What are the best strategies for ensuring quality in ...

1 What are the best strategies for ensuring quality in hospitals? November 2003. ABSTRACT. Health Evidence Network (HEN) synthesis report on the best strategies for ensuring quality in hospitals ensuring the safety of patients and personnel and improving quality have become important objectives for national health systems in developed and developing countries alike, in response to research highlighting poor quality , increasing patient expectations, and media reports. There is a general belief, supported by growing research literature, that there are effective methods to improve quality and safety. This report is HEN's response to a question from a decision-maker. It provides a synthesis of the best available evidence, including a summary of the main findings and policy options related to the issue. HEN, initiated and coordinated by the WHO Regional Office for Europe, is an information service for public health and health care decision-makers in the WHO European Region.

2 Other interested parties might also benefit from HEN. This HEN evidence report is a commissioned work and the contents are the responsibility of the authors. They do not necessarily reflect the official policies of WHO/Europe. The reports were subjected to international review, managed by the HEN team. When referencing this report, please use the following attribution: vretveit J. (2003) What are the best strategies for ensuring quality in hospitals? Copenhagen, WHO Regional Office for Europe (Health Evidence Network report; , accessed 27 November 2003). Keywords quality OF HEALTH CARE. HOSPITALS STANDARDS. STRATEGIC PLANNING. DECISION SUPPORT TECHNIQUES. EUROPE. Address requests about publications of the WHO Regional Office to: by e-mail (for copies of publications). (for permission to reproduce them).

3 (for permission to translate them). by post Publications WHO Regional Office for Europe Scherfigsvej 8. DK-2100 Copenhagen , Denmark World Health Organization 2003. All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation country or area appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

4 The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policy of the World Health Organization. 2. What are the best strategies for ensuring quality in hospitals? WHO Regional Office for Europe's Health Evidence Network (HEN). November 2003.

5 Summary .. 4. The 4. 4. Policy 4. Introduction .. 6. Sources for this 7. Findings from research and other 7. Which approaches could be used to improve quality and patient safety in hospitals? .. 7. What is the evidence about hospital quality strategies ? .. 8. Is there evidence that one type of strategy is better than another for improving quality and patient safety in hospitals? .. 12. Gaps in evidence and conflicting evidence .. 12. The quality of the evidence used in the synthesis .. 13. Current debate in the 14. Other aspects .. 15. Conclusions .. 16. Policy 16. References .. 18. Annex 1. Grading of 23. Annex 2. Sources and methods for review and synthesis .. 24. 3. What are the best strategies for ensuring quality in hospitals? WHO Regional Office for Europe's Health Evidence Network (HEN). November 2003.

6 Summary The issue ensuring the safety of patients and personnel and improving quality have become important objectives for national health systems in developed and developing countries alike, in response to research highlighting poor quality , increasing patient expectations, and media reports. There is a general belief, supported by growing research literature, that there are effective methods to improve quality and safety. Health care organizations are increasingly expected by governments, funders and patients to introduce quality control systems and outcome improvement strategies . Many health care managers and practitioners also believe that action should be taken, but are unsure of how to proceed, especially within resource constraints. There are many approaches to improve quality and safety, and diverse strategies to encourage hospitals to do so.

7 Which strategies are most appropriate and cost effective for a particular hospital in a specific situation? Which approach should a government or funder promote? Findings There is little research assessing the effectiveness of one or more hospital or national quality strategies that can be used to answer these questions. This lack of evidence does not show that strategies are not effective, but is rather due to the difficulty of evaluating interventions and of proving that the results are due to the strategy and not to other factors. There is some research into local team projects which shows that continuous quality improvement . approaches can be effective. There is also research indicating the conditions needed to support and encourage these approaches. Many publications and reports describe different strategies , but few are well-designed research projects, or report scientifically valid evidence of results.

8 There is an even larger quantity of literature by consultants, academics and commentators advising on the best approach; some is based on sound experience, but little is based on scientific research. No single quality strategy cannot be recommended above any other on the basis of evidence of effectiveness, ease of implementation or costs. Policy considerations Some of the main recommendations from this synthesis of the literature are based on a few valid outcome studies and a critical assessment of the descriptive literature. 1. When reviewing types of strategies , hospitals and governments should question the claims of proponents of any one approach because there is no strong evidence of effectiveness. 2. Decision-makers should be aware that the same strategy applied in a different location or institution may well yield different results, even if fully implemented in exactly the same manner.

9 3. A chosen quality strategy should be reviewed regularly and adapted to the hanging situation and the responses of personnel. Efforts should be made to assess whether any lack of results is due to the wrong strategy, poor implementation, or the time necessary to observe results. Flexibility without sudden radical change appears to be important. 4. quality experts with wide experience can be useful, but need to be chosen with care. One or more independent experts should be used to give independent feedback on a strategy for regular reviews. 4. What are the best strategies for ensuring quality in hospitals? WHO Regional Office for Europe's Health Evidence Network (HEN). November 2003. 5. Hospital quality strategies should include improving inter-service quality for different patients groups, and address hospital-community coordination of care issues.

10 Patient experiences and outcomes are affected by how hospitals provide access, outreach and linking with non-hospital services. 6. It is possible that time and money that could be used for patient care is currently wasted on some strategies . There is a strong case for more independent and scientific research. 7. Fuller reviews of the evidence for particular strategies than were possible in this report should be carried out. 5. What are the best strategies for ensuring quality in hospitals? WHO Regional Office for Europe's Health Evidence Network (HEN). November 2003. The author of this HEN synthesis report is: Professor John vretveit, Director of Research, The Karolinska Institute Medical Management Centre, Stockholm, Sweden, and The Nordic School of Public Health, Gothenburg, Sweden, and Bergen University Faculty of Medicine, Norway Introduction Research has shown significant avoidable patient injury occurring in hospitals, increasing the risk of adverse outcomes and higher costs (1).