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It set out a vision for how NHS services need to change to meet the needs of the population, and argued that the NHS needs to make improvements in three main areas:. Since then, sustainability and transformation plans have been developed across England to provide more detail on the local changes needed to make this vision a reality Ham et al ; Alderwick et al The plans are broad in scope, proposing changes in all parts of the NHS by Alderwick and Ham They also call for major improvements in NHS efficiency — typically at well above the rate of improvement achieved in the recent past.
A national framework to guide action on improvement capability building and leadership development in NHS services in England has also been launched NHS Improvement The challenge now lies in delivering the plans and making tangible improvements in NHS care as a result. This is easier said than done.
The plans themselves lack detail on how their ambitious goals for improving care will be implemented Ham et al And NHS leaders involved in developing the plans are concerned about their ability to make change happen in practice Alderwick et al This challenge is made harder still by the lack of a single, coherent national strategy for how to improve quality of NHS services Ham et al A recent review of approaches to improving quality in the NHS found that, while improving quality remains a stated priority, implementation is weak Molloy et al Gaps in leadership, complex organisational arrangements, inconsistent approaches to measurement and accountability, and insufficient attention to the skills needed to make change happen have held back progress.
So too have changes in government policy on the approach to NHS improvement and reform Ham This briefing makes the case for quality improvement to be at the heart of local plans for redesigning NHS services. By quality improvement, we mean the use of methods and tools to try to continuously improve quality of care and outcomes for patients. The idea of making the case for quality improvement is not new, but there is an urgent need for more systematic approaches to improving quality to be adopted across the NHS in England if the ambitious goals described in the Forward View and sustainability and transformation plans are to be delivered.
The briefing does this by drawing on existing literature and examples from within the NHS of where quality has been improved and describing how this was done. It describes the potential benefits from investing in quality improvement — including for patients, staff and the financial sustainability of the system. The primary audience for this briefing is senior leaders in the NHS, given the need for new approaches within organisations and across local systems to improve quality of care. Leadership and management practices are strongly related to performance on quality, and there is a well-established relationship between board commitment to quality improvement and quality of care within their organisations Jones et al ; Jones and Woodhead ; Tsai et al Many NHS organisations have started to use quality improvement techniques in discrete projects.
A smaller but growing number have developed more systematic, organisation-wide programmes to ensure that continuous improvement happens at scale Ross and Naylor Quality and finance are closely related through the many opportunities that exist to deliver better outcomes at lower cost improving value. The NHS, like all other health care systems across the world, sometimes fails to deliver high-quality care. This can lead to poor outcomes for patients and wasted resources for the NHS. Evidence tells us that there are a range of opportunities to improve value in the NHS Alderwick et al Including in primary care practices, diagnostic tests, rates of hospital referrals and procedures, and access to services NHS Right Care , , , In other words, they are both unwarranted and avoidable, and represent inappropriate care being delivered to patients.
It uses national data to identify variation, shares that data with the local staff involved in running and delivering the services including clinicians, clinical and medical directors, managers and chief executives and monitors the changes that are implemented. The programme began with orthopaedics and is now being rolled out to 32 different surgical and medical specialisms across the NHS in England. Early evidence suggests that the programme is identifying significant opportunities to improve value, through changes to procurement practices, productivity and quality.
Overuse is bad for people receiving care because they get services that might cause them harm, or at least waste their time or cause unnecessary stress and anxiety. It also creates an opportunity cost for the NHS, as resources are diverted from more effective care. Examples of overuse can be found across the NHS — including the overuse of some acute hospital services, overdiagnosis and overuse of diagnostic tests, and overprescribing of drugs. One example is the overprescribing of antibiotics for people with coughs, colds and sore throats.
One example of underuse is care for people with diabetes. Around 22, people in England die from potentially avoidable diabetes-related causes every year National Audit Office The overall scale of harm in the NHS is not clear, but evidence suggests that preventable harm happens both inside and outside of hospitals in the NHS Alderwick et al It is important to recognise, however, that most errors happen as a result of the systems people work in, not the people who work in them.
One example is medication errors. Estimates suggest that there are around 50 million prescribing errors in the community, 45, prescribing errors in an average acute hospital NHS England and 2, potentially preventable deaths in hospitals in England related to medication each year NHS England ; Hogan et al Identifying and removing steps that do not add value for the patient, or delay their access to care on return home, can help to improve patient outcomes and experience while freeing up clinical time Fillingham et al ; The Health Foundation Examples include delays in admitting or discharging patients needing acute care due to a failure to enable timely access to clinical decision-makers, diagnostic tests or medicines.
