This paper examines the implementation of four of the most common approaches to nursing quality assurance in England, namely Monitor, Qualpacs, nursing audits and a patient satisfaction questionnaire entitled 'What the Patient Thinks'. The primary aim of the study was to look more closely at the context, processes and outcomes of selecting and implementing specific quality assurance tools. Data were analysed at three distinct levels. The findings are presented around the structure of this three-level framework and indicate that the process of implementing a quality assurance tool is more important than the tool itself. It is suggested that a bottom-up approach to implementation, which locates ownership and control of the quality assurance tool with practitioners, is seen to result in more favourable staff responses and positive programme outcomes. The implementation of Qualpacs is used to illustrate some of the tensions that can occur between the inherent principles of the tool and the method of implementation. In studying the factors that might influence the method of implementing a quality assurance tool, a number of organizational and managerial factors are identified.