Objective. To develop a framework to support the institutionalization of quality assurance (QA). Design. The framework for institutionalizing QA consists of a model of eight essential elements and a ‘roadmap’ for the process of institutionalization. The essential elements are the building blocks required for implementing and sustaining quality assurance activities. Core QA activities include defining, measuring and improving quality. The essential elements are grouped under three categories: the internal enabling environment (internal to the organization or system), organizing for quality, and support functions. The enabling environment contains the essential elements of leadership, policy, core values, and resources. Organizing for quality includes the structure for implementing QA. Three essential elements are primarily support functions: capacity building, communication and information, and rewarding quality. The model can be applied at the level of an organization or a system. The paper also describes the process of institutionalizing QA, starting from a state of pre-awareness, passing through four phases (awareness, experiential, expansion, and consolidation), and culminating in a state of maturity. The process is not linear; an organization may regress, vacillate between phases, or even remain stagnant. Some phases (e.g. awareness and experiential) may occur simultaneously. Conclusion. The framework has been introduced in nearly a dozen countries in Latin America and Africa. The conceptual model has been used to support strategic planning and directing Ministry of Health work plans, and also as a resource for determining the elements necessary to strengthen and sustain QA. The next step will be the development and evaluation of an assessment tool to monitor developmental progress in the institutionalization of QA. Keywords: framework for quality assurance, institutionalization framework, leadership for quality, organizing for quality, quality assurance, sustainability of quality assurance

A revolution is taking place in the field of healthcare. The concept of "quality of care," a major concern in the '90s, is now reverberating into the new millennium, speeded by the advent of healthcare reform in many countries. Providing quality healthcare within the constraints of available resources is a challenging undertaking. Nonetheless, even in an environment with limited resources, methods are available to regularly monitor the quality of care by collecting and analyzing a core set of health indicators, and thereby laying the groundwork for improvement. This guide provides a systematic approach to implementing quality monitoring in a hospital. Quality monitoring is only one part of a comprehensive approach to improving the quality of healthcare. Some of the other components include: providing feedback to healthcare workers, training and supporting staff to undertake improvements leading to quality care, and designing solutions for closing identified quality gaps. The focus of this guide ison measuring and analyzing processes rather than individuals. Seeking a culprit for poor outcomes is not the objective of monitoring. Too often individuals are held accountable for poorly designed systems and processes. In order to develop trust and involve staff in quality monitoring, the emphasis must be placed on the improvement of processes. The involvement of healthcare managers and providers in designing the monitoring process and assuming ownership are critical to establishing, implementing, and using an effective system that can lead to improved healthcare. (author's)

Self-assessment could be particularly valuable in developing country healthcare settings where individual service providers often work without a supervisor or colleague to guide their performance. The QA Project has an interest in self-assessment and its impact on performance because of the intricate link between performance and quality. This paper examines the issues relating to self-assessment, such as the different types of self-assessment, its uses, and its validity. It also reviews the literature (largely from developed countries) that informs our knowledge of self-assessment. The paper makes recommendations for future research and concludes that while much remains to be done to assure that self-assessment has the impact it promises, it may also be less costly and easier to implement than alternatives. (author's)

The Quality Assurance Project (QAP), funded by the US Agency for International Development, provides comprehensive, technical expertise in the design, management, and implementation of quality assurance programs in developing countries. As such, a monograph was created which represents an update on quality improvement methodology for health care delivery. Divided into nine sections, the monograph outlines the principles and frameworks underlying quality improvement in health care. A history of the QAP is presented in Section 1. Section 2 describes the spectrum that covers the range of quality improvement methods and defines four points along this spectrum, namely: individual problem solving, rapid team problem solving, systematic team problem solving, and process improvement. Sections 3, 4, 5, 6, 7, and 8 detail the methodology for improvement for each four approaches, with accompanying illustrations. Finally, Section 9 describes the tools used in quality improvement that include data collection, process description, and data analysis tools.

For the last decade, stand-alone training offered on computers has been used extensively in the US for training medical students and health providers. In many instances, health providers have demonstrated improved knowledge scores upon completing computer-based tutorials, and when compared with traditional facilitator-led training, computer-based training has yielded equal and sometimes higher test scores. However, there remain serious questions on the long-term performance of providers after using computer-based training and the cost issues associated with its development and implementation. In this paper, the Quality Assurance Project (QAP) reviews the current body of published and nonpublished research on the effectiveness of computer-based training in health care. Special focus is made on its implementation in developing country settings and on areas of research that QAP feels should be addressed.

This monograph presents a conceptual framework to help healthcare systems and organizations analyze, plan, build, and sustain efforts to produce quality healthcare. The framework synthesizes more than ten years of QA Project experience assisting in the design and implementation of QA activities and programs in over 25 countries. That experience has shown that the key institutionalization question is often not so much a technical one--how to "do" QA activities--but rather, how to establish a culture of quality within the organization and make QA an integral, sustainable part of the health system. As with any kind of organizational change, the road to institutionalizing QA can be long and complex. This monograph was written to provide practical information to Ministries of Health and other health organizations in their quest for sustainable quality of care. It both describes the components necessary to inculcate a culture of quality and provides practical information on how to facilitate the process necessary to reach this goal. A framework of eight essential elements and a phased process for institutionalization of QA outline the critical aspects and a road map for creating a lasting program to improve the quality of healthcare. The institutionalization framework draws heavily on management literature and organizational change models, as well as QA program experiences in diverse countries. (excerpt)