These and other examples highlight the types of opportunities available in the NHS to improve quality of care and make better use of resources. This briefing focuses on the range of benefits that can be achieved from investing in quality improvement — including better care for patients, benefits for staff and improvements in productivity and efficiency. Conventional management wisdom also often says that improving quality can save money. While this is sometimes the case, as demonstrated by the significant savings being identified through the GIRFT programme, the relationship between quality and cost in health care is complex and poorly understood Hussey et al ; Smith et al ; James and Savitz Both quality and cost can be measured in different ways, and the impact of the relationship between the two is often spread widely across a health system and over time.
One improvement in quality may take years to save money, while others may never save money at all. Another improvement may save money for one NHS organisation but shift costs elsewhere, while others may expose a new cost that was previously being met outside the health system. The review confirmed that there are significant opportunities to improve quality and reduce costs in health care — mainly because of the high cost of poor-quality care to patients and the health system.
But evidence showing that providers have been able to act on these opportunities is much harder to come by. While some interventions often on a small scale resulted in quality improvements and reduced costs for providers, others particularly on a large scale failed to do so. The literature is also hampered by a lack of high-quality evaluations. It is also worth recognising that many quality improvements will generate productivity gains — for example by removing waste and speeding up processes — rather than cashable financial savings. These improvements will nonetheless have a major impact on NHS finances — for example by allowing more patients to be treated without spending more money.
Finally, it is important to remember that the primary goal of quality improvement is — to state the obvious — to improve quality of care, not to save money. While driving better value is important, quality improvement has a fundamental role in improving all aspects of quality — including the safety, effectiveness and experience of care. All health and care systems should be seeking to improve these aspects of care for people using their services, on a continuous basis.
This section uses five examples to illustrate how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money. For each example, we summarise the problem being addressed, the methods used to improve quality and some of the benefits that are being delivered using data reported from the sites. We also provide links to further resources and information about the work.
All of the examples have received some funding or support from The Health Foundation. The five examples given above represent pockets of innovation in particular areas. They demonstrate that even relatively small-scale quality improvement initiatives can lead to significant benefits for patients, staff and health system costs.
The potential benefit is even greater if quality improvement techniques are applied consistently and systematically across organisations and systems. However, making this happen is not simple, and many quality improvement initiatives fail to deliver positive results. In this section, we draw on relevant evidence and experience from the literature, and the examples given, to highlight 10 key lessons for NHS leaders seeking to embed quality improvement within their local systems.
Senior leaders, and boards in particular, play a vital role in setting the strategic direction of NHS organisations and creating a supportive culture and environment for quality improvement. Numerous studies have found an association between board commitment to quality improvement and quality of care within their organisations Jones et al ; Tsai et al ; Jha and Epstein ; Jiang et al , Boards with higher levels of maturity in governing for quality improvement are also skilled in balancing short-term external priorities with the needs of their own long-term improvement initiatives.
Drawing on these studies and other evidence, researchers have created a framework that can be used to assess organisational maturity in governing for quality improvement Jones et al While the role of boards is key, responsibility for leading quality improvement also extends well beyond the most senior leaders in the NHS. Leadership for improvement must be distributed within organisations. A clear, unifying vision for improving quality should be enacted at multiple levels, with co-ordination and alignment between teams, departments and individuals Bohmer ; Dixon-Woods et al The examples given above illustrate how leadership for improvement comes from all parts of an organisation or multiple organisations , as well as from patients and service users.
But the support of senior leaders in the organisations involved is important in getting a project off the ground and creating time for staff to design and test new ways of working, as shown in example 5 on dementia care in Sussex. Improving quality of care is complex and takes time to achieve. Analysis of major improvements in NHS productivity over the past 30 years shows that progress is typically made through a series of small steps rather than giant leaps forward Alderwick et al Individual quality improvement initiatives often take considerable time to demonstrate impact, and even the most successful efforts will face obstacles and setbacks along the way.
