Quality Assurance Approach

The Quality Assurance (QA) approach to addressing quality of care issues incorporates three core quality assurance functions: defining quality, measuring quality, and improving quality (QAP/URC, 2001a.) The QA triangle effectively illustrates the synergy between these three QA functions.

Quality Assurance Triangle

Each core function actually represents a constellation of activities, as explained below. The triangle shape indicates that rather than a unique sequence of steps that initiate QA activities, all core functions need to take place in a balanced manner for a QA strategy to be effective. The greatest impact on quality of care results only when all three functions are implemented in a coordinated fashion. In this database, the focus is on issues relevant to the measurement of quality.

Defining Quality means developing expectations or standards of quality. Standards can be developed for inputs, processes, or outcomes (expected outputs, results or impact on health status); they can be clinical or administrative. Standards state the expected level of performance for an individual, a facility, or an entire health care system. A good standard is reliable, realistic, valid, clear, and measurable. Standards of quality can be developed for each of the nine dimensions of quality shown below, which cover widely recognized attributes of quality of care.

Dimensions of Quality

Clinical care standards should be based on the best scientific evidence available. The definition of quality standards also includes stakeholder perception and expectations of quality (including client and community).

If standards do not exist, practitioners must design or adapt them from international standards. Although standards are context specific, universally accepted standards are often a good starting point for developing local standards. Sometimes, even when national standards exist, they must be refined or made operational for local use.

Improving Quality uses quality improvement methods (problem solving, process re/design or re-engineering) to close the gap between the current and the expected level of quality (defined by the standards). This core function applies quality management tools and principles to:

  1. identify/determine what one wants to improve;
  2. analyze the system of care/problem;
  3. develop a hypothesis on which changes (solutions) might improve quality;
  4. test/implement the changes to see if they really yield improvement; and
  5. based on the results of testing, decide whether to abandon, modify, or implement the solutions (QAP/URC, 2001b).

Measuring Quality consists of quantifying the current level of performance or compliance with expected standards. This process requires identifying indicators of performance, collecting data, and analyzing information. Measuring quality is inextricably linked with defining quality because the indicators for measuring quality are related to the specific definition or standard of quality under study. When standards define quality, measuring quality requires assessing the level of compliance with standards. Hence, measuring quality is easier with a clear definition or standard, because the indicators are directly derived from the expression of the standards. Likewise, measuring quality leads directly to identifying areas for improvement or enhancement - the first step in quality improvement. A few key points in the measurement deserve highlighting; the details appear in different publications (QAP/URC, 2000a and 2000b):

  • If one starts the QA approach with measuring quality, the scope of measurement should be limited to what the system is able/willing to improve (i.e., a quality improvement objective must be defined).
  • The QA team must be realistic about what data the team can readily collect at the facility level or across the system. A simple performance monitoring system with a limited number of indicators related to the improvement goal is usually very effective.
  • Measurement strategies, such as special surveys, self-assessment, audits, and supervision visits, must be carefully designed so that those stakeholders ultimately controlling the quality of care (usually the providers) take full ownership of the quality improvement process. The team in charge of making improvements should fully participate in defining standards, identifying indicators, and developing a measurement strategy.

The indicators used to measure quality will vary in each setting, based on the particular standards used and the level of the system (facility, district, regional, or national) on which measurement focuses.  With regard to maternal health, indicators are based on existing Neonatal and Emergency Obstetrical Care (EmOC) standards relating to newborns and safe motherhood. However, even when well-defined national standards exist, defining new standards (and indicators) specific to the needs of the facility and community served may be necessary. 

Organizational Levels of Care

When developing indicators to monitor the quality of maternal care, one needs to consider various organizational levels of the health care system (operational/facility, intermediate, and strategic). The indicators will vary based on the level and on the specific standards selected for measuring quality (QAP/URC, 2001c). Whenever possible, the QA team should select indicators that use available data collected through the routine health information system. A brief description of organizational levels follows.

  • Operational level - refers to the facility where processes that directly affect users and generate the monitoring data are carried out.
  • Intermediate level - involves decision-makers who influence quality and the delivery of care, such as heads of departments, sections, or services.
  • Intermediate level - involves decision-makers who influence quality and the delivery of care, such as heads of departments, sections, or services.
  • Strategic level - includes top management and political decision-makers at local, provincial, and national levels.

The table below describes the differences among these levels.

Level Monitoring Objective Process People Involved

Track service delivery processes, results, and the availability of inputs

Emphasize individual processes or services at the facility level Management and improvement teams that examine the quality of processes at the facility level
Intermediate Compare processes carried out at the operational level Emphasize the results and products of the combined processes or services Heads of departments, programs, and services at the district level
Strategic Evaluate the overall system results, compare results with objectives, act on differences, assure the quality of the entire system Emphasize the overall results of the system and strategy to better meet objectives Top organizational management at the national, regional, or local government levels

A complete quality monitoring system for neonatal and EmOC will include indicators for the processes, outputs, and outcomes of the different levels of services. They should reflect levels of compliance with the best clinical evidenced-based standards available. The frequency of measuring indicators varies; whereas some require monthly or quarterly measurements (compliance with process of care standards), others will require less frequent measurements (outcome measures such as disease-specific maternal mortality rates). When the number of cases are small, one can pool the data of several facilities in a region. Plotting those data over time allows evaluators to follow trends or patterns of performance and improvement (the product of which is called a "run chart").



QAP/URC. 2000a. "The Health Manager's Guide for Monitoring the Quality of Primary Care." Bethesda, MD: University Research Co., LLC.

QAP/URC. 2000b. "The Health Manager's Guide for Monitoring the Quality of In-Patient Care." Bethesda, MD: University Research Co., LLC.

QAP/URC. 2001a. "QA Monograph on Institutionalizing Quality Assurance." DRAFT. University Research Co., LLC.,

QAP/URC, 2001b. "A Modern Paradigm for Improving Quality of Health Care Services." Bethesda, MD: University Research Co, LLC.

QAP/URC. 2001c. "The Latin American Maternal Mortality (LAMM) Initiative." Bethesda, MD: University Research Co., LLC.