated accreditation with self-appraisal are two such complex interventions that improve quality in an organized way. Another solution that can arise from QI is Quality Design, which employs a well-developed methodology to create new services or processes.

QI is only one methodology in the larger QA system, and as such, it is not the sole entry point for improving the performance of a healthcare system. One can just as easily begin with QD or QM. In fact, there are many entry points by which quality can be introduced into a healthcare system. It is a function of QA's maturity, and the great needs of healthcare systems in developing countries, that the interventions mentioned in this article can be implemented and achieve results without necessarily going through the QI process.

Both QA/QI and PI emphasize standards, but the former is more systematic and comprehensive. In QA/QI, standards are classified into two domains: technical (clinical, based on evidence-based medicine) and administrative. In each domain, there exist model standards for inputs (e.g., staff, equipment, supplies), processes (e.g., patient care, admission, housekeeping), and outcomes (the results of the inputs and processes: e.g., delivery of a baby, health gain of a patient, mother appropriately following a health provider's guidance for the care of her child). QA recognizes that standards must be in place and met for these inputs, processes, and outcomes in order to maximize the potential for desired health outcomes.

In PI, the term "standards" is most often applied to worker performance expectations, namely job descriptions or specifications although, as mentioned above, clinical guidelines are a well recognized performance factor and solution in PI. However, PI uses terminology for performance factors (e.g., "environment") that include elements QI would call "input standards." The different terminology can cause confusion. QI and PI may both recognize the same deficiencies, but while one sees the lack of a standard, the other sees a lack of an environmental support mechanism. In this case, the two perspectives may lead to the same conclusion, but 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.

 

⁶ This statement excludes Joint Commission Resources, Inc. (JCR), an internationally focused subsidiary of the US-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and JCAHO, who use the term "Performance Improvement" slightly differently from the PICG. For more information on JCR, see their website at <www.jcrinc.com>.