Table 2.

Roles and responsibilities for improving QoC within the health system

Health system level	Role in learning for QoC
Facility	Staff involved in QoC should: Participate in peer-to-peer learning activities. Be open to sharing and learning with other facilities. Seek support, when needed, in learning how to: Use various methods and tools to identify the causes of poor care in their setting. Systematically make changes in how they provide care. Use data to learn how effective those changes are. Adapt changes until care has improved. The QI team should: Share its experience of improving QoC with peers, facility leadership and other facilities (eg, in-person meetings, exchange visits, webinars, emails, instant messaging). Document how they are improving their services, their challenges and the results of their improvement efforts. Facilities should document which solutions worked and which did not and share them with the coach and the district support team. Such documentation can be shared with other facilities and used to understand what works and what does not. Facility leadership should: Provide QI teams regular mechanisms and opportunities to share learning (eg, routine facility meetings). Facilitate staff learning. Communicate improvement work and the results to mothers, families and communities. Participate in district-level events (collaboratives) where the facility can compare and discuss its indicators and QI activities with other facilities. Larger facilities with multiple departments should use this opportunity to introduce QoC activities to other departments.
District	District leadership should: Provide public and private facilities with opportunities to share their experiences in improving care (eg, integrate QoC into existing meetings; organise new meetings focused on improving QoC; create new forums for sharing such as WhatsApp; exchange visits). These sessions should not be training or monitoring sessions. Ideally, facility staff working on QoC will have a chance to meet and share every two to 3 months. Ensure that facility staff can discuss challenges and successes without fear of being reprimanded by senior staff. Plan how to help collect learning from facilities and how to organise meetings that encourage sharing. Develop a district-level QI team.
National	National leadership should: Recognise that QoC and learning at the national leadership level are crucial to ensure the sustainability of learning health systems and prioritisation of QoC in policies and mandates. Develop a national-level QI team. Foster collaboration by connecting facilities, leaders and managers around the country. Proactively seek out information from efforts to improve QoC (eg, case studies, stories that combine data with details of the context and how improvement was achieved). Facilitate documentation of improvement activities. Create opportunities for evidence sharing and learning (eg, websites, online resource libraries, webinars, communities of practice, virtual or face-to-face meetings). Disseminate QoC implementation knowledge and tools (eg, newsletters, national forums, podcasts). Identify and respond to any learning needs in districts and facilities. Foster a positive, sustainable environment for learning and sharing. Use implementation science to learn and generate evidence for scale up. Update government policies based on QoC learning outcomes. Connect with other countries on QoC. Stay up to date on global developments in QoC. Integrate the national learning centre into the budget and advocate for the learning centre. Not become a bottleneck.

QI, quality improvement; QoC, quality of care.