The drivers of health service improvement are also multiple and overlapping; there is rarely if ever a single, magic bullet for improving quality. Local context is crucial in understanding the success of different quality improvement programmes Fulop and Robert ; Bate et al ; Kaplan et al This means that NHS leaders must make a long-term, overarching commitment to improving quality within their own organisation, and set realistic goals for improvement. Rather than searching for magic-bullet solutions, leaders should focus on developing the processes, systems and cultures to support the delivery of high-quality care on a continuous basis Dixon-Woods and Martin Frontline staff engaged in quality improvement need to be given the skills required to identify quality problems, carry out tests of change, measure their impact and act on the results.
These things do not happen by accident. NHS leaders need to invest time and resources in building the capabilities required for quality improvement within their organisation. Some NHS organisations that have adopted a systematic approach to quality improvement and invested in developing the skills and capabilities of frontline staff have demonstrated increases in staff satisfaction and retention rates and lower sickness and absence rates Ross and Naylor ; Jones and Woodhead Despite differences in terminology, all of these methods draw on a similar set of tools and principles such as rapid cycles of testing.
The evidence suggests that no single quality improvement method works better than others; what matters more is having a consistent approach — in other words, choosing a model and applying it rigorously in practice Leis and Shojania ; Kaplan et al ; Powell et al ; Boaden et al To avoid quality improvement efforts becoming a disjointed or worse, conflicting set of initiatives, organisations also need to put in place systems to co-ordinate different improvement projects and ensure that learning is shared between them Bohmer ; Dixon-Woods and Pronovost Intelligent use of data is central to any efforts to improve quality.
Data should be used to identify quality problems, define indicators for improvement and track the impact of different interventions on quality of care. But doing this is not simple; the approach to measurement must be designed carefully if it is to be useful to clinicians and avoid unintended consequences. Clinical teams wanting to improve quality will require disaggregated data on processes and outcomes of care, as well as time trends to allow analysis such as statistical process control time series analysis used to identify variation beyond predictable limits. This is likely to be different from data collected for overall performance assessment and management Raleigh and Foot Measures that are too burdensome or lack credibility are likely to alienate clinicians and lead to confusion about the impact of interventions Dixon-Woods et al The importance of having access to robust, real-time data is highlighted in example 1 , which focuses on the surveillance system developed by the Heart of England NHS Foundation Trust to help renal teams identify people at risk of end-stage kidney disease.
Relationships and behaviours are just as important, if not more so. Sustained change is more likely to happen in an environment where staff across an organisation can reflect on how things are done now and think about how they could be done better in the future.
Given the pressures facing NHS staff today, this licence to improve is vital. Health care organisations must create a culture and environment that supports the delivery of high-quality, continually improving care. In practice, this means having:. Leadership is a major determinant of organisational culture West et al NHS leaders must therefore work to model and build these cultural elements.
For those leading specific improvement projects, it will be necessary to spend time building relationships and engaging with relevant stakeholders involved in the change — for example to gain buy-in and surface any challenges or unintended consequences. Many of the most successful quality improvement initiatives in the NHS have been identified, designed and implemented by teams working at the front line. In some cases, they have done so without the explicit support or encouragement of senior leaders within their organisation, or without any meaningful resources Bohmer A shared determination to make a difference, together with an ability to carve out time to focus on improvement work, have been critical to their success.
However, it can be difficult for clinicians to engage in quality improvement Wilkinson et al They face several barriers — including a lack of time and resources and a lack of knowledge and skills for quality improvement. There is no simple solution to overcoming these barriers. Providing dedicated resources and project management capacity, having committed leaders capable of sparking enthusiasm, with skills in monitoring and evaluation to clearly demonstrate results, and ensuring alignment with other clinical priorities and health system changes, are all likely to help Ling et al Finding ways to free up staff time to take part in improvement work or training is another necessary step.
It is also important to understand what is likely to motivate clinicians to change their practices — critically, their intrinsic motivation to improve quality of care for their patients rather than improving efficiency or cutting costs. Rather than being seen as the business of managers, it is important for there to be an understanding that quality improvement approaches can help frontline teams to deliver better and more effective services for their patients. It is also possible to encourage participation by using more formal measures — for example by including involvement in quality improvement as part of required professional development activities, or by visibly reporting data on performance between peers Dixon-Woods et al , However, it is important to prepare the ground carefully.
Equally, any effort to highlight variation needs to go hand in hand with practical support to help teams and organisations to close the gap with their peers.
