Operational guidelines for quality improvement in public health facilities. National Quality Assurance Standards Development

Author

Dr J N Srivastava, Dr Deepika Sharma, Dr Arpita Agrawal, Dr Ratan Shekhawat - National Health Systems Resource Centre

Country

India

Country snapshot

India, with its vast population, diverse health needs, and complex disease burden, has long recognized the challenge of delivering safe, equitable, and people-centred health care across over 200’000 public health facilities. Over the past two decades, the Government of India has demonstrated sustained political and programmatic commitment to quality improvement—starting with early initiatives under the Reproductive and Child Health (RCH) programme in late 1990s, institutionalized further under the National Rural Health Mission (NRHM) in 2005, and later consolidated through the National Health Mission (NHM) in 2013. The NHM brought both rural and urban health under one umbrella, aiming to achieve universal access to affordable, high-quality health care services.

During this evolution, India piloted multiple quality models, including the ISO 9001 standard, the Indian Public Health Standards (IPHS), NABH accreditation, and state-led initiatives such as the Family-Friendly Hospital Initiative (FFHI). While these models provided foundational learning, the fragmented approach revealed the urgent need for a unified, scalable national quality framework for their health care facilities.

In response, the Ministry of Health and Family Welfare (MoHFW) developed the Operational Guidelines for Quality Improvement in Public Health Facilities in 2013, and then comprehensively revised them in 2021. These guidelines form the national policy and strategic roadmap for improving the quality of care and ensuring patient safety across the public health system. India’s quality strategy, articulated through the 2021 Operational guidelines, represents a systemic shift from fragmented efforts to a harmonized, nationally guided, and locally responsive framework.

National Quality Standards Development

India introduced the Operational Guidelines for Quality Assurance in 2013 to establish a national framework for institutionalizing quality in public health facilities. Following the release of the WHO NQPS handbook in 2018, the guidelines were revised in 2021 through extensive stakeholder consultations, field-level learnings, and alignment with global best practices. The guidelines provide a standardized and adaptable framework applicable at national, state, district, and health care facility levels.

As part of these operational guidelines, the National Quality Assurance Standards (NQAS) was developed by the Ministry of Health and Family Welfare (MoHFW), offering measurable, verifiable standards for various tiers of the health care system—from district hospitals to sub-health centers. The NQAS framework aligns with the WHO quality-of-care domains and has been accredited by the International Society for Quality in Health Care (ISQua), ensuring global credibility.

This ensured that the NQAS remained evidence-based, patient-centric, scalable and practical for implementing across all levels of care, firmly embedded within India’s health system governance. Meanwhile, the NQAS has been periodically revised in alignment with global frameworks, particularly the WHO Global Patient Safety Action Plan 2021–2030, the WHO Global Action Plan on Antimicrobial Resistance (GAPAMR), and the WHO Core Components for Infection Prevention and Control (IPC). These international instruments have provided strategic direction in embedding patient safety, infection prevention and control and antimicrobial stewardship into the country's public health quality assurance efforts. The standards are regularly updated to reflect emerging clinical protocols, international best practices, and national programme requirements. The standards are regularly updated to reflect emerging clinical protocols, international best practices, and national programme requirements.

Institutional mechanisms were also formalized through the creation of dedicated quality assurance committees and units at the national, state, district and facility levels, to support planning, implementation, mentoring and monitoring. This architecture fosters decentralized ownership while maintaining national consistency.

Though NQAS already has many patient safety practices in its existing framework, it has been further strengthened by referencing the WHO Global Patient Safety Action Plan (GPSAP) into the eight areas of concern, in particular:

  • Strategic Objective 3 (Assuring safety of clinical processes) is reflected in NQAS standards related to safety protocols in clinical care, rational drug use and safe surgical practices.
  • Strategic Objective 5 (Infection prevention and control) directly informs the infection control standards across all facility levels, from district hospitals to Ayushman Arogya Mandir sub-health centres (SHCs).

In alignment with the Global Action Plan on Antimicrobial Resistance (GAP-AMR), NQAS incorporates provisions for rational antibiotic use, antimicrobial audits and prescription monitoring. Facilities must establish standard treatment guidelines and document antimicrobial use, in line with GAP-AMR’s Objective 4 (Optimize the use of antimicrobial medicines).

The infection control standards under NQAS have been strengthened by integrating the WHO core components of IPC programmes (2016). Core areas such as health care-associated infection surveillance, hand hygiene compliance, biomedical waste management, and regular IPC training for staff are mandatory assessment components and apply to all levels of health care facilities.

