In the 1980s weaknesses in the inspection process, the persistence of poor quality, and the emergence of new management techniques in industry, together with rising costs, led health care professionals in developed countries to begin reassessing accreditation and standards-based quality assurance (194, 262, 305). US health care organizations began testing the industrial philosophies of Continuous Quality Improvement (CQI) and Total Quality Management (TQM) (38, 194). At the same time, the hospital accreditation system expanded its focus from inspections to promoting quality improvement (50, 305). In the UK the National Health Service adopted a formal quality policy in 1991 and recognized CQI as the most cost-effective way to implement it (262).

These approaches contend that good quality should be designed into products and processes at the start, to prevent problems from ever arising. Inspections are important, to reject substandard products or services, but they cannot raise the quality of products or services produced (79). Therefore, quality management practitioners have devised a series of tools and methods for managers and employees to strengthen organizational systems, prevent problems, and improve quality (62, 262).

Still, health care differs from consumer product industries in two important ways: First, most clients lack the knowledge to judge technical quality in health care and family planning; second, a client's physical well-being and sometimes very life, not just satisfaction and loyalty, may depend on the quality of services. Therefore conventional quality control methods, such as licensing, standard setting, and accreditation, remain uniquely important in health care to eliminate substandard care and protect clients (9).