Table 4 Practice points

 • The implementation strategy was successful for the introduction of the quality system (QS) in the institutes.

 • Creating a sense of togetherness and peer pressure can stimulate the use of the QS.

 • In addition to directors and quality coordinators, staff also needs to be involved in the development and implementation of a QS.

 • The appropriateness and benefits of the QS to local contexts needs to be clear.

 • The relative absence of short-term effects should be communicated clearly.