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Monographs & Methodology

Manual para la humanización y adecuación cultural de la atención del parto (HACAP) [Manual on the Humanization and Cultural Adaptation of Delivery Care]: Developed jointly by QAP, the Ministry of Health of Ecuador, and Family Care International, this manual facilitates a process to adapt delivery care to cultural expectations.  It provides guidance for conducting a series of three workshops that bring together health care providers, traditional birth attendants, community leaders, and mothers to discuss cultural practices and preferences and to identify changes that can be made to facility-based delivery care to make institutional delivery more acceptable to expectant mothers.  Through role-playing and discussion, participants learn how delivery care is provided at a hospital and by traditional midwives in the community.  Those who would change facility-based delivery are allowed to make suggestions, while medical staff have opportunities to consider community preferences and explain to participants any evidence that controverts those preferences. Through the process, hospital staff and midwives come to understand and respect each other’s practices (82 pages including survey instruments; available only in Spanish). Download report. (82 pages including survey instruments; available only in Spanish).  

Health Systems Assessment Approach Manual

The manual provides a framework for looking at health systems issues at a national level, focusing on governance, health financing, health service delivery, human resources, pharmaceutical management, and health information systems. The health systems assessment approach seeks to systematize lessons from past experiences and develop new approaches to build capacity to recognize and respond effectively to health system strengthening challenges. The manual is intended as a tool to assist health program planners and evaluators identify strengths and weaknesses in health systems and prioritize intervention opportunities.

Download complete manual (17.2 MB) (right click on link and select "Save Target As")

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Chapter 6

Chapter 1

Chapter 7

Chapter 2

Chapter 8

Chapter 3

Chapter 9

Chapter 4

Chapter 10

Chapter 5

Chapter 11




Applying Benchmarking in Health: Benchmarking is a process for finding, adapting, and applying best practices and then measuring the applied best practice to assess its effectiveness. This report defines benchmarking and related terms, and then describes the types and range of benchmarking and the QA Project's general approach to benchmarking. A case example illustrates those descriptions, and practical advise and further reading are suggested.
Download report (7 pages)

Improving Interpersonal Communication Between Health Care Providers: Positive health outcomes are associated with effective communication, but many providers lack skills in this area. After briefly describing the characteristics of effective interpersonal communication (IPC) and setting out norms and guidelines for effective IPC, this monograph provides materials for presenting training in IPC. Activities/Tools: Reports of results of three IPC trainings, IPC job aids, three training manuals (one in Spanish), and the data collection instruments that were used to evaluate the IPC courses (one is the Roter Interaction Analysis System and one is in Spanish).
Download report (60 pages plus appendices).

Institutionalization of Quality Assurance: Predating the QA Project monograph titled, "Sustaining Quality of Healthcare: Institutionalization of Quality Assurance," this earlier report sets out the essential elements that make institutionalizing QA possible and provides several examples from Niger and Zambia.
Download report (38 pages)

Job Aids Symposium
The Quality Assurance Project and Child Survival Collaborations and Resource (CORE) Group cosponsored a symposium to exchange views and evidence about the state-of-the-art in job aids, to share particular job aids that have been successfully used in international health, and to identify future developments that will make job aids more useful in field applications for child survival and international health. Seminar participants heard from leading practitioners in the field of job aids on the evidence of their effectiveness and practical applications of job aids for health in developing countries.
View and download presentations and transcripts from the symposium

Licensure, Accreditation, and Certification: Approaches to Health Services Quality: This monograph helps decision makers analyze the three approaches to health services quality evaluation and management. It describes each approach and its implicatons, such as resource requirements. Activities/Tools: Table comparing existing hospital accreditation organizations and another comparing emerging hospital accreditation organizations.
Download report (38 pages plus appendices)
Licenciamento, Acreditação e Certificação: Abordagens à Qualidade de Serviços de Saúde
Licenciatura, Acreditación y Certificación: Enfoques para la Evaluación y Administración
de la Calidad de los Servicios de Salud

A Modern Paradigm for Improving Healthcare Quality sets out the methodologies for four approaches to quality improvement (QI). The four approaches, which vary in the intensity of resources and time they require, are individual problem solving, rapid team problem solving, systematic team problem solving, and performance improvement. Activities/tools: systems view, evidence-based medicine, hierarchy of evidence, hypothesis testing, interpreting data variation, four steps to QI, continuous QI, Shewart's Cycle for Learning and Improvement (Plan, Do, Study, Act), matrix of QI tools, descriptions of 21 QI tools and activities with advice on when and how to use each.
Download report (78 pages)
Un paradigma moderno para mejorar la calidad de la atención de salud fffffffff
Un Paradigme Moderne de lAmélioration de la Qualité des Soins de Santé

