What are the most effective strategies for improving quality and safety of health care?

Internal Medicine Journal

Volumn 39, Issue 6, 2009, Pages 389-400

  Scott, I ^a  

^a PRINCESS ALEXANDRA HOSPITAL   (Australia)

Author keywords

Evaluation; Improvement; Meta review; Quality; Safety; Strategy

Indexed keywords

ACCREDITATION; CONTINUING EDUCATION; CONTROLLED STUDY; DECISION SUPPORT SYSTEM; EFFECT SIZE; EVIDENCE BASED MEDICINE; HEALTH CARE QUALITY; MEDICAL AUDIT; PEER REVIEW; PRIORITY JOURNAL; PROCESS DESIGN; PROFESSIONAL DEVELOPMENT; PROFESSIONAL STANDARD; REVIEW; RISK MANAGEMENT; SAFETY; TOTAL QUALITY MANAGEMENT;

HUMANS; QUALITY OF HEALTH CARE; RISK FACTORS; SAFETY; SAFETY MANAGEMENT;

EID: 67650733071     PISSN: 14440903     EISSN: 14455994     Source Type: Journal    
DOI: 10.1111/j.1445-5994.2008.01798.x     Document Type: Review

References (117)

1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC : National Academy Press 2001.
2. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med 2006 354 : 1147 56.
3. Scott IA, Derhy P, O'Kane D, Lindsay KA, Atherton JJ, Jones MA CPIC Cardiac Collaborative. Discordance between level of risk and treatment intensity in patients with acute coronary syndromes. Med J Aust 2007 187 : 153 9.
4. Brownlee S. Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer. New York : Bloomsbury 2007.
5. Brown P, McArthur C, Newby L, Lay-Yee R, Davis P, Briant R. Cost of medical injury in New Zealand: a retrospective cohort study. J Health Serv Res Policy 2002 7 (Suppl 1 S29 34. (Pubitemid 34760623)
6. Wennberg JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002 325 : 961 4.
7. Grol R, Wensing M, Eccles M. Improving Patient Care. The Implementation of Change in Clinical Practice. London : Elsevier 2005.
8. Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007 357 : 608 13.
9. Grol R, Baker R, Moss F. Quality Improvement Research. Understanding the Science of Change in Health Care. London : BMJ Publishing Group 2004.
10. Blumenthal D, Scheck AC, eds. Improving Clinical Practice. Total Quality Management and the Physician. San Francisco : Jossey-Bass 1995.
11. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996 312 : 71 2.
12. Coomarasamy A, Khan KS. What is the evidence that post-graduate teaching in evidence-based medicine changes anything? A systematic review. BMJ 2004 329 : 1017 22.
13. Flores-Mateo G, Argimon JM. Evidence-based practice in postgraduate healthcare education: a systematic review. BMC Health Serv Res 2007 7 : 119 26.
14. Parkes J, Hyde C, Deeks J, Milne R. Teaching critical appraisal skills in health care settings. Cochrane Database Syst Rev 2001 3 : CD 001270.
15. Bennett KJ, Sackett DL, Haynes RB, Neufeld VR, Tugwell P, Roberts R. A controlled trial of teaching critical appraisal of the clinical literature to medical students. JAMA 1987 257 : 2541 4.
16. Shin JH, Haynes RB, Johnston ME. Effect of problem-based, self-directed undergraduate education on life-long learning. Can Med Assoc J 1993 148 : 969 76.
17. Shuval K, Berkovits E, Netzer D, Hekselman I, Linn S, Brezis M et al. Evaluating the impact of an evidence-based medicine educational intervention on primary care doctors' attitudes, knowledge and clinical behaviour: a controlled trial and before and after study. J Eval Clin Pract 2007 13 : 581 98.
18. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993 342 : 1317 22.
19. Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004 8 : iii iv, 1 72.
20. Thomson R, Lavender M, Madhok R. How to ensure that guidelines are effective. BMJ 1995 311 : 237 42.
21. Scott IA, Denaro CP, Bennett CJ, Mudge AM. Towards effective use of decision support in clinical care - What the guidelines for guidelines don't tell you. Intern Med J 2004 34 : 492 500. (Pubitemid 39208277)
22. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005 294 : 718 24.
23. Kwan J, Sandercock P. In-hospital care pathways for stroke: a Cochrane systematic review. Stroke 2003 34 : 587 8.
24. Cannon CP, Hand MH, Bahr R, Boden WE, Christenson R, Gibler WB et al. National Heart Attack Alert Program (NHAAP) Coordinating Committee Critical Pathways Writing Group. Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program. Am Heart J 2002 143 : 777 89.
