It is now widely accepted that the mixed effect and success rates of strategies to improve quality and safety in health care are in part due to the different contexts in which the interventions are planned and implemented. The objectives of this study were to (i) describe the reporting of contextual factors in the literature on the effectiveness of quality improvement strategies, (ii) assess the relationship between effectiveness and contextual factors, and (iii) analyse the importance of contextual factors. We conducted an umbrella review of systematic reviews searching the following databases: PubMed, Cochrane Database of Systematic Reviews, Embase and CINAHL. The search focused on quality improvement strategies included in the Cochrane Effective Practice and Organisation of Care Group taxonomy. We extracted data on quality improvement effectiveness and context factors. The latter were categorized according to the Model for Understanding Success in Quality tool. We included 56 systematic reviews in this study of which only 35 described contextual factors related with the effectiveness of quality improvement interventions. The most frequently reported contextual factors were: quality improvement team (n = 12), quality improvement support and capacity (n = 11), organization (n = 9), micro-system (n = 8), and external environment (n = 4). Overall, context factors were poorly reported. Where they were reported, they seem to explain differences in quality improvement effectiveness; however, publication bias may contribute to the observed differences. Contextual factors may influence the effectiveness of quality improvement interventions, in particular at the level of the clinical micro-system. Future research on the implementation and effectiveness of quality improvement interventions should emphasize formative evaluation to elicit information on context factors and report on them in a more systematic way in order to better appreciate their relative importance.

High performing hospitals attain excellence across multiple measures of performance and multiple departments. Studying high performing hospitals can be valuable if factors associated with high performance can be identified and applied. Factors leading to high performance are complex and an exclusive quantitative approach may fail to identify richly descriptive or relevant contextual factors. The objective of this study was to undertake a systematic review of qualitative literature to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement. Methods used to collect and summarise the evidence contributing to this review followed the ‘enhancing transparency in reporting the synthesis of qualitative research’ protocol. Peer reviewed studies were identified through Medline, Embase and Cinahl (Jan 2000-Feb 2014) using specified key words, subject terms, and medical subject headings. Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Title, abstract, and full text screening was undertaken by four reviewers, and inter-rater reliability statistics were calculated for each review phase. Risk of bias was assessed. Following data extraction, thematic syntheses identified contextual factors important for explaining success. Practical strategies for achieving high performance were then mapped against the identified themes. A total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued. This review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance.

Patient-centred care is increasingly being acknowledged as an integral part of evaluating health care. Yet, from a quality improvement perspective the rationale, measurement and implementation of strategies to improve patient-centred care is often subject to debate. The aim of this paper is to review why quality improvement efforts should embrace patient-centredness, to examine some of the measurement issues and to assess conceptual underpinnings that should inform both measurement and actions to improve patient-centred care. The causal pathway through which quality improvement affects and/or is associated with patient centredness is complex and goes beyond patients' rights and assessing patient views. Interventions to improve patient-centred care should reflect on key rationale, measurement strategy and underlying theory.

Assessing the quality of health care has become increasingly important in health care in response to growing demands from purchasers, providers, clinicians and the public. Given the increase in projects and programs to assess performance in health care in the last 15 years, the purpose of this paper is to review current indicator projects for hospital performance assessment and compare them to the Performance Assessment Tool for Quality Improvement in Hospitals (PATH), an initiative by the WHO Regional Office for Europe. We identified current indicator projects through a systematic literature search and through contact with experts. Using an inductive approach based on a review of the literature, we identified 10 criteria for the comparison of indicator projects. We extracted data and contacted the coordinators of each indicator project to validate this information. In addition, we carried out interviews with coordinators to gather additional information on the evaluation of the respective projects. We included 11 projects that appear to have adopted a common methodology for the design and selection of indicators; however, major differences exist with regard to the philosophy, scope and coverage of the projects. This relates in particular to criteria such as participation, disclosure of results and dimensions of hospital performance assessed. Hospital performance assessment projects have become common worldwide, and initiatives such as the WHO PATH project need to be well coordinated with existing projects. Our review raised questions regarding the impact of hospital performance assessment that should be pursued in further research.

To investigate the relationship between ISO 9001 certification, healthcare accreditation and quality management in European hospitals. A mixed method multi-level cross-sectional design in seven countries. External teams assessed clinical services on the use of quality management systems, illustrated by four clinical pathways. Seventy-three acute care hospitals with a total of 291 services managing acute myocardial infarction (AMI), hip fracture, stroke and obstetric deliveries, in Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey. Four composite measures of quality and safety [specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies (PSS) and clinical review (CR)] applied to four pathways. Accreditation in isolation showed benefits in AMI and stroke more than in deliveries and hip fracture; the greatest significant association was with CR in stroke. Certification in isolation showed little benefit in AMI but had more positive association with the other conditions; greatest significant association was in PSS with stroke. The combination of accreditation and certification showed least benefit in EBOP, but significant benefits in SER (AMI), in PSS (AMI, hip fracture and stroke) and in CR (AMI and stroke). Accreditation and certification are positively associated with clinical leadership, systems for patient safety and clinical review, but not with clinical practice. Both systems promote structures and processes, which support patient safety and clinical organization but have limited effect on the delivery of evidence-based patient care. Further analysis of DUQuE data will explore the association of certification and accreditation with clinical outcomes.