The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews

We conducted a review of systematic reviews of the literature on the effectiveness of QI strategies [12]. The following electronic databases were searched: PubMed, Cochrane Database of Systematic Reviews, Embase and CINAHL. The search was limited to literature reviews published in English language between January 2000 and November 2012. The search focused on QI strategies included in the Cochrane Effective Practice and Organisation of Care (EPOC) Group taxonomy, which include various forms of continuing medical education (CME), quality assurance projects, financial, organizational, or regulatory interventions that can affect the ability of health care professionals to deliver services more effectively and efficiently [13]. A Boolean search strategy for PubMed was developed (see Additional file 1) covering all quality management topics, including a combination of text words and Medical Subject Headings (MeSH) terms, searched in titles and abstracts of studies. The Boolean search strategy was adapted for the other databases.

The review strategy was guided by a manual for performing systematic literature reviews on a health services research topic [14]. The results from the databases were checked for duplicates using Reference Manager. This was followed by a three-step screening procedure. Studies were excluded if they did not focus on the effectiveness, performance or impact of quality management strategies in hospital settings. An initial screening of studies was based on titles and abstract, performed by two reviewers (OG, DK) independently. In the second screening, the full texts of the reviews were assessed for inclusion by OG and DK independently. In the third step, the final list of included studies was evaluated for their completeness by a panel of quality management experts from European countries, comprised of mostly senior researchers and medical professionals who participated in a European Commission (EC) funded research project (Deeping our understanding of quality improvement in Europe (DUQuE), see www.​duque.​eu and acknowledgment section). This evaluation led to five additions to the publication list. Only systematic literature reviews with a focus on the effectiveness, performance or impact of quality management strategies in hospital settings were included. This covered both qualitative and qualitative reviews and meta-analyses. Figure 1 shows the complete study selection process, including the number of disagreements among reviewers which were resolved by a third independent reviewer (RS).

Data on the effectiveness of quality management strategies and the influence of both internal and external contextual factors were extracted using a structured data entry form. Panel experts from the DUQuE team were each independently assigned to extract the data from a limited set of studies which fit with their expertise. The following information was extracted from the studies that met our inclusion criteria: type of QI intervention, number of included studies and participants, objective, description of intervention, description of primary and secondary outcome, effect of primary and secondary outcome, and contextual factors.

Data extraction on contextual factors was categorized according to an assessment tool based on the Model for Understanding Success in Quality (MUSIQ) (Textbox 1) [9]. We coded context-based factors against the MUSIQ tool and added up the number of studies which displayed each one and noted if the study had produced an effective outcome.

The MUSIQ tool was developed by Kaplan et al. to facilitate research on the contextual factors affecting QI strategies, and has been shown to be reliable and valid [9, 15]. It identifies 25 contextual factors for quality improvement, covering six overarching themes that they labelled as: external environment, organization, quality improvement capacity, the clinical microsystem, the quality improvement team, and a number of miscellaneous issues. Detailed descriptions of the six themes and 25 contextual factors are included in Additional file 2: Table S1.

Textbox 1: Domains of the MUSIQ Tool [9]

All data entry forms were double-checked by two independent reviewers (OG, DK) and complemented or altered when both reviewers agreed. In case of disagreement, a third independent reviewer (RS) made the final decision. The quality of the included studies was assessed using a valid and reliable [16, 17] measurement tool to assess the methodological quality of systematic reviews (AMSTAR) [18]. The overall quality of each study was assessed by the proportion of items of the AMSTAR Checklist each study complied with (number of “Yes” answers to 11 questions). Studies are rated as low quality when AMSTAR score is 0–4, moderate quality when AMSTAR score is 5–8, and high quality when AMSTAR score 9–11 [19]. The quality assessment was undertaken by two independent reviewers (OG, DK).

This research did not involve human subjects. Ethics approval is covered by the DUQUE project, financed by the EU Commission under grant agreement number 241822 and approved by the Health department of the Government of Catalonia, Spain.

In terms of direct effects, financial incentives or administrative support were related with the effectiveness of QI strategies [5, 28]. Resource requirements, too, were a key factor, in particular for large up-front organizational support and capital investment required to introduce a Computerised Physician Order Entry [29]. QI strategies were not equally effective across health care settings: Clinical decision support systems (CDSS) were more effective in institutional settings than community settings due to types of conditions, stricter controls on professional behaviour, and different attitudes of professionals towards externally imposed rules [30]. The external environment also affected the interpretation of QI effectiveness more broadly. Priority areas of external inspections differed between high and low income countries, making the results of studies on the effectiveness of accreditation programmes difficult to compare and transfer [31].

There was a substantial amount of literature referring to the effect of supportive organizational cultures [21, 32, 33]. The creation of a patient safety culture (including having clear policies and actively support training) positively impacted on the effectiveness of infection control policies [21], on the implementation of Six Sigma and Lean approaches to QI) [32]. The visible support of managerial staff (both at ward/unit and above ward/unit level) also impacted positively on the effectiveness of accreditation of health care services [34], on clinical decision support systems [35], and on hospital incident reporting [26].

Another example for organizational context factors was the embedding of feedback systems in organizational QI: Feedback on a physician’s clinical performance was more likely to be effective when provided by an authoritative, credible source, systematically over multiple years [36], and a high frequency of performing audit and feedback increased its effectiveness in modifying health professionals’ behaviour [37]. Having a closed safety-feedback cycle (e.g. effective dissemination channels and the capacity for rapid action) at all levels of the organization positively affected the effectiveness of hospital incident reporting [26].

