QA vs. QI: The role of continuous quality improvement

As described in the PEPFAR Quality Strategy, quality assurance (QA) is an approach to assuring that service delivery sites meet minimum standards through regulatory approaches such as accreditation which are based on the application of explicit standards of care and external quality assessment (EQA) to measure the extent of compliance to these standards, often conducted by independent individuals or organizations using standard tools.  Both EQA and Site Improvement Through Monitoring Systems (SIMS) are examples of QA approaches.

Quality improvement (QI) is the process of collecting and using valid data to:

  • understand the current level of quality (defined by compliance with standards of care),
  • identify gaps between actual quality and expected quality for that setting
  • introduce changes in the care system (affecting inputs and processes of care), and
  • frequently measuring the effect of those changes on health outcomes and system performance.  

QI approaches include ad hoc team-based problem solving, performance improvement, collaborative improvement, and continuous quality improvement (CQI), which embeds the improvement process in the routine delivery of services.
CQI engages frontline health care providers and site managers in an ongoing process of comparing their own performance again standards and figuring out what they can do to meet those standards by introducing changes in care processes and monitoring the results in a continuous cycle of assessment and action.

Implementation of and support for CQI involves forming a team at the site level to do the improvement work, training in CQI and in the use of tools, regular assessment using these tools, and ongoing coaching and mentoring support, and sharing of learning across teams.  Most importantly, CQI engages site-level.

In CQI, changes introduced address both what is done (content of care) and how it is done (process of care). This paradigm for improvement makes organizations more efficient and able to provide quality care with increased access and decreased waste, often at lower cost.

QA and QI for VMMC

QA and QI approaches are mutually reinforcing to lead to better quality services. QA approaches like EQA and SIMS seek to ensure that the PEPFAR VMMC programs for HIV prevention are conducted according to recommended national policies and guidelines, WHO guidelines, and PEPFAR policy directives and technical considerations and to provide feedback regarding the quality of specific service delivery elements. 

Whereas EQA is a periodic formal assessment carried out typically by outside experts to identify performance gaps against a set standard, CQI is an ongoing process, structured but potentially less formal, carried out by site-level staff to identify inadequate performance against either defined standards or their own insights and then take concrete actions to achieve improvement.

PEPFAR EQA assessments place additional emphasis on program efficiency and productivity and ability to meet impact targets.  CQI helps sites to introduce changes to improve quality, efficiency, and productivity and thus strongly complements EQA and SIMS.