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Institutionalization is an ongoing process in which a set of activities, structures, and values becomes an integral and sustainable part of an organization. The QA Project defines institutionalization in the context of quality assurance as follows:

Quality assurance will be institutionalized when it is formally and philosophically incorporated into the structure and functioning of a health system (or organization), consistently implemented, and supported by a culture of quality, as reflected in organizational values and policies that advocate quality care.

Quality Assurance Institutionalization Circle depicting structure of Institutionalization of QA: Policy, Core Values, Resources, Leadership.  Circle within: Quality Design, Improvement, and Management with Capacity Building, Information and Communication, and Rewarding Quality
© QA Project, 2000

The QA Project has found that merely having the capacity to carry out technical quality assurance activities (e.g., defining quality standards, monitoring quality, and quality improvement) does not ensure that QA is institutionalized within an organization. An environment that enables the initiation, growth, and continuity of QA activities must also incorporate supportive policies, effective leadership, structures that support the performance of QA technical activities, and adequate resource allocation that emphasizes the importance of quality and encourages people to practice QA activities as part of their daily work.

The QA Project has developed a conceptual model describing the fundamental elements and components of an institutionalized quality assurance proram:

The core or center of the model is quality care, the desired outcome. Technical approaches or activities for improving quality of care are represented by the QA triangle of: defining quality (QD), measuring quality (QM) and improving quality (QI). The QA Project has found that these technical QA activities will have the most impact when all three are implemented in a coordinated fashion. Success over the long term in achieving quality of care also depends on supporting technical activities with an enabling environment, a structure that delineates roles, responsibilities, and accountability for the implementation of QA activities, and support functions to sustain their implementation.

The Essential Elements of Institutionalizing QA

QA and improved quality of care require more than a technical approach of tools and methods. Sustained improvements often require a change in attitude and sense of ownership for the quality of services provided by an organization. Many supporting factors are required to integrate QA into the structure and function of an organization. These are the building blocks which we call the essential elements of institutionalization.

Essential Elements for the Institutionalization of QA

Internal enabling environment:

Core values

Organizing for quality (structure)

Support functions:

Capacity building
Rewarding quality

As shown in the box, there are eight essential elements that make up the QA institutionalization framework, and they can be divided into three categories:

  • Internal enabling environment
  • Structure
  • Support functions

These essential elements are derived from a combination of the organizational development and quality management literature, and from QA Project experience implementing QA activities and building QA programs in developing countries. While recognizing that every health organization functions within a larger environment that influences its ability to implement QA, this framework of essential institutionalization elements focuses on those that operate within the organization’s sphere of influence.

To learn more about the essential elements for QA institutionalization, link to the topics below:

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The Internal Enabling Environment

An internal environment conducive to initiating, expanding, and sustaining QA is necessary to institutionalize QA. Such an enabling environment includes the following elements, each important individually, but also supportive of each other in a synergistic fashion:

  • Policy: written policies that support quality through clear, explicit, and communicated directions/directives and provide support, guidance, and reinforcement for QA as an integral part of the organization
  • Leadership: leaders who work directly and openly to improve quality by setting priorities, modeling core values, promoting a learning atmosphere, acting on recommendations, advocating for supportive policies, and allocating resources for QA
  • Core values: organizational values are articulated, promoted, and practiced. These values emphasize quality of care, ongoing learning, and continuous improvement of services
  • Resources: sufficient allocation of human and material resources for conducting, supporting, and maintaining QA activities

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A Structure to Support QA Implementation

The institutionalization of QA requires a clear delineation of oversight roles and responsibilities and accountability for the implementation of QA activities. The specific organizational structure for implementing QA can vary greatly from one organization to another, and will evolve over time as the QA program matures. It could be, or other forms. There is no "correct" or "best" structure; an effective structure for QA may combine many forms, such as a QA unit, quality improvement teams at facilities, or an oversight committee.

Through the years, the QA Project has learned that there is more than one effective way to organize QA. This reflects both differences in the evolution of QA within an organization and the political, technical, and economic environment in which the organization operates. Organizations in more centralized environments will structure QA differently than those who operate in more decentralized environments. Technological development and economic status will also drive decisions about how QA programs are organized.

Whatever form the QA structure takes, institutionalization needs mechanisms to ensure oversight, coordination, delegation of roles and responsibilities, and accountability:

  • Oversight: Any description of structure must address where the responsibility for oversight of QA activities lies. This oversight includes both leadership support (developing strategic direction, setting priorities, follow-up, monitoring of progress) and technical oversight for QA efforts.
  • Coordination: The very nature of QA implies that it will be implemented in a variety of settings, circumstances, and levels of an organization. The structure must also define how the different components and levels of a QA program fit together and how they will be coordinated and synchronized. For example, the collection and use of data is essential for QA to be most effective––which means coordination with those in charge of national databases is vital. Likewise, because QA activities run across specific service delivery and administrative programs, coordination with technical experts and with those implementing specific programs is critical for effective standards development, monitoring, and improvement. Lastly, there must be coordination between the core QA activities (defining, measuring, and improving quality) and between the various stakeholders.
  • Roles and responsibilities: The true structure for QA is manifested in how the roles and responsibilities for performing QA activities are divided and/or delegated within the organization. Eventually, responsibilities for QA should appear in routine job descriptions for individuals as well as in the scope of work for organizational units.
  • Accountability: With maturity of a QA program, every individual becomes accountable for results and responsible for quality. However, in the early stages of QA development, it may be useful to clearly outline the specific duties, lines of reporting, and accountability for results, to ensure that QA activities are duly implemented and that there is necessary time allocated for staff participation in QA. During the initial stage of development, it may be important to have some individuals solely devoted to QA, working within a designated "QA Unit" that focuses on QA training and capacity-building. During this stage, a visible organizational location for QA, with explicit leadership support may be useful to boost awareness of QA and grant recognition of its importance.