Quality Assurance of Health Care in Developing Countries: This monograph provides a brief overview of several aspects of quality assurance, including its cost-effectiveness and its feasibility in less developed countries. The monograph describes the dimensions of quality, the four principles of quality assurance, the QA process, and key activities in the development of a QA program. Activities/tools: QA cycle (since replaced by the QA triangle); analytical tools, including the cause and effect (fishbone) diagram, flowchart, and systems model; statistical and presentation tools, including the run chart, histogram, check sheets, pareto chart, scattergram, and control chart .
Download report (27 pages)
Garantía de calidad de la atención de salud en los países en desarrollo

Sustaining Quality of Healthcare: Institutionalization of Quality Assurance: Amid impressive worldwide efforts to improve healthcare using quality assurance, too many disappointments can be attributed to a single cause: a failure to fully root QA into an organization's culture, including its daily routine. This work sets out a framework showing the essential elements where QA must take root (leadership, core values, reward programs, etc.) and the phases leading to institutionalization. Healthcare managers and policy makers can use this work to analyze the degree of QA institutionalization in their own settings and plan how to move toward institutionalization. It also provides specific activities for moving each essential element into the next phase of maturity. The text is amplified with case examples of developing country-based experiences in institutionalizing QA. Activities/tools: QA triangle showing core and related activities and four steps to quality improvement, including Shewart's Cycle (Plan, Do, Study, Act).
Download report (52 pages)
Pérenniser la Qualité des Soins de Santé: LInstitutionnalisation de lAssurance de Qualité
Sostenibilidad de la Calidad en la Atención de Salud: Institucionalización de la Garantía de la Calidad

Taxonomy of Health System Standards: Written for people developing healthcare standards, this report describes and provides examples of the various components and aspects of standards, explaining such terms as "algorithms," "clinical pathways," and "standing orders."
Download report (25 pages)

Training Manager's Guide: This monograph has practical guidance for creating successful learning experiences. It is organized to help managers implement training sessions, with step-by-step instructions covering topics from assessing whether training would be effective to evaluating the training. Includes several exercises to reinforce learning from text. Activities/Tools: training process chart, management chart (108 pages).
Download report (108 pages)

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Health Manager's Guides

Monitoring the Quality of Hospital Care: This guide looks at a hospital as having a series of interactive systems, each with inputs, processes, and outcomes. It explains how to determine which processes or outcomes to monitor and then outlines two quality monitoring approaches: the "Quick Start" for monitoring a few indicators for a short period and "Implementing a Monitoring System" for developing an ongoing, multi-indicator method. Both approaches are highlighted with a running case example. Activities/tools: Systems view, taxonomy of health system standards, defining an indicator and its data source(s), presenting data with a line or bar chart or tables, flowcharts, fishbone diagram, dimensions of quality, steering committee action plan, vision statement and organizational structure, prioritization matrix, communications plan, analysis and action plan, and monitoring tool. Appendices include "Use of Specific Standard Formats," Infection Control Administrative Policies," "Pharmacy Department: Medication Errors," "Standing Operating Procedures: Medication Errors," "Five Processes of Care That Affect the Risk of Surgical Site Infection," and others.
Download report (59 pages)

Monitoring the Quality of Primary Care: Written for midlevel managers seeking to improve primary care at the facility level, this guide details one of the core activities of quality assurance: quality monitoring. The three-step approach to measuring quality is described and a running case example highlights the description of the approach. Activities/tools: Dimension of quality of care, systems view, steps and substeps of quality monitoring, prioritization matrix, flowchart, identifying standards that staff could appropriately monitor, selecting indicators, data collection methods and how to choose the most appropriate one(s), sample data collection tools, scoring provider performance and tabulating results, interpreting and using results from quality monitoring, and disseminating results.
Download report (31 pages)
Le Monitorage de la Qualité des Soins de Santé Primaires
Vigilancia de la calidad de la atención primaria

Vendor-to-Vendor Education to Improve Malaria Treatment by the Private Sector: A "How-To" Manual for District Managers: Private vendors, rather than government facilities or even government-monitored facilities, are most frequently the source for medicine to treat malaria. Unfortunately, however, these vendors are often not well informed with regard to government-specified medication or dosage. This guide was written for district health management teams wanting to work with private vendors to improve vendor practices. It explains how to equip wholesale vendors with job aids to communicate treatment guidelines to retailers. Retailers would then inform patients and patient caretakers of proper treatment. Activities/tools: Eight-step vendor-to-vendor process; data collection, including mystery shoppers; job aids; agreement forms; training vendors; monitoring; and tools for implementing the program.
Download report (49 pages)


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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.