By embedding global best practices into NQAS, India has institutionalized a culture of quality, patient safety and clinical governance across public health facilities. This alignment enhances global comparability, strengthens system resilience and supports evidence-based care through integrated decision-support tools. This is advancing India towards its goal of 100% NQAS certification by December 2026.

In addition, the NQAS promoted convergence through multi-disciplinary teams, cross-cutting training, and standardized indicators to foster collective accountability and integration.

NQSA development challenges and their mitigation

The development of the NQAS was a complex, adaptive process, tailored to the diverse needs of India’s public health care system.

The main challenge was limited awareness and capacity among public health staff regarding quality and patient safety. This challenge was addressed by implementing a comprehensive, tiered capacity-building strategy. Facility-level service provider trainings sensitized staff on standards and protocols; state-level internal assessor trainings built in-house review capability; and national external assessor trainings empaneled experts for certification assessments.

Over 8800 state and 2170 national assessors have been trained to date. These efforts were reinforced by national and state awareness campaigns to embed a culture of quality.

Progress made since NQAS implementation

India has made notable advances in aligning its National Strategy for Quality of Care and Patient Safety, underpinned by a commitment to deliver equitable, safe and people-centred health care services.

Since its inception, NQAS has been phased in across all levels of care, beginning with district hospitals and extending to community health centres (CHCs) and primary health centres (PHCs) in 2014, urban primary health centres (UPHCs) in 2015, and Ayushman Arogya Mandirs (sub-health centres) from 2020 onwards. The expansion of PM-JAY (Pradhan Mantri Jan Arogya Yojana) has further reinforced the urgency of ensuring quality in public health service delivery, particularly for poor and vulnerable populations. In line with this momentum, quality standards are also being developed for newly constructed medical colleges to ensure uniformity in care and adherence to quality and safety protocols.

As of 2025, over 36’967 public health facilities have been certified under NQAS, demonstrating strong implementation, institutional support, trained personnel, digital platforms and political commitment. These elements highlight India’s progress toward its quality and safety goals.

Key challenges encountered and how they were addressed during the implementation

Implementing the National Quality Assurance Standards (NQAS) across India’s public health system faced several systemic and operational challenges, which we addressed through targeted strategies.

Until 2020, certification uptake remained low due to limited support, perceived complexity, and low visibility of impact. To address this challenge, rapid improvement events (RIEs) were introduced to identify gaps and implement change ideas with measurable outcomes. Complementary initiatives like LaQshya, MusQan, Kayakalp and SaQushal provided programme-specific momentum aligned with NQAS goals.

Another challenge was to sustain post-certification quality as facilities often struggled to maintain quality after certification. This challenge was addressed through periodic surveillance and surprise assessments to ensure continued compliance.

Key lessons learned

Several lessons emerged from India’s development and implementation experience:

  • Explicit political endorsement, integration into national health policies, and institutional backing at the highest levels are critical. This ensures legitimacy, cross-sectoral alignment, and long-term sustainability of the implementation.
  • A tailored, system-integrated approach was adopted to suit India’s diverse public health system, considering resource constraints, service variations and governance needs. This flexible yet standardized framework enabled effective implementation across the different levels of care. Aligning vertical programmes under this model prevented duplication, optimized resources and promoted a unified culture of quality, ensuring coherence with broader health goals.
  • Integrating quality improvement, quality control, and quality assurance enabled the policy to address both systemic reforms and daily operational standards, ensuring sustained quality gains over time.
  • Engaging policy-makers, programme managers, facility teams, patients and communities from the outset ensured the quality standards were context-specific, feasible, and more widely accepted. This inclusive, bottom-up approach fostered ownership, strengthened accountability and improved adherence to quality standards.
  • Robust data integration allowed real-time quality tracking in SaQsham. Data was used for compliance, learning, innovation, and adaptive responses, driving evidence-based decisions. 

What would you do differently?

Earlier integration of digital tools. The delayed incorporation of platforms like SaQsham, which now provide real-time monitoring, facility-wide tracking and performance analytics, would have, from the outset, enabled a more responsive and data-driven implementation of NQAS. These tools are now being effectively leveraged to strengthen transparency, streamline assessments, and support evidence-based decision-making at all levels.

Disclaimer

This learning brief is only presented for learning purposes. Its content has been developed by the organization and author(s) named and as such does not represent the views, policies, or approaches of WHO.