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.

© 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.

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:

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:

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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:

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:

"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:

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.