A system for quality assurance has been institutionalized

Quality refers to offering a service or product in a way that consistently meets the clients' needs. Quality assurance (QA) is a generic term describing a number of management approaches (Continuous Quality Improvement (CQI), Total Quality Management (TQM)), all of which recognize that many organizational problems result from systems and processes, as well as from a lack of clear performance expectations, rather than negligence on the part of individuals. QA, as it applies to the management of reproductive health programs, generally involves the encouragement of staff members at all levels to analyze systems and processes, to use information to identify the nature and size of each problem, and to design and implement activities to improve services and client satisfaction. (For more detail on QA, see the Service Delivery - Quality of Care indicators.)


Evidence of the availability of quality standards and protocols; budget allocation for QA activities; performance/provider reviews of adherence to standards; client satisfaction feedback on quality; staff feedback on involvement in quality initiatives.


Organizational documents including service delivery guidelines; interviews with managers, supervisors, and other staff at all levels; budget; staff performance reviews; training curricula; client satisfaction surveys; suggestion boxes.


This indicator measures organizational commitment to QA; more detailed indicators can be found in "Managing Quality and Clinical Services".10

From a management perspective, the following six items are essential to developing a composite score of commitment to QA:

  • Evidence of integration of quality assurance into the organization's mission and strategy

By measuring this item, an evaluator will first understand if an environment or organizational culture of quality improvement exists.

  • Evidence of integration of quality assurance into the organization's plans and budget

Not all QA activities will require a separate line item budget; some of them are combined with other activities and are done only at marginal cost. Assessment of budget allocation can be difficult unless the budget is highly detailed/annotated.

  • Evidence of the availability of quality standards or protocols.

This indicator is easy to measure but requires identification of protocols for service delivery (clinical protocols, counseling) as well as for management (e.g., supervision, storage of supplies, infection prevention, MIS reporting) for each major type of reproductive health service.

  • Performance/provider review of adherence to standards.

As with the previous item, this aspect requires measurement according to service delivery and management standards for each reproductive health area. It requires direct observation of staff (such as by a supervisor or mystery client); measurement can therefore be time consuming depending on the volume of services at a given facility.

  • Mechanisms for obtaining client satisfaction/ feedback on quality.

Measuring client satisfaction is the principal means of knowing whether QA initiatives are reaping any benefits. Among the numerous methodologies for measurement, the most common is the client exit interview. One of the weaknesses of exit interviews is that clients sometimes forget details of a visit or do not know what practices are acceptable. Clients may fear impact of negative responses on availability of and access to services.

  • Mechanisms for collecting provider perspectives on quality.

Measurement in this area can reveal gaps between client and provider understandings of quality. It can also help managers understand the extent to which providers feel encouraged or rewarded for taking initiative to address quality.


management, quality
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