25. O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2007 4 : CD 000409.
26. Soumerai SB, McLaughlin TJ, Gurwitz JH, Guadagnoli E, Hauptman PJ, Borbas C et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA 1998 279 : 1358 63.
27. Doumit G, Gattellari M, Grimshaw J, O'Brien MA. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2007 1 : CD 000125.
28. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006 2 : CD 000259.
29. Hearnshaw HM, Harker RM, Cheater FM, Baker RH, Grimshaw GM. Are audits wasting resources by measuring the wrong things? A survey of methods used to select audit review criteria. Qual Saf Health Care 2003 12 : 24 8.
30. Balas EA, Boren SA, Brown GD, Ewigman BG, Mitchell JA, Perkoff GT. Effect of physician profiling on utilization. Meta-analysis of randomized clinical trials. J Gen Intern Med 1996 11 : 584 90.
31. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. Lancet 1995 345 : 840 42.
32. Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgements of appropriateness of care. JAMA 1991 265 : 1957 60.
33. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005 330 : 765 72.
34. Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005 293 : 1223 38.
35. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999 282 : 867 74.
36. Sibley JC, Sackett DL, Neufeld V, Gerrard B, Rudnick KV, Fraser W. A randomized trial of continuing medical education. N Engl J Med 1982 306 : 511 15.
37. Norcini JJ. Recertification in the United States. BMJ 1999 319 : 1183 5.
38. Boonvasai RT, Windish DM, Chakraborti C, Feldman LS, Rubin HR, Bass EB. Effectiveness of teaching quality improvement to clinicians: a systematic review. JAMA 2007 298 : 1023 37.
39. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence. A systematic review. JAMA 2006 296 : 1094 102.
40. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003 138 : 476 81.
41. Fox RD, Bennett NL. Learning and change: implications for continuing medical education. BMJ 1998 316 : 466 8.
42. Pérol D, Boissel JP, Broussolle C, Cêtre JC, Stagnara J, Chauvin F. A simple tool to evoke physicians' real training needs. Acad Med 2002 77 : 407 10.
43. Kiefe CI, Allison JJ, Williams OD, Person SD, Weaver MT, Weissman NW. Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. JAMA 2001 285 : 2871 9.
44. Beney J, Bero LA, Bond C. Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes. Cochrane Database Syst Rev 2000 3 : CD 000336.
45. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2005 2 : CD 001271.
46. O'Connor TM, Hooker RS. Extending rural and remote medicine with a new type of health worker: physician assistants. Aust J Rural Health 2007 15 : 346 51.
47. Coffman J, Rundall TG. The impact of hospitalists on the cost and quality of inpatient care in the United States: a research synthesis. Med Care Res Rev 2005 62 : 379 406. (Pubitemid 41026289)
48. Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med 2007 357 : 2589 600.
49. Zwarenstein M, Reeves S. Knowledge translation and interprofessional collaboration: where the rubber of evidence-based care hits the road of teamwork. J Contin Educ Health Prof 2006 26 : 46 54.
50. Cooper H, Carlisle C, Gibbs T, Watkins C. Developing an evidence base for interdisciplinary learning: a systematic review. J Adv Nurs 2001 35 : 228 37.
51. Hall P, Weaver L. Interdisciplinary education and teamwork: a long and winding road. Med Educ 2001 35 : 867 75.
52. Schmitt MH. Collaboration improves the quality of care: methodological challenges and evidence from US health care research. J Interprof Care 2001 15 : 47 66. (Pubitemid 32166408)
53. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet 2003 362 : 1225 30.
54. Mehta RH, Das S, Tsai TT, Nolan E, Kearly G, Eagle KA. Quality improvement initiative and its impact on the management of patients with acute myocardial infarction. Arch Intern Med 2000 160 : 3057 62.
55. O'Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2003 2 : CD 001431.
56. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonald HP. Interventions to enhance medication adherence. Cochrane Database Syst Rev 2005 4 : CD 000011.
57. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ 2007 335 : 24 7.
58. Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev 2006 4 : CD 005182.
