A large variety of approaches to reduce risks and improve performance can be observed in long-term care across and within countries, depending on the role of public, private for-profit and non-profit care providers, as well as on governance mechanisms at national, regional or local levels. The introduction of quasi-markets and public tendering has triggered the need to increase transparency of providers’ service quality towards public purchasers and users. This led to new types of supervising institutions and related instruments, such as performance measurement, public reporting and quality certification. These instruments and their rationales are not always compatible and contribute to tensions between stakeholders involved, for example concerning individual needs related to quality of life, dignity and self-determination. It is argued that internal quality management within and across organisations providing care services needs to be supported by enabling policies and mechanisms at the systems level to trigger a process of continual improvement. This entails further development of indicators that should be informed by evidence from multiple perspectives, to measure not only quality of clinical care, but in particular quality of life across care pathways. Ill designed quality assurance systems may hamper improvement processes and lead to bureaucracy, high administrative burdens and feelings of alienation of care workers.