Table 2

Quality programme formative assessment

No.Quality programme assessment tool questionWCKZNNWLPPrivate
Quality structure
 A.1Does the organisation have an organisational structure in place to plan, assess and improve the quality of care?21135
 A.2Have adequate resources been committed to fully support the quality programme?42024
 A.3Do the leadership support the quality programme?31135
Subtotal (max=15)942814
Quality planning
 B.1Does the organisation have a comprehensive quality improvement/management plan?23132
 B.2Does the organisation have clearly described roles and responsibilities for the quality programme?41014
 B.3Does the work plan specify timelines and accountabilities for the implementation of the quality programme?41033
Subtotal (max=15)105179
Quality measurement
 C.1Are appropriate outcome and process quality indicators selected in the quality programme?13112
 C.2Does the organisation regularly measure the quality of care?13013
 C.3Are processes established to evaluate, assess and follow-up on quality data?33023
Subtotal (max=15)59148
Quality improvement activities
 D.1Does the organisation conduct specific quality activities and projects to improve the quality of care?31123
 D.2Are quality improvement teams formed for specific projects?31024
 D.3Are systems in place to sustain quality improvements?33022
Subtotal (max=15)95169
Staff involvement
 E.1Are staff routinely educated about the programme’s quality programme?21021
 E.2Does the organisation routinely engage all levels of staff in quality programme activities?23022
 E.3Are patients involved in quality-related activities?30023
Subtotal (max=15)74066
Evaluation of quality programme
 F.1Is a process in place to evaluate the quality programme?33021
 F.2Does the quality programme integrate findings into future planning?33023
 F.3Does the programme have an information/data system in place to track patient care and measure quality indicators?23013
Subtotal (max=15)89057
Total (max=90)483653653
  • 0—no plan/structure/process.

  • 1—limited plan/structures/process in place.

  • 2—early implementation.

  • 3—full implementation.

  • 4—developing systematic approach to quality.

  • 5—full systematic approach to quality.

  • KZN, KwaZulu Natal; LP, Limpopo; NW, North West; WC, Western Cape.