Monitoring quality of care across a framework for action

Clinical Expertise
This is the first article in the Evidence for Action quality of care series. The paper presents a quality of care framework and a case study of its application to measure emergency care for mothers and newborns in northern Nigeria.


Evidence for Action’s second series of papers published in the International Journal of Gynecology and Obstetrics (IJGO) focuses on different views and evidence on quality of care for mothers and newborns. 

This article presents a revision of the quality of care framework by Hulton and colleagues and a case study of its application for measuring emergency care for mothers and newborns in northern Nigeria.

The original framework

Quality of care is necessary for the survival of mothers and babies. The term is made up of multiple components, which means that a framework is a useful way of monitoring it.In 2000, Hulton and colleagues developed a quality of care framework using their experience and evidence from medical, health policy, and social science literature.The framework separates quality into two interlinked dimensions and ten measurable elements (see figure below):

Dimension 1 - Provision of care: refers to the quality of care provided by the institution and consists of six elements.

Dimension 2 - Experience of care: refers to the quality of care experienced by users and consists of four elements.The original framework has been used in several settings, including India and Nepal, as well as being used to inform the World Health Organization’s framework for quality of care.

The updated framework

The updated framework divides quality of care into the same two dimensions – provision and experience of care - but each dimension consists of seven elements (see figure below). The updated framework draws from changes in quality of care over the past 15 years, particularly the growing emphasis on accountability for improving quality by the Commission on Information and Accountability

The framework’s application in northern Nigeria

The updated framework has been used in six states in northern Nigeria to help measure the quality of facilities providing emergency care for mothers and newborns. For example, using this framework it was found that, on average for facilities where information was collected, less than 50 per cent had a sink with running water and soap, but nearly 70 per cent had a minimum of two trained healthcare workers to cover normal deliveries.


The authors conclude that a framework can be used to inform certification schemes, which can help not only to improve and reward high quality standards, but also build accountability.

Hulton, L., Matthews, Z., Bandali, S., Izge, A., Daroda, R., & Stones, W. (2016). Accountability for quality of care: Monitoring all aspects of quality across a framework adapted for action. International Journal of Gynecology & Obstetrics, 132(1), 110–116.