We describe the iterative process of developing a locally-appropriate quality of care approach and its role in emergency obstetric care (EmOC) programming in Nepal. We describe the context of maternal health issues in Nepal, the rationale for developing a quality of care approach within a model to improve EmOC, and outline the outcomes and catalytic effects of the process. The lessons learned during the development of this approach are detailed. The program developed and implemented a quality of care approach at three district hospitals in Nepal. This resulted in improvements in the structure, process and outcomes of EmOC in these institutions. The process also resulted in improved understanding of quality of care approaches on both local and national levels and the creation of a Nepalese quality of care evaluation framework for maternity services. While the theoretical concept of quality of care is difficult to translate into a concrete approach, we used a process in rural hospitals in Nepal that created highly motivated teams and improved the overall functioning of these hospitals.