One important lesson from organisations that have successfully built improvement capability at scale is to avoid doing too much, too quickly. Delivering and sustaining change in a few key areas, and working first with a small cohort of volunteers, can help to generate momentum and provide a platform for the roll-out of an organisation-wide programme Jones and Woodhead This is no surprise: But it can be difficult to know how this should be done in practice.
Armstrong et al identify a number of tips for successful patient involvement in improvement projects, including but not limited to:. A range of tools and approaches can also be used to help achieve these aims, such as the Patient and family-centred care toolkit. Examples of how patients and professionals have worked together to embed change can also be found in the examples above. Meanwhile, people with dementia and their carers helped to co-design the core elements of the Dementia Golden Ticket model of care example 5. Improving quality will often require organisations to work together and pool resources across local systems of care Ham and Alderwick Developing new care models for people with multiple long-term conditions, for example, may depend on collaboration between primary and community services, acute hospitals, mental health and social services, as well as services outside the health and care system such as housing and employment services.
The approach taken in Sussex to improve dementia services example 5 is a good illustration of this, involving collaboration between primary care, acute and community services, and patients and their carers, to improve the quality and experience of care. STPs have an important role to play in co-ordinating local improvement efforts and developing new approaches across organisational boundaries.
Working as a system can also be key to spreading improvements in quality. There are a range of opportunities for NHS organisations to improve quality of care and value for money. Examples can be found across the NHS where teams and organisations are already acting on these opportunities and demonstrating positive results for their patients, as the examples given in this briefing show.
But the systematic use of quality improvement approaches within the NHS is still patchy, and many improvement efforts fail to deliver the results expected. NHS leaders — and boards in particular — have a vital role to play in creating a supportive environment for quality improvement within their organisation — for example by providing a clear vision and objectives for improving quality and putting in place the capabilities and support needed for staff to improve services.
Leaders must also work between organisations to develop new care models and co-ordinate improvements. The 10 key lessons outlined provide a starting point for NHS leaders seeking to more firmly embed quality improvement within their local plans for improving services. Academy of Medical Royal Colleges Quality improvement — training for better outcomes [online].
Sustainability and transformation plans in the NHS: Alderwick H, Ham C British Medical Journal , vol , j Better value in the NHS: Health Expectations , vol 16, no 3, pp e36—e Azad N, Lemay G Journal of Geriatric Cardiology , vol 11, no 4, pp — Bevan G, Hood C British Medical Journal , vol , pp — New England Journal of Medicine , vol , pp — British Heart Foundation An integrated approach to managing heart failure in the community [online]. The influence of teamwork processes enabled those within the team to improve relationships across departments.
Teamwork can have many advantages, but only a few were discussed in the reports reviewed. Teams were seen as being able to increase the scope of knowledge, improve communication across disciplines, and facilitate learning about the problem. Group work was seen as difficult for some and time consuming, and problems arose when everyone wanted their way, 97 which delayed convergence toward a consensus on actions. Team members needed to learn how to work with a group and deal with group dynamics, confronting peers, conflict resolution, and addressing behaviors that are detrimental.
As suggested by Berwick, the leaders of the quality improvement initiatives in this review found that successful initiatives needed to simplify; 96 , standardize; stratify to determine effects; improve auditory communication patterns; support communication against the authority gradient; 96 use defaults properly; automate cautiously; 96 use affordance and natural mapping e. Simplification and standardization were found to be effective as a forcing function by decreasing reliance on individualized decisionmaking.
Several initiatives standardized medication ordering and administration protocols, 78 , 87 , , , — , , — realizing improvements in patient outcomes, nurse efficiency, and effectiveness. Related to simplification and standardization is the potential benefit of using information technology to implement checks, defaults, and automation to improve quality and reduce errors, in large part to embedding forcing functions to remove the possibility of errors.
Often workflow and procedures needed to be revised to keep pace with technology. Data and information were needed to understand the root causes of errors and near errors, 99 to understand the magnitude of adverse events, to track and monitor performance, 84 , and to assess the impact of the initiatives.
Using and analyzing data was viewed as critical, yet some team members and staff may have benefited from education on how to effectively analyze and display findings. The meaning of data can be better understood by using measures and benchmarks.
Repeated measurements were found to be useful for monitoring progress, but only when there was a clear metric for measuring the degree of success. When multiple measures were used, along with better documentation of care, it was easier to assess the impact of the initiative on patient outcomes. The cost of the initiative was an viewed as important factor in the potential for improvement, even when the adverse effects of current processes were considered as necessitating rapid change.
