Significant strides have been made in health research particularly in the area of hospital based quality improvement. The strength of this review is that it is the first systematic attempt to collate and appraise the very large volume of literature on quality of care interventions over a ten year period. This review has established that despite the volume of literature, there is a paucity of hospital interventions with a theoretically based design or implementation.
The broad scope of the review search strategy resulted in the inclusion of a diverse range of interventions in terms of scope and scientific rigour. Studies varied from small scale improvements for specific patient groups to large scale quality improvement programmes across multiple settings. This heterogeneous group of interventions is a product of the rigorous adherence by the researchers to the review inclusion criteria. This approach succeeded in highlighting a number of areas for improvement for future quality of care interventions.
The inclusion of heterogeneous interventions in this review meant that data synthesis was limited to broad qualitative descriptions of the main components of interventions. Interventions were broadly categorised into two categories. Interpersonal interventions sought to improve patient satisfaction and tended to be implemented by nursing staff while technical interventions were generally implemented by physicians and reported measurable improvements in medical outcomes for patients with specific illnesses. There was a tendency for both categories of interventions to focus on evaluating outcomes without due regard to the mechanisms that produced these outcomes. The result was that interventions appeared to select quality of care outcomes on an ad-hoc or local basis and this arbitrary selection of outcomes makes measurement and comparison of quality of care outcomes difficult.
Technical interventions had a tendency to achieve more substantial improvements in quality of care. This may be because improving and measuring improvements in technical aspects of care is more straightforward and precise than interpersonal aspects of care. When physicians implement interventions to improve processes of care, they tend to have independent control over those processes and this makes implementation of change easier [31
]. Also, it is suggested in the literature that physicians are more likely than other health professionals to alter their behaviour when the outcome will affect the medical outcomes of their patients such as mortality [31
] or perhaps physicians were more likely to identify outcomes which they felt confident that they could actually improve.
Difficulties in achieving quality improvements may also be related to external factors such as administration with one of the major challenges in implementing an intervention to improve teamwork cited as the lack of administrative support [23
]. However, they stressed that when staff are empowered, quality improvements were made. One study concluded that organisational support for change should be achieving by offering financial incentives in the form of salary increments [36
One of the acknowledged shortcomings in interpersonal interventions to improve maternity care was the failure to appreciate the difficulties in achieving organisational change [29
]. The authors concluded that maternity care interventions would be more successful when they adopted multifaceted approaches which involved various stakeholders [29
]. In contrast, one of the main strengths of technical interventions was the involvement of teams or panels of experts prior to intervention [31
]. This approach helped to identify local barriers, establish key areas for quality improvement and establish a plan for achieving manageable tasks [38
]. The use of expert panels acted as an integral part of state wide interventions as this approach facilitated the alignment of resources and expertise from multidisciplinary organisations [32
Interpersonal interventions stressed the importance of recognising the views of the patient prior to intervention [27
]. In maternity care, it was established that this patient group are aware of their own needs and that this information will be valuable in designing future quality improvement programmes [30
]. Similarly, if nursing staff are implementing an intervention to encourage the uptake of childbirth companions, they should be interviewed prior to intervention to provide an insight into the potential barriers to the intervention [29
]. Also, if an intervention seems to improve care for two groups such as patients and family members, it is imperative that the different needs of both groups are recognised. An intervention to improve both staff and family satisfaction acknowledged that while it achieved improved staff satisfaction, it failed to achieve improved family satisfaction as the intervention lack components which directly targeted family members [27
In response to the need for effective interventions, the Medical Research Council UK Framework has released guidelines stating that interventions need a clear theoretical basis to inform their hypothesis. This increased emphasis on the importance of a theoretical base for interventions will facilitate the development and evaluation of interventions [42
]. The majority of studies excluded from this review neglected to mention the theoretical basis of the intervention or to identify their position along the quality of care paradigm. This is the primary reason why the number of studies included in this review was small relative to the very large volume of literature. In light of this lack of clarity, it is suggested that the lack of theoretical grounding of intervention studies may partly explain the minimal transfer of health research into health policy [43
The findings of this review and those of other authors suggest that collaborative research is a key strategy for implementing future theory based interventions [43
]. Collaborative research encapsulates the expertise of all relevant stakeholders (academic researchers, hospital management, patients and their families and policy makers). In this way the theoretical basis of the intervention is not solely based on the perspectives of those who are implementing the intervention. The contributions of policy makers and hospital management ensure that interventions which reach implementation stage are those which are most cost-effective and sustainable in the long term.
The results of this review must be interpreted with caution. As this was the first systematic review of its kind, a broad reaching search strategy was necessary in order to capture all potentially relevant studies. One of the disadvantages of this search strategy was that studies of heterogeneous design were included which resulted in the use of a modified version of the GRADE criteria for quality assessment.
The inclusion of studies of varied design and scientific restricted us to presenting a broad assessment or overview of studies. Different approaches were explored for presenting the studies in a meaningful way. While interventions in the main focused on improving either technical or interpersonal aspects of care, there was overlap with some interventions seeking to improve patient satisfaction along with medical outcomes. However, interventions categorised as technical reported primary medical outcomes and interpersonal interventions reported interpersonal primary outcomes.
The majority of interventions included in this review were pre/post design. Results of any before and after study must be interpreted with caution. In hospital based pre-post interventions, it is often the case that participants at time one and time two differ and this can have the effect of diluting the intervention effects. Improved outcomes reported in the pre/post designed intervention studies may have several possible explanations including secular or temporal trends. The most effective method of overcoming this possibility is to use a randomized controlled trial (RCT). However, using RCTs is difficult when implementing complex interventions involving multiple components since it is not possible to ‘blind’ providers or recipients to the control and intervention groups and it is also difficult to establish which components of a complex intervention worked and which did not.