59. Scott IA. Chronic disease management: a primer for physicians. Intern Med J 2008 38 : 427 37.
60. Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database Syst Rev 2004 1 : CD 003798.
61. The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper. Boston: Institute for Healthcare Improvement; 2003 [cited 2008 Sep 20]; Available from URL: http://www.IHI.org
62. Horbar JD, Carpenter JH, Buzas J, Soll RF, Suresh G, Bracken MB et al. Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial. BMJ 2004 329 : 1004 7.
63. Holman WL, Allman RM, Sansom M, Kiefe CI, Peterson ED Anstrom KJ et al. Alabama CABG Study Group. Alabama coronary artery bypass grafting project: results of a statewide quality improvement initiative. JAMA 2001 285 : 3003 10.
64. Landon BE, Wilson IB, McInnes K, Landrum MB, Hirschhorn L, Marsden PV et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med 2004 140 : 887 96.
65. Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ 2008 336 : 1491 4.
66. ØVretveit J, Bate P, Cleary P, Cretin S, Gustafson D, McInnes K et al. Quality collaboratives: lessons from research. Qual Saf Health Care 2002 11 : 345 51.
67. Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q 1998 76 : 593 624, 510. (Pubitemid 128463046)
68. Elkhuizen SG, Limburg M, Bakker PJ, Klazinga NS. Evidence-based re-engineering: a systematic review of the literature on business process redesign (BPR) in hospital care. Int J Health Care Qual Assur Inc Leadersh Health Serv 2006 19 : 477 99.
69. Wang MC, Hyun JK, Harrison M, Shortell SM, Fraser I. Redesigning health systems for quality: lessons from emerging practices. Jt Comm J Qual Patient Saf 2006 32 : 599 611.
70. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003 348 : 2218 27.
71. Davis P, Lay-Yee R, Scott A, Gauld R. Do hospital bed reduction and multiple system reform affect patient mortality? A trend and multilevel analysis in New Zealand over the period 1988-2001. Med Care 2007 45 : 1186 94.
72. McCloskey BA, Diers DK. Effects of New Zealand's health reengineering on nursing and patient outcomes. Med Care 2005 43 : 1140 46.
73. UK National Health Service Modernisation Agency. Ten high impact changes for service improvement and delivery: a guide for NHS leaders. Leicester : NHS Modernisation Agency, 2004 [cited 2008 Feb 23]; Available from URL: http://www.ogc.gov.uk/documents/Health-High-Impact-Changes.pdf
74. O'Connell TJ, Ben-Tovim DI, McCaughan BC, Szwarcbord MG, McGrath KM. Health services under siege: the case for clinical process redesign. Med J Aust 2008 188 : S9 13.
75. Bagian JP, Gosbee J, Lee CZ, Williams L, McKnight SD, Mannos DM. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv 2002 28 : 531 45.
76. Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA. Experiences of health professionals who conducted root cause analysis after undergoing a safety improvement program. Qual Saf Health Care 2006 15 : 393 9.
77. Mills PD, Neilly J, Luan D, Osborne A, Howard K. Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2006 32 : 130 41.
78. Wu AW, Lipshutz AKM, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008 299 : 685 7.
79. Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin Pract 2008 14 : 520 36.
80. Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors: a review of the literature. Arch Intern Med 2004 164 : 1690 97.
81. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organisations to develop and evaluate a safety scorecard. JAMA 2007 298 : 2063 5.
82. Scott IA, Poole PJ, Jayathissa S. Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform. Intern Med J 2008 38 : 44 55.
83. Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA 2008 299 : 445 7.
84. Berg M, Schellekens W, Bergen C. Bridging the quality chasm: integrating professional and organisational approaches to quality. Int J Qual Health Care 2005 17 : 75 82. (Pubitemid 40260147)
85. Shepperd S, Parkes J, McClaren J, Phillips C. Discharge planning from hospital to home. Cochrane Database Syst Rev 2004 1 : CD 000313.
86. Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G. Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database Syst Rev 2007 2 : CD 002214.
87. Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005 3 : CD 000356.
