Overall, a reassessment was done and could be documented in 27 facilities belonging to 9 different countries, belonging to Central and Eastern Europe (3 countries), Central Asia (3), sub-Saharan Africa (2) and Latin America (1).

Time elapsing from first to the second assessment varied from around a year to almost 4 years. In all countries the reassessment was carried out by a national multidisciplinary team with the supervision of an international team [12,13]. In most countries the exercise was led by international agencies in collaboration with national authorities, in two by NGOs in collaboration with local authorities. In one the assessment was made within a project funded by a national research institution.

Table 1 provides an overview of countries, dates, number of hospitals involved and organizing agencies.

To our knowledge this is the first report documenting, in a variety of low and middle income countries and health system settings and by using a homogeneous approach, improvements in the quality of MN hospital care along the continuum of care from admission to discharge. We believe that the review provides several useful indications about the observed improvements and their adherence to WHO standards [11], as well as about key factors influencing change.

Improvements were observed in all areas of care and were particularly important and more frequently observed in the areas corresponding to appropriate case management and respectful care for both mothers and newborns (WHO standards 1 to 6) than in those related to staffing and infrastructure (WHO standards 7 and 8). This is not surprising since changes in the latter areas are more difficult to be achieved by the hospital management and key staff alone, as they usually require action at higher health system levels. Although remarkable and widespread across most facilities and countries, the observed improvements did not cover all the quality gaps that were observed at the baseline assessment nor were they always sufficient to achieve standard care. This could be attributed to the relative shortness of the period elapsing from the baseline assessment to reassessment. However, none of the three studies investigating factors influencing change reported time constraints as a major obstacle, and many assessors involved in reassessment confirmed that change either initiated soon after the assessment or it did not occur. This further underlines the importance of including the development of a draft action plan with timelines and responsibilities to address priority quality gaps as part of the baseline assessment visit, since this allows to use the momentum created by the feedback on quality gaps to create the commitment and identify the individuals who would take on responsibility for it.

While we underline the uniqueness of our findings, in terms of both comprehensiveness of coverage along the continuum of care and variety of settings, we must also recognize their limitations. These derive on one side by the fact that in most countries we were not able to document the details of the process between the two assessments and the extent to which the leading agencies were able to ensure follow-up and support, on the other by the difficulty in disentangling the effects of the inputs provided by the baseline quality assessment from the changes produced by independent factors acting in the same period, such as new laws, regulations and development assistance. However, the very specific features of many of the observed improvements, particularly regarding medical and nursing procedures are hardly explained by inputs other than internal leadership and commitment by involved professionals, and the merit can be attributed with reasonable certainty to the process started through the WHO QA/QI MN tool. In particular, the tool adopts a participatory approach that builds awareness among both managers and staff about the quality gaps and their causes, provides professional support in identifying appropriate practices and providing evidence, and introduces guiding concepts and tools such as the WHO quality of care standards. Indeed, standards cannot be implemented without a learning process that needs professional and contingent inputs along the continuum of care [17], not just bureaucratic recording of what is missing and written protocols of what should be done. The participatory and professional feature of the assessment required by the WHO tool is key to prompt this learning process, as indicated also by the review of the studies on barriers and facilitators. This analysis identified some commonalities across the variety of health system contexts. Among these, the human resource component emerged as crucial, in all its dimensions of manpower availability and deployment, training, continuous professional development and motivation. The capacity of hospital managers and of key professionals, such as unit or department heads, to motivate their staff, and to provide opportunities for professional development emerged as a factor that ultimately made most of the difference at facility level. Although staff numbers, qualification and salaries are obviously important, the issue of human resource management by hospital leading staff is still greatly undervalued, when not neglected. In fact, the differences in the quality of care provided among hospitals belonging to the same system and struggling with the same structural and budgetary difficulties point to the human factor dimension as something which should have a higher place in the health system agendas, and to the need of integrating preservice curricula of all health professionals, from nursing and midwifery staff to managers [18-21]. Based on this evidence, it appears crucial that quality assessments not only provide a snapshot of the existent, but include a dynamic component, namely by initiating the development of a plan of action and defining a time frame for its implementation, as envisaged in the process promoted by the WHO MN tool. Ideally, in addition, prospective identification of barriers and facilitators may help to avoid potential frustration of good will by setting realistic targets for the action plan thus increasing the likelihood of success. A recent review of MN quality assessment tools indeed identified the lack of a clear path leading to action as one of the main pitfalls of the existing tools [9].

In spite of recent progress, the attention paid to quality of care, the capacity to implement quality improvement cycles and take into account patients’ rights and perspectives is still insufficient in all health systems and at all levels [4,9,10]. At facility level, quality assessment tools should promote a constructive dialogue with hospital managers and key staff and build their awareness of quality issues and their capacity of implementing quality cycles also including patients’ views. The review of the experience made with the WHO QA/QI MN tool is encouraging as it shows that this is possible. This refocuses the need of policy changes at national level in support of QI at local level, such as efforts to build capacity for supportive supervision and coaching of auditing processes, including patients’ views: professional staff, managers and patients are all key players of a quality movement [10,22,23].