The absence of an effective multidisciplinary infection control team perceived as exercising positive leadership at ward or unit level was a risk for the effectiveness of infection control strategies on health care associated infections [21].

The availability and functionality of information technology (IT) systems facilitated data collection and improved the effectiveness of QI interventions [38], notably, interventions targeting handovers [24], accreditation programs in rural health care services [34], and Six Sigma [39]. Sufficient resources, too, were paramount for the implementation of QI strategies [38, 40, 41]. Insufficient administrative support impacted on the effectiveness of interventions promoting safety cultures [41] or on strategies aimed at implementing quality indicators [40]. An excessive workload (not matched to available staffing) and insufficient staff training were a risk for the effectiveness of Six Sigma [39] and infection control strategies on health care associated infections [21]. High staff turnover and an excessive use of external staff members limited the effectiveness of infection control strategies [21].

Clinical micro-systems have previously been described as the key settings in which QI interventions are implemented [42‐46]. Low staff morale and scepticism of health care professionals towards the positive impact of QI interventions (e.g. accreditation programs or CDSS) on the quality of health care services were serious barriers to the successful implementation of QI interventions [21, 23, 33]. Alignment of physicians’ views on the content and implementation of interventions aimed at improving handovers was beneficial to its effectiveness [24, 47]. The training or education in the proper use of QI strategies (e.g. safety checklists, accreditation standards) was beneficial to the effectiveness of the QI strategies [34, 48]. Integrating QI strategies in the working practices of health professionals promoted the effectiveness of the QI strategies [23] and the ‘motivation to change’ [22, 40].

Team composition is a major determinant for QI effectiveness. Involving physicians in the development and implementation of QI interventions (such as CDSS, accreditation programs, audit and feedback) has been shown to be an important success factor for their effectiveness [22, 23, 34, 37, 49]. Involving multidisciplinary QI teams (including nurses and physicians, and sometimes also pharmacists) in the development and implementation of QI strategies increased the effectiveness of the intervention [22, 24, 50, 51]. ‘Subject matter experts’, where more than one team member has detailed knowledge about the outcome, process, or system being changed were shown to be beneficial for the a range of QI strategies (CDSS, CME, Six Sigma and Lean). Awareness, attitude, knowledge of and understanding performance data (generic ‘QI skills’) [52] were all essential facilitators for the implementation of QI interventions.

A number of additional contextual factors were identified from the literature, not all of which are addressed in the MUSIQ tool. These include, in particular, structural factors of service organization, including turnover of staff or bed occupancy [21], workload and time constraints [24], but also the flexibility to update the QI intervention (guidelines or computerised decision support systems) [22, 23]. Detailed information on the contextual factors identified in the literature is presented in Additional file 3.

This study has important implications for future research on the relationship between QI context and effectiveness. For some QI interventions the evidence is substantial, and is supported by clear recommendation on how context factors mediate effectiveness (e.g. the Cochrane review on audit and feedback [37] gives clear indication on the factors and the magnitude to which they increase or attenuate the effect of QI strategies). For other QI interventions, the evidence base is still weak and adaptation and implementation should be pursued with caution, since generalisability is limited when context factors are unknown.

Future studies on the effectiveness of QI interventions need to place more emphasis on studying and reporting outcomes in relation to contextual factors [53]. Pooled averages are misleading and do not reflect the varying contexts in which QI are implemented. Ideally, alongside major evaluations of effectiveness, studies should be conducted looking at context factors and recording such factors using existing tools (e.g. [9, 53]). This would permit future reviews on the effectiveness of QI to stratify on the type of context, sample size permitting. In parallel, qualitative studies (including ethnographic studies) could be conducted to gain a deeper understanding of professional, organizational, cultural and structural context factors [54]. This would be a complex and difficult undertaking. For example, a true investigation of context factors cannot be achieved retrospectively at the stage of writing up a research project, but rather requires engaging multiple perspectives and stakeholders from the start to ensure all relevant aspects of QI implementation (both formal and informal) are considered. Once identified, such factors need to be observed and monitored over time and statistical models could aim to assess the association of context factors with the effectiveness of QI interventions, where appropriate. We have recently illustrated some of the methodological challenges related to these tasks [55, 56] and at current, the multiple relationships and pathways between exposure, outcome, and context variables in research on QI strategies are not yet sufficiently understood. Alternatively, context might be considered as an integral component of the subject area that evolves, changes and interacts with the intervention during the time period of QI project implementation. In this case, in-depth qualitative assessment is needed. Finally, the research output should report on the role of context factors in order to facilitate generalisability and replicability of the QI intervention. This issue, too, has been subject to debate and the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines are one approach to address a better understanding of QI context factors [57]. The SQUIRE guidelines demonstrate the difficulties and practical issues when reporting on the factors that potentially impact on a QI intervention. Nevertheless, improving understanding, conceptualization, analysis and reporting of context factors in QI is important to advance the field of research. It will help in understanding the mixed results of some QI interventions and help replicate successful projects or, equally important, inform implementers were replication is unlikely to be successful due to different contexts. Our findings suggest that some of the most relevant context factors are those close to the clinical microsystem in which the QI intervention is delivered. This provides cues for action for improvement practitioners who may include an assessment of such factors, and dedicated change processes, in their local plans for quality improvement.