As QA becomes more integrated into the job descriptions (roles and responsibilities) of staff throughout the organization, the type of oversight required shifts, as does its location. Routine management structures (such as a district management committee) may assume daily oversight of QA activities, and the role of the designated QA Unit may become more focused on the development of standards. In other situations, early QA activities may be coordinated through a more umbrella-like structure as the program is taking shape. Accountability holds both for results achieved and for the resources used to achieve those results.

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Essential Support Functions

In addition to creating an internal environment that supports a culture of quality, provides resources and guidance for implementation, and has outlined clear roles and responsibilities for QA, those doing the day-to-day implementation of QA require more specific types of support. As the name implies, support functions provide "support" for the staff to undertake and sustain technical QA activities. The development of ongoing systems to ensure QA Capacity Building, Communication of QA Efforts, and Rewarding Quality Work are critical for an organization to move beyond performing QA as isolated activities, to a state of continuously implemented QA, embedded in the organizational work ethic. There are many other support functions, such as logistics and financial management, but these three have particular importance in QA institutionalization.

Capacity Building

Capacity building refers to the ongoing process of ensuring that staff have the necessary knowledge and skills to carry out their QA responsibilities and that they know when and how to best use these skills. Capacity building is vital for the development of a critical repository of QA technical, managerial, and leadership expertise within the organization. Capacity building encompasses the whole range of activities that increase QA knowledge, skills, and ability, from formal QA training to self and peer appraisals to supervisory activities. Essential capacity-building activities include:

  • Provision of basic QA expertise: Institutionalization of QA requires that a critical mass of health providers and managers receive initial and continuing knowledge and skill development in QA techniques and methods. As appropriate, the ability to manage QA activities would also be included. Developing basic QA expertise should ultimately be integrated into the pre-service and in-service training systems. Training activities can take place on-site or off-site, in the context of the job or distance-based. Staff needs will evolve over time, and thus, training should be tailored to these evolving QA responsibilities and related training needs. QA Project experience has shown that it is most effective to train staff and providers at the time of direct need for information, when they can immediately use it (just-in-time training).
  • On-going coaching and mentoring: Coaching and mentoring provide ongoing technical and qualitative support to facilitate the behavior changes needed to undertake and sustain QA activities, while simultaneously encouraging the development of a "culture of quality." The term coach refers to an individual who is well-versed in QA techniques and principles and can provide on-the-job technical support to staff implementing QA activities. In contrast, a mentor refers to someone who acts more as a guide or advisor; a mentor does not need to be a QA expert, but can identify when additional intervention or expertise would be useful, and facilitate connection with an appropriate resource person.
  • Supervision: Staff also need day-to-day support and correction as they undertake QA activities. Supportive supervision requires enhancing the facilitating role of the supervisor, assuring that supervisors have a foundation of QA expertise, as well as teaching supervisors how to observe, give feedback, and assess a situation.

"Doing QA" is really more than the simple application of technical methods. It often requires behavior change––learning to work differently. Traditional approaches to capacity building through one-time classroom training are not adequate to achieve behavior change. Alternative modes of learning, such as participatory adult learning and mentored on-the-job practice, are more appropriate for QA capacity building.

Communication of QA Efforts

Communication is a two-way interaction, with information imparted from various parts of the organization to staff within the organization, to the communities being served, and to other stakeholders, including policy makers, and then received back from these sources. Communication allows for the identification of priority areas for quality improvement efforts, reinforcement of core values, and demonstration of results for advocacy, benchmarking, and change management. The establishment of formal mechanisms to assure the communication of new standards, policies, and improvement activities increases the likelihood of acceptance of and compliance with such initiatives. Communication reinforces the notion that QA is everyone’s business, that successes should be shared, and that lessons can be learned (and shared) when things do not go as well as planned.

Successful communication support for QA includes:

  • Recording improvements and changes, illustrated by data to demonstrate results that have been achieved and by the stories behind these results.
  • Sharing what has been achieved and how it was done, both with the organization’s staff and the community it serves, as well as with others who might learn from it and become motivated to improve their own services.
  • Using the results for advocating policy changes. When activities are well documented with supporting data, it is easier to convince decision makers.

Rewarding Quality Work

In addition to having the capacity to do QA and having information available about what can be achieved, staff members also need to see that their efforts in QA are important to organizational leadership and the community served. Rewarding quality work (or efforts to improve quality) fosters a commitment to quality and motivation to strive for excellence. Providing individual, group, or even organizational rewards reinforces interest in QA endeavors and assures that staff values are aligned with organizational values. Not only should an organization develop incentives (both material and intangible) that bolster workers’ motivation to undertake QA activities and ultimately improve quality of care, it should also examine what kind of disincentives or barriers to quality currently exist and identify ways to remove them.

Every organization has implicit, if not explicit, incentives that influence staff behavior. Institutionalization requires developing incentives that can stimulate and reward workers for participating in QA activities, for making improvements, and for ultimately providing quality services. Incentives can be material, such as rewarding the best staff with bicycles, or non-material, such as public recognition of staff to foster employee self-esteem and encourage their continual efforts. Other examples of rewarding quality include featuring the work of the teams through meetings, conferences, employee-of-the-month publicity, and/or facility-based QA documentary posters. All of these examples publicly acknowledge the individuals selected and recognize the value of quality work.



The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development (USAID) under Contract Number GPH-C-00-02-00004-00.