Institutionalization is an ongoing process in which a set of activities, structures, and values becomes an integral and sustainable part of an organization.

Health care improvement and sustained high quality 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 QI 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:

• • Internal enabling environment
• • Structure
• • Support functions

An internal environment conducive to initiating, expanding, and sustaining improvement is necessary to institutionalize QI. 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 quality improvement 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 improvement.

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 QI activities

A Structure to Support QI Implementation

The institutionalization of QI requires a clear delineation of oversight roles and responsibilities and accountability for the implementation of QI activities. The specific organizational structure for implementing QI 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 QI may combine many forms, such as a Quality Assurance Unit, quality improvement teams at facilities, or an oversight committee.

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

Whatever form the QI 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 QI activities lies. This oversight includes both leadership support (developing strategic direction, setting priorities, follow-up, monitoring of progress) and technical oversight for QI efforts.

Coordination: The very nature of improvement 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 QI program fit together and how they will be coordinated and synchronized. For example, the collection and use of data is essential for QI to be most effective––which means coordination with those in charge of national databases is vital. Likewise, because QI 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.

Roles and responsibilities: The true structure for QI in an organization is manifested in how the roles and responsibilities for performing QI activities are divided and/or delegated within the organization. Eventually, responsibilities for QI should appear in routine job descriptions for individuals as well as in the scope of work for organizational units.

Accountability: With maturity of a QI program, every individual becomes accountable for results and responsible for quality. However, in the early stages of development, it may be useful to clearly outline the specific duties, lines of reporting, and accountability for results, to ensure that QI activities are duly implemented and that there is necessary time allocated for staff participation in QI. During the initial stage of development, it may be important to have some individuals solely devoted to QI, working within a designated “Quality Unit” that focuses on QI training and capacity-building. During this stage, a visible organizational location for QI, with explicit leadership support may be useful to boost awareness of QA and grant recognition of its importance.

As QI 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.

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.

Resources to Learn More

• Sustaining Quality Healthcare: Institutionalization of Quality Assurance