Institutionalization

Quality 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.

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 quality improvement is institutionalized within an organization. An environment that enables the initiation, growth, and continuity of improvement activities must also incorporate supportive policies, effective leadership, structures that support the performance of quality improvement activities, and adequate resource allocation that emphasizes the importance of quality and encourages people to practice improve health care quality as part of their daily work.

The graphic at left depicts a conceptual model of the fundamental elements and components of an institutionalized program to improve health care quality:

The core or center of the model is quality health care, the desired outcome. Technical approaches or activities for improving quality of health care are represented by the quality assurance triangle of: defining quality (QD), measuring quality (QM) and improving quality (QI). Experience with quality improvement in developing and middle income countries has shown that these 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 quality improvement activities, and support functions to sustain their implementation.

The Essential Elements of Institutionalizing Quality Improvement

Improved health care requires 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 quality improvement 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

Internal enabling environment:

Policy
Leadership
Core values
Resources

Organizing for quality (structure)

Support functions:

Capacity building
Communications
Rewarding quality

As shown in the box, there are eight essential elements that make up the quality improvement 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 experience implementing quality improvement activities and building quality assurance programs in developing countries. While recognizing that every health organization functions within a larger environment that influences its ability to improve quality, 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 quality improvement institutionalization, link to the topics below:

The Internal Enabling Environment
A Structure to Support Quality Improvement
Essential Support Functions

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The Internal Enabling Environment

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

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A Structure to Support Quality Improvement Implementation

The institutionalization of quality improvement requires a clear delineation of oversight roles and responsibilities and accountability for the implementation of QI activities. The specific organizational structure for implementing quality improvement activities can vary greatly from one organization to another, and will evolve over time as the program matures. Organizations in more centralized environments will structure quality improvement activities differently than those who operate in more decentralized environments. Technological development and economic status will also drive decisions about how quality improvement programs are organized. There is no "correct" or "best" structure; an effective structure for quality improvement may combine many forms, such as a quality unit, quality improvement teams at facilities, or an oversight committee.

Whatever form the quality improvement structure takes, institutionalization requires 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 quality improvement 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 quality 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 quality improvement program fit together and how they will be coordinated and synchronized. For example, because 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 quality activities (defining, measuring, and improving quality) and between the various stakeholders.
Roles and responsibilities: The true structure for quality is manifested in how the roles and responsibilities for performing quality improvement activities are divided and/or delegated within the organization. Eventually, responsibilities for quality should appear in routine job descriptions for individuals as well as in the scope of work for organizational units.
Accountability: With maturity of a quality improvement 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 quality improvement activities are duly implemented and that there is necessary time allocated for staff participation in quality improvement. During the initial stage of development, it may be important to have some individuals solely devoted to quality improvement, working within a designated "Quality Unit" that focuses on quality improvement training and capacity-building. During this stage, a visible organizational location for quality improvement, with explicit leadership support, may be useful to boost awareness of quality issues and improvement methods and grant recognition of their importance.

As quality improvement 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 district management committees) may assume daily oversight of quality improvement activities, and the role of the designated Quality Unit may become more focused on the development of standards. In other situations, early quality improvement 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 quality improvement, those doing the day-to-day implementation of quality improvment activities require more specific types of support. As the name implies, support functions provide "support" for the staff to undertake and sustain technical quality improvement activities. The development of ongoing systems to ensure Capacity Building, Communication of Quality Improvement Efforts, and Rewarding Quality Work are critical for an organization to move beyond performing quality improvement as isolated activities, to a state of continuously implemented improvement activities, 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 quality improvement institutionalization.

Capacity Building

Capacity building refers to the ongoing process of ensuring that staff have the necessary knowledge and skills to carry out their quality improvement 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 QI technical, managerial, and leadership expertise within the organization. Capacity building encompasses the whole range of activities that increase quality improvement knowledge, skills, and ability, from formal training to self and peer appraisals to supervisory activities. Essential capacity-building activities include:

Provision of basic QI expertise: Institutionalization of quality improvement requires that a critical mass of health providers and managers receive initial and continuing knowledge and skill development in QI techniques and methods. As appropriate, the ability to manage quality improvement activities would also be included. Developing basic quality improvement 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 quality improvement responsibilities and related training needs. 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: Coaching provides ongoing technical and qualitative support to facilitate the behavior changes needed to undertake and sustain quality improvement activities, while simultaneously encouraging the development of a "culture of quality." The term coach refers to an individual who is well-versed in quality improvement techniques and principles and can provide on-the-job technical support to staff implementing quality improvement activities.
Supervision: Staff also need day-to-day support and correction as they undertake quality improvement activities. Supportive supervision requires enhancing the facilitating role of the supervisor, assuring that supervisors have a foundation of QI expertise, as well as teaching supervisors how to observe, give feedback, and assess a situation.

Improving quality of health care 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 quality improvement capacity building.

Communication of Quality Improvement 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 quality 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 quality improvement 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 conduct quality improvement activities and having information available about what can be achieved, staff members also need to see that their efforts in quality improvement 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 quality improvement 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 quality improvement 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 making improvements and for 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 teams in meetings, conferences, newsletters, and/or recognitions posted in health facilities. All of these examples publicly acknowledge teams and recognize value of quality work.

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).
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A framework for institutionalizing quality assurance, article in International Journal for Quality in Healthcare supplement
article abstract can be viewed online at http://intqhc.oxfordjournals.org/cgi/content/abstract/14/suppl_1/67

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