A framework for institutionalizing quality assurance.

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 QA 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 preawareness, 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.