a network of primary health facilities has been constructed from alma - ata declaration , to improve the quality of health care system ( 1 ) . in iran , the majority of rural and urban population receive primary health services from health centers . providing health services such as visiting students , examining women health , vaccination , dental health and environment health are some of specific activities of health centers in iran ( 2 , 3 ) . major outcomes of health services would be researchable almost in the future , thus , it is hard to measure the outcomes instantaneously . inefficacy of reliable data resources about health is another challenging item ( 4 ) . nonetheless , there are some available factors to determine quality of health centers and their services ( 5 - 7 ) . it is widely accepted that the use of organizational quality systems in the health care sector helps the organizations for improving the quality of services provided and the efficiency and effectiveness of the personnel ( 8 , 9 ) . 
 
 to our knowledge , there has not been any previous study regarding a model for immediate quality measurement indicators for iranian health centers . the main objective of this study was to develop a list of indicators to measure quality of iranian health centers . this qualitative study was conducted in three stages : first , a narrative review of the literature was conducted to identify the list of organizational quality indicators for health centers ; second , the delphi process was used to select the main quality indicators for immediate assessing the organizational quality of iranian health centers . then analytical hierarchy process ( ahp ) the research team searched through elsevier , scopus , web of science , emerald and springer databases for quality measurement indicators for health centers . 
 
 the medical subject heading ( mesh ) terms used for searching were  quality  ,  quality of health  ,  health center  ,  primary health center  and  indicator  in the title / topic of articles . after the first search the duplicate articles were removed by endnote software ( x3 version ) . then two reviewers reviewed all the articles for study inclusion criteria . the inclusion criteria were : 1 ) articles which were published in peer reviewed english language journals , 2 ) articles which were cited in eligible databases , 3 ) articles which were published from 2001 to 2011 . consequently , we identified 27 indicators for measuring organizational quality for health centers . 
 
 to reach consensus a delphi procedure was used . indicators collected from literature were used as the basis for the questions , which the experts were then asked to proofread . we designed an ascending assessment scale from 1 to 5 ; 1 : extremely disagree , 2 : disagree , 3 : neutral , 4 : agree , 5 : extremely agree . 
 
 to answer the questions of the questionnaire the experts must have sufficient professional knowledge , and related experience . therefore , this study selected experts with one of the following qualifications : ( 1 ) a current or previous health center manager with at least 5 years of practical experience ; ( 2 ) a phd degree of health services management with related experience ; ( 3 ) a professional and technical staff with 10 or more years of practical experience . 
 
 based on the qualifications , 18 people were selected as experts for delphi procedure . each expert was asked to fill out the questionnaire . they could suggest any item related to quality measurement that was not included the questionnaire . the delphi members answers were collected and then analyzed by spss 19 . in this study for the first round of delphi , we distributed 18 questionnaires with a return rate of 100% . after the two rounds of delphi , the data were analyzed to develop a list of indicators . after designing the primary list adopted from the delphi results , we sent back the list of developed indicators to the experts to confirm it . if two out of three of the experts agreed to add or omit any indicator we considered it to develop the main list the analytical hierarchy process ( ahp ) technique was developed by saaty ( 10 , 11 ) as a powerful instrument used for multiple criteria decision making purposes ( 12 ) . ahp uses pair wise comparisons to identify the priority of alternatives in a multi - criteria decision - making problem ( 13 ) . at the top of the hierarchy in this study therefore , wefirst defined the indicators , then , made a series of pair wise comparisons , and finally , estimated relative weights for measurement of overall performance ( 14 ) . after revealing the quality indicators , 5 experts estimated relative weights by using ahp method . application of ahp to rank / order the 27 indicators required 3 steps . in stepone , 18 experts selected 4 main indicators . in step 2 , five experts compared indicators and discussed why a given indicator would be more or less important than another and the degree of the difference . in order to help the comparison it was created a nine - point scale of importance . the suggested numbers were to express degree of importance between each two indicators as shown in table 1 . intermediate values ( 2 , 4 , 6 and 8) were used to represent comparisons . in step 3 , researchers calculated the weights for each indicator by k. goepel version 9.5.2012 software . the search strategy and application of the inclusion criteria yielded relevant articles published in specified period of time . based on the literature review we found 27 related indicators of quality . the number of participants that filled in the questionnaires and attended the delphi procedure is presented in table 2 . about 55% ( n=3 ) of participants were female and 50% ( n=3 ) were male . about 22% ( n=1 ) were educated in health services management filled and 33.3% ( n=2 ) were general practitioners . the selected indicators from analysis of the data in the first round of delphi were used to develop a quality plan for the health center . in the second round 3 indicators were selected as : having a quality development team in health center , patient satisfaction rate , and percentage of followed complaints.table 3 shows the results of delphi rounds for selecting quality indicators . about 3.7% ( n=1 ) of indicators were statistically significant in first round and 62.9% ( n=17 ) of indicators were asked in the second questionnaire . in the second round after the analysis of the second round of delphi , the primary indicators of organizational quality measurement were developed . the descriptive statisticsof four selected indicators is shown in table 4 . 
 
 after developing the primary list of indicators , they were asked to proof the indicatorsand make some changes if necessary to develop the main list . in iranian health system there is a particular interest in quality assessment , both in healthcare services and in healthcare organizations . , conducting different programs like iso , organizational excellence , clinical governance and similar programs can be seen in medical and therapeutic centers like hospitals . in this research as indicators of quality , two indicators of  developing a quality plan  and  having a quality development team  in health centers are in line with other studies ( 7 , 9 ) . as a major component of quality of health care , patient satisfaction is a key determinant of pay - for - performance metrics ( 6 ) . dib et al ( 2010 ) showed that patient satisfaction rate can predict the degree of the healthcare quality . they declared that increasing the rate of healthcare quality leads to increasing of patients satisfaction ( 15 ) . having a strong primary health system needs an appropriate performance measurement model to cause a positive impact on population health ( 16 ) . our proposed list of indicators could be used to guide the development of quality in health centers . different studies have emphasized on quality as an important issue in organizations ( 15 , 17 , 18 ) . there is a pressure to improve the performance worldwide , though it is not achievable without a measurement tool ( 19 ) . in this research feedbacks from the managers , health workers and academia were used to develop the list of indicators . in this article we developed a 4 indicator listfor rapid measuring of organizational quality for iranian health centers . this model can be used as a template for rapid quality assessment in other developing countries.this model was developed by calculating weights of each indicator . this study is unique because a new methodology was used to design a list of indicators .
background : recently , quality is a serious concern in development of organizations 
 . there are 
 various indicators to assess quality and the purpose of this study was to identify the main indicators 
 for quality measurement of iranian health centers . 
 methods : this qualitative study was conducted in three stages : first , review of the literature was 
 performed to identify different indicators for quality measurement in health centers ; second , a tworound 
 delphi process was used with participation of 18 experts in both rounds ; third , analytical hierarchy 
 process ( ahp ) method was applied to give weights to each indicator . 
 results : twenty - seven indicators were identified from the literature review stage . 
 the delphi 
 method reduced the list to 4 indicators . developing a quality plan in the health center had the highest 
 weight ( 38% ) and percentage of followed complaints the lowest ( 12% ) . 
 the consistency rate was 
 7.2% indicating appropriateness of the data . 
 conclusion : this list of indicators can be used as a template for measuring quality of health centers 
 in iran and possibly in other developing countries .