Although Joseph Juran did not include Quality Assurance in his famous “Trilogy” of Quality Planning, Quality Control, and Quality Improvement, Quality Assurance and other inspection methods have been popular in health care for decades. Only relatively recently have Quality Control (QC) and Quality Improvement (QI) asserted themselves as key methods for improving quality in health care. The reality is that Quality Assurance (QA), accreditation, audit, and other inspection methods are alive and well in the health care industry. But on their own, inspection methods cannot move a system to a higher level of performance beyond that dictated by its underlying design. If you want better performance, you need a better design. Using system analysis, generation and testing of new ideas, and measurement to see if the new ideas are leading to improvement, QI provides the opportunity for system or process redesign that can lead to higher levels of performance.
The difference between measurement of improvement and measurement for improvement is covered in a book chapter in Quality Measurement in Family Planning: Past, Present, Future, a publication that reflects the deliberations of a meeting in Bellagio in October 2015. This chapter describes the various types of Quality Control and Quality Improvement, focusing on the interplay between them, their development and use in low- and middle-income countries (LMIC), and their advantages and disadvantages.
While Juran described the differences between Quality Control and Quality Assurance, he saw no place for Quality Assurance in his Trilogy: “Under Quality Control, the prime purpose is to serve those who are directly responsible for conducting operations—to help them regulate current operations. Under Quality Assurance, the prime purpose is to serve those who are not directly responsible for conducting operations but who have a need to know—to be informed as to the state of affairs and, hopefully, to be assured that all is well.” Although they use different methods (Quality Assurance is measured by those who are external to the process being reviewed, while Quality Control as defined by Juran is measured internally by those who are responsible for the process), Quality Assurance and Quality Control have a similar purpose: Each works within the constraints of an existing system design, compares performance to goals, and acts on the difference.
Much confusion reigns on the differences between QA, QP, QC, and QI. Given these realities, and to help make sense of these different methods and associated measurement approaches, we place both routine internal monitoring and external measurement in the category of “Quality Control” (monitoring performance within existing process designs) and distinguish these activities from Quality Improvement (redesigning processes to achieve new levels of performance). We describe data collection activities and reports that are associated with QC and QI below.
Pierre M. Barker, MD, MBChB, is IHI's Chief Global Partnerships and Programs Officer.