Over the past twenty years, there has been substantial growth in the number of quality improvement teams [7
]. Under the direction of clinical or administrative leadership, teams have collectively directed their efforts to changing clinical and/or system processes and structures with the goal to improve patient, provider and system outcomes. This review revealed that the foci within each of the dimensions of quality, the interventions implemented by teams, the composition of teams, and the context in which initiatives occur were diverse. It was surprising to find that best evidence (i.e
., best practice guidelines or national guidelines) or research-based evidence was not always utilized in these initiatives.
Few papers focused on barriers and facilitators to establishing and measuring the impact of quality and safety team initiatives, however, most researchers reported factors that they believed influenced the success of the teams. Many factors that were identified as facilitators (i.e
., senior leadership support, supportive organizational cultures, resources, ability to work as a team, physician 'opinion' leaders) are attributes of effective teams [118
]. Often, these factors were identified as barriers if they were absent. Teams' perception of their success or failure often revolved around these factors. These findings are consistent with other authors [119
] who have emphasized that strategic direction and vision of senior leadership, organizational culture, and support of leadership to remove barriers for teams are key to making a difference in quality and safety in organizations.
We found a lack of evidence about the attributes of successful and unsuccessful team initiatives, descriptions of how to establish and implement the teams, the unique or combined contribution of selected interventions, and the cost-benefit analyses of such initiatives. Future research could focus on the behaviours and actions of participants themselves, such as what actions senior leaders did to assure the team was successful and what role physicians and nurse champions played in winning the support of their colleagues [18
We noted few methodologically strong studies. As a result, it is difficult to know whether the 'success' or 'failure' of quality and safety team initiatives are the result of the attributes and ideal mix of team members, team processes, period over which the initiatives occurs, certain clinical conditions and system processes, selected or combined interventions, the outcomes measured, or context in which the interventions occur. Understanding the unique and combined contributions of quality improvement interventions will require the use of rigorous designs and synthesis of study results through a systematic review. A broad-based scoping review does not seek to synthesize or weight evidence from various studies [13
Despite this lack of evidence about the mechanisms by which intervention components and contextual factors may influence the study outcomes, quality improvement methodologies and quality collaboratives are popular methods for understanding and organizing quality improvement and safety efforts in hospitals. The nature of quality improvement is pragmatic; an examination of the 'real world.' Health systems are living laboratories that are complex, frequently unpredictable, and change is often multifaceted. Unfortunately, RCTs are often not an option and control groups may not be possible to understand localized microsystem or mesosystem change. However, moving away from weaker study designs (e.g., before and after designs) to designing evaluation of change initiatives that utilize more robust designs (e.g., interrupted time series or step wedge design) would enhance the science of quality improvement as well as strengthen the evidence about the actual effectiveness of methods used in initiatives.
Healthcare providers, senior leaders, and boards strongly affirm the importance of improving processes for assuring quality and safety, and require access to the best evidence to help achieve that goal. We observed that many documented improvements, and identified 'successes' have been reported using percentage changes over time without comparisons to control groups or subject to statistical testing. There needs to be more rigorous evaluation of the interventions to propose legitimately that 'evidence-based' practices be accepted. Considerable resources are allocated to changes associated with these initiatives. The time has come to decide whether this investment is justified.
] proposes that researchers, users, and stakeholders engage in rigorous evaluation and creation of a valid, useful knowledge and evidence base for quality and safety. This will require improved conceptions of the nature of quality and safety issues, an understanding of the mechanisms by which various structures and processes (e.g
., quality improvement interventions) impact outcomes, stronger designed studies (i.e
., time series), reliable and valid measurements, data quality control, and statistical processes to evaluate the impact of initiatives [123
A strength of this review was the quality appraisal of reporting excellence using the newly established SQUIRE guidelines. Ogrinc et al
] have called for excellence in reporting as a means to share organizational learning and benefit care delivery. Our review revealed that the quality of current reporting varies widely. Improving the rigor of study methods and the reporting of study findings will build a stronger foundation and more convincing argument for future studies and the practice of quality improvement and safety in healthcare.
Limitations should be considered in interpreting the results of this review. First, the search was broad and included studies of quality and safety team initiatives without operational definitions of quality and safety. This may have introduced misclassification of the studies. However, we believe our selection process of an independent review by two investigators and unresolved disagreements on inclusion referred to a team of two reviewers strengthened our classification. Second, this review only addressed studies conducted in an acute care setting, thus results may not be applicable to outpatient and community settings.