Defining quality indicators

Quality of care measures can be constructed in varying ways, depending on the specific technical content, data source, and measurement method and feasibility in an individual context. In most cases, quality of care process indicators measure the adherence of the care provided to evidence-based standards. Two approaches can be used to measure adherence to standards: (1) all-or-nothing, where all elements of the standard must be met for the encounter to be judged as acceptable quality or (2) percent adherence across all possible standards:

  • Percentage of cases adherent to standards, all or nothing adherence, such as percentage of diarrheal cases managed per minimum standards)
  • Average percentage adherence to minimum standards, such as average percentage of adherence with diarrheal case-management standards; n=30 cases reviewed x 6 minimum standards per case = 180 possible standards to be met)

All-or-nothing adherence may be useful for simpler interventions, such as administration of vitamin A; average percentage adherence may be more useful for tracking more complex interventions, such as community case management of febrile illness, where achieving adherence with essential standards may be more gradual.

Regardless of the construction of the measure, it is very important to standardize operational definitions of quality of care indicators (performance measures) to include, at a minimum,: (a) clear numerator, (b) denominator, (c) source of data, and (d) frequency of data collection (see Table 2). The specific measurement method that is best suited to a particular indicator depends on a range of factors, including feasible data sources and those factors must be considered when constructing an indicator. For example, it is difficult to measure the quality of counseling provided to a pregnant woman by auditing a register. Instead, periodic observation of actual counseling or simulated counseling using a structured checklist may be the most appropriate measurement method.

Table 2: Illustrative Quality of Care Measures—Effectiveness of Care

Quality of Care Measure

Operational Definition

Data Source, Sample

(measurement method)

Frequency of Data Collection



Percentage of pregnant women seen at the health post who had blood pressure measured at their last ANC visit

Number of pregnant women seen in the health post in the last month who had their blood pressure documented

Total number of pregnant women seen for ANC in the health post in the last month

Antenatal care register in health post


Average adherence

to with post-partum counseling standards for mother

Number of observed post-partum care counseling sessions in the last month adherent with specified standards

Total number of post-partum counseling sessions observed in the last month

Structured observation using checklist by supervisor or peer