88. Anderson C, Ni Mhurchu C, Brown PM, Carter K. Stroke rehabilitation services to accelerate hospital discharge and provide home-based care: an overview and cost analysis. Pharmacoeconomics. 2002 20 : 537 52.
89. Legg L, Langhorne P Outpatient Service Trialists. Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials. Lancet 2004 363 : 352 6.
90. Schauffler HH, Mordavsky JK. Consumer reports in health care: do they make a difference? Annu Rev Public Health 2001 22 : 69 89. (Pubitemid 32452499)
91. Scott IA, Ward M. Public reporting of hospital outcomes based on administrative data: Risks and opportunities. Med J Aust 2006 184 : 571 575. (Pubitemid 43950028)
92. Fung CH, Lim Y-W, Mattke S, Damberg C, Shekelle PG. Systematic review: The evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008 148 : 111 23.
93. Hibbard JH, Stockard J, Tusler M. Does publicizing hospital performance stimulate quality improvement? Health Aff (Millwood) 2003 22 : 84 94. (Pubitemid 41399275)
94. Peterson ED, Delong ER, Jollis JG, Muhlbaier LH, Mark DB. The effects of New York's bypass surgery provider profiling on access to care and patient outcomes in the elderly. J Am Coll Cardiol 1998 32 : 993 9.
95. Rosenthal GE, Quinn L, Harper DL. Declines in hospital mortality associated with a regional initiative to measure hospital performance. Am J Med Qual 1997 12 : 103 12.
96. Kaiser Family Foundation. A National Survey on Consumer Experiences with Patient Safety and Quality Information. 2004 November [cited 2008 Jan 21]; Available from URL: http://www.kff.org/kaiserpolls/7209.cfm
97. Duckett SJ, Coory M, Sketcher-Baker K. Identifying variations in quality of care in Queensland hospitals. Med J Aust 2007 187 : 571 5.
98. Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med 2006 145 : 265 72.
99. Lindenauer PK, Remus D, Roman S, Rothberg MB, Benjamin EM, Ma A et al. Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007 356 : 486 96.
100. Scott IA. Pay for performance in healthcare - strategic issues for Australian experiments. Med J Aust 2007 187 : 31 5.
101. Miller MR, Pronovost P, Donithan M, Zeger S, Zhan C, Morlock L et al. Relationship between performance measurement and accreditation: implications for quality of care and patient safety. Am J Med Qual 2005 20 : 239 52.
102. Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care 2008 (in press).
103. Faunce TA, Bolsin SNC. Three Australian whistle blowing sagas: lessons for internal and external regulation. Med J Aust 2004 181 : 44 7.
104. Snyder C, Anderson G. Do quality improvement organisations improve the quality of hospital care for Medicare beneficiaries? JAMA 2005 293 : 2900 907.
105. Queensland Health. Clinical Networks Policy, February 2006 Feb [cited 2007 Jan 2]; Available from URL: http://www.qheps.qld.gov.au
106. Southon G, Perkins R, Galler D. Networks: a key to the future of health services. Aust Health Rev 2005 29 : 317 26.
107. Edwards N. Clinical networks. BMJ 2002 324 : 63.
108. Proenca EJ, Rosko MD, Dismuke CE. Service collaboration and hospital cost performance. Direct and moderating effects. Med Care 2005 43 : 1250 58.
109. Fleury MJ. Integrated service networks: the Quebec case. Health Serv Manage Res 2006 19 : 153 65.
110. Scally G, Donaldson L. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998 317 : 61 5.
111. Hine D. Clinical governance and the Commission for Health Improvement. In : West R, Norris R, eds. Measurement of Clinical Performance. Practical Approaches in Acute Myocardial Infarction. London : Royal College of Physicians 2001 7 15.
112. Thomas M. The evidence base for clinical governance. J Eval Clin Pract 2002 8 : 251 4.
113. Freeman T, Walshe K. Achieving progress through clinical governance? A national study of health care managers' perceptions in the NHS in England. Qual Saf Health Care 2004 13 : 335 43.
114. Braithwaite J, Westbrook MT, Hindle D, Iedema RA, Black DA. Does restructuring hospitals result in greater efficiency? An empirical test using diachronic data. Health Serv Manage Res 2006 19 : 1 12. (Pubitemid 43205146)
115. Grol R, Berwick D, Wensing M. On the trail of quality and safety in health care. BMJ 2008 336 : 74 6.
116. Scott IA. The evolving science of translating research evidence into clinical practice. ACP J Club 2007 146 : A8 11.
117. Berwick DM. The science of improvement. JAMA 2008 299 : 1182 4.