It was also purported that the costs associated with change will be recouped either in return on investment or in reduced patient risk and thus reduced liability costs. Ensuring that those implementing the initiative receive education is critical. There were several examples of this. Two initiatives that targeted pain management found that educating staff on pain management guidelines and protocols for improving chronic pain assessment and management improved staff understanding, assessment and documentation, patient and family satisfaction, and pain management.
Despite the benefits afforded by the initiatives, there were many challenges that were identified in implementing the various initiatives:. Despite the aforementioned challenges, many investigators found that it was important to persevere and stay focused because introducing new processes can be difficult, 84 , but the reward of quality improvement is worth the effort. Other considerations were given to the desired objective of sustaining the changes after the implementation phase of the initiative ended.
Influential factors attributed to the success of the initiatives were effecting practice changes that could be easily used at the bedside; 82 using simple communication strategies; 88 maximizing project visibility, which could sustain the momentum for change; establishing a culture of safety; and strengthening the organizational and technological infrastructure. Collaboratives could also be a vehicle for encouraging the use of and learning from evidence-based practice and rapid-cycle improvement as well as identifying and gaining consensus on potentially better practices.
Quality tools used to define and assess problems with health care were seen as being helpful in prioritizing quality and safety problems 99 and focusing on systems, 98 not individuals.
The various tools were used to address errors and growing costs 88 and to change provider practices. These are discussed as follows:. Plan-Do-Study-Act PDSA was used by the majority of initiatives included in this analysis to implement initiatives gradually, while improving them as needed. The rapid-cycle aspect of PDSA began with piloting a single new process, followed by examining results and responding to what was learned by problem-solving and making adjustments, after which the next PDSA cycle would be initiated.
The majority of quality improvement efforts using PDSA found greater success using a series of small and rapid cycles to achieve the goals for the intervention, because implementing the initiative gradually allowed the team to make changes early in the process 80 and not get distracted or sidetracked by every detail and too many unknowns. Failure modes and effects analysis FMEA was used to avoid events and improve or maintain the quality of care. Health failure modes and effects analysis HFMEA was used to provide a more detailed analysis of smaller processes, resulting in more specific recommendations, as well as larger processes.
HFEMA was viewed as a valid tool for proactive analysis in hospitals, facilitating a very thorough analysis of vulnerabilities i. From the improvement strategies and projects assessed in this review, several themes emerged from successful initiatives that nurses can use to guide quality improvement efforts. The strength of the following practice implications is associated with the methodological rigor and generalizability of these strategies and projects:.
Given the complexity of health care, assessing quality improvement is a dynamic and challenging area. The body of knowledge is slowly growing in this area, which could be due to the continued dilemma as to whether a quality improvement initiative is just that or whether it meets the definition of research and employs methodological rigor—even if it meets the requirements for publication.
Because of the long standing importance of quality improvement, particularly driven by external sources e. With this in mind, researchers, leaders and clinicians will need to define what should be considered generalizable and publishable in the peer-reviewed literature to move the knowledge of quality improvement methods and interventions forward.
While the impact of many of the quality improvement projects included in this analysis were mentioned in terms of clinical outcomes, functional outcomes, patient satisfaction, staff satisfaction, and readiness to change, cost and utilization outcomes and measurement is important in quality improvement efforts, especially when variation occurs. There are many unanswered questions.
Some key areas are offered for consideration:. In planning quality improvement initiatives or research, researchers should use a conceptual model to guide their work, which the aforementioned quality tools can facilitate. To generalize empirical findings from quality improvement initiatives, more consideration should be given to increasing sample size by collaborating with other organizations and providers.
We need to have a better understanding of what tools work the best, either alone or in conjunction with other tools. It is likely that mixed methods, including nonresearch methods, will offer a better understanding of the complexity of quality improvement science. We also know very little about how tailoring implementation interventions contributes to process and patient outcomes, or what the most effective steps are that cross intervention strategies. Lastly, we do not know what strategies or combination of strategies work for whom and in what context, why they work in some settings or cases and not others, and what the mechanism is by which these strategies or combination of strategies work.
Whatever the acronym of the method e. Quality improvement requires five essential elements for success: To identify quality improvement efforts for potential inclusion in this systematic review, PubMed and CINAL were searched from to present. The following key words and terms were used: Findings from the projects and research included in the final analysis were grouped into common themes related to applied quality improvement. Turn recording back on.
