What are the best strategies for ensuring quality in hospitals?





The issue

Ensuring the safety of patients and personnel and improving quality have become important objectives for national health systems in developed and developing countries alike, in response to research highlighting poor quality, increasing patient expectations, and media reports. There is a general belief, supported by growing research literature, that there are effective methods to improve quality and safety.

Health care organizations are increasingly expected by governments, funders and patients to introduce quality control systems and outcome improvement strategies. Many health care managers and practitioners also believe that action should be taken, but are unsure of how to proceed, especially within resource constraints.

There are many approaches to improve quality and safety, and diverse strategies to encourage hospitals to do so. Which strategies are most appropriate and cost effective for a particular hospital in a specific situation? Which approach should a government or funder promote?


There is little research assessing the effectiveness of one or more hospital or national quality strategies that can be used to answer these questions. This lack of evidence does not show that strategies are not effective, but is rather due to the difficulty of evaluating interventions and of proving that the results are due to the strategy and not to other factors.

There is some research into local team projects which shows that “continuous quality improvement” approaches can be effective. There is also research indicating the conditions needed to support and encourage these approaches.

Many publications and reports describe different strategies, but few are well-designed research projects, or report scientifically valid evidence of results. There is an even larger quantity of literature by consultants, academics and commentators advising on the best approach; some is based on sound experience, but little is based on scientific research.

No single quality strategy can be recommended above any other on the basis of evidence of effectiveness, ease of implementation or costs.

Policy considerations

Some of the main recommendations from this synthesis of the literature are based on a few valid outcome studies and a critical assessment of the descriptive literature.

  1. When reviewing types of strategies, hospitals and governments should question the claims of proponents of any one approach because there is no strong evidence of effectiveness.
  2. Decision-makers should be aware that the same strategy applied in a different location or institution may well yield different results, even if fully implemented in exactly the same manner.
  3. A chosen quality strategy should be reviewed regularly and adapted to the changing situation and the responses of personnel. Efforts should be made to assess whether any lack of results is due to the wrong strategy, poor implementation, or the time necessary to observe results. Flexibility without sudden radical change appears to be important.
  4. Quality experts with wide experience can be useful, but need to be chosen with care. One or more independent experts should be used to give independent feedback on a strategy for regular reviews.
  5. Hospital quality strategies should include improving inter-service quality for different patients groups, and address hospital-community coordination of care issues. Patient experiences and outcomes are affected by how hospitals provide access, outreach and linking with non-hospital services.
  6. It is possