This paper examined the evidence of the effectiveness of a broad range of organizational changes in patient care in terms of effects on professional performance, patient outcomes, and costs. We found evidence that professional performance can be improved by enhancement of the professional roles of non-physicians (nurses, pharmacists, etc.) and by computer systems both for reminding and decision support. Patient outcomes were improved by multidisciplinary teams for patient care, integrated care services, and computer decision support. Few studies considered costs, but cost savings were reported from reviews of integrated care services and not consistently for any other organizational changes. There was little evidence of the effectiveness of quality management.
We have not searched exhaustively so it is possible that we have missed relevant reviews. The conclusions need to be regarded as tentative. The lack of a widely accepted taxonomy for organizational interventions is a problem for the examination of their effectiveness. A previous review on organizational change concluded that the available evidence was difficult to locate, even for expert researchers, and may therefore be largely inaccessible to health care managers [7
]. There was a range of organizational approaches to improvement that were not explicitly covered by this paper, such as leadership, process redesign, breakthrough series, organizational culture interventions, and organizational learning [2
]. We found no systematic reviews focused on these strategies. The use of a 'percentage studies with improvements' (PSI) implies a vote counting method, which has substantial risk for bias and should therefore be interpreted carefully.
This paper shows that a considerable number of rigorous evaluations of organizational changes have been performed, including many controlled trials. Few reviews report on the efficiency of organizational interventions, although many interventions may be primarily targeted at efficiency gains. While further studies are needed, there is some research evidence available to guide decisions. Integrated care services are particularly promising. Their effectiveness may be based on the fact that these are multifaceted interventions that comprise various organizational changes such as revised professional roles, multidisciplinary teams, use of computers systems, and components of quality management. Continued education of health professionals and patient education are usually components of these integrated care services as well. In this way, they can address a wide range of potential barriers for change, which is likely to increase their effectiveness. Further work should focus on analysing the contributions of the specific components in integrated care services, to identify which particularly contribute to their effectiveness.
To allow interpretation by decision-makers in various contexts which strategies to select it is important to provide sufficient background information on the local context in published studies and reviews of these studies. For instance, it may be important whether an improvement is implemented in a small practice (with informal relationships) or in a large hospital department with formalized structures. In future reviews it would be helpful to provide this background information. It may be helpful to have a set of key factors for such descriptions, which are likely to influence change, such as physicians' attitudes regarding a proposed change, organizational structures and financial incentives.