National Center for Biotechnology Information , U. Show details Hughes RG, editor. Author Information Authors Ronda G. Background The necessity for quality and safety improvement initiatives permeates health care. Quality Improvement Strategies More than 40 years ago, Donabedian 27 proposed measuring the quality of health care by observing its structure, processes, and outcomes.
Six Sigma Six Sigma, originally designed as a business strategy, involves improving, designing, and monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing financial stability. Root Cause Analysis Root cause analysis RCA , used extensively in engineering 62 and similar to critical incident technique, 63 is a formalized investigation and problem-solving approach focused on identifying and understanding the underlying causes of an event as well as potential events that were intercepted.
Failure Modes and Effects Analysis Errors will inevitably occur, and the times when errors occur cannot be predicted. Research Evidence Fifty studies and quality improvement projects were included in this analysis. Lack of time and resources made it difficult to implement the initiative well. Some physicians would notaccept the new protocol and thwarted implementation until they had confidence in the tool.
Hospital leadership was not adequately engaged. There was insufficient emphasis on importance and use of measures. The number and type of collaborative staffing was insufficient.
The time required for nurses and other staff to implement the changes was underestimated. The extent to which differences in patient severity accounted for results could not be evaluated because severity of illness was not measured. Improvements associated with each individual PDSA cycle could not be evaluated. The full impact on the costs of care, including fixed costs for overhead, could not be evaluated.
Failure to consider the influence of factors such as fatigue, distraction, time pressures. The Hawthorne effect may have caused improvements more so than the initiative. Many factors were interrelated and correlated. There was a lack of generalizability because of small sample size. Addressing some of the problems created others e.
These are discussed as follows: Evidence-Based Practice Implications From the improvement strategies and projects assessed in this review, several themes emerged from successful initiatives that nurses can use to guide quality improvement efforts. The strength of the following practice implications is associated with the methodological rigor and generalizability of these strategies and projects: The importance of having strong leadership commitment and support cannot be overstated.
Leadership needs to empower staff, be actively involved, and continuously drive quality improvement. Without the commitment and support of senior-level leadership, even the best intended projects are at great risk of not being successful. Champions of the quality initiative and quality improvement need to be throughout the organization, but especially in leadership positions and on the team. A culture of safety and improvement that rewards improvement and is driven to improve quality is important. The culture is needed to support a quality infrastructure that has the resources and human capital required for successfully improving quality.
Due to the complexity of health care, multidisciplinary teams and strategies are essential. Quality improvement teams and stakeholders need to understand the problem and root causes. There must be a consensus on the definition of the problem. To this end, a clearly defined and universally agreed upon metric is essential.
This agreement is as crucial to the success of any improvement effort as the validity of the data itself. Use a proven, methodologically sound approach without being distracted by the jargon used in quality improvement. The importance given to using clear models, terms, and process is critical, especially because many of the quality tools are interrelated; using only one tool will not produce successful results. Standardizing care processes and ensuring that everyone uses those standards should improve processes by making them more efficient and effective—and improve organizational and patient outcomes.
Efforts to change practice and improve the quality of care can have multiple purposes , including redesigning care processes to maximize efficiency and effectiveness, improving customer satisfaction, improving patient outcomes, and improving organizational climate. Appropriate use of technology can improve team functioning, foster collaboration, reduce human error, and improve patient safety.
Continually collect and analyze data and communicate results on critical indicators across the organization. The ultimate goal of assessing and monitoring quality is to use findings to assess performance and define other areas needing improvement. Research Implications Given the complexity of health care, assessing quality improvement is a dynamic and challenging area. Some key areas are offered for consideration: How can quality improvement efforts recognize the needs of patients, insurers, regulators, patients, and staff and be successful?
What is the best method to identify priorities for improvement and meet the competing needs of stakeholders? What is the threshold of variation that needs to be attained to produce regular desired results? How can a bottom-up approach to changing clinical practice be successful if senior leadership is not supportive or the organizational culture does not support change? Conclusions Whatever the acronym of the method e. Evidence Table Quality Methods. National Healthcare Quality Report. Agency for Healthcare Research and Quality; Crossing the quality chasm: National Academy Press; A strategy for quality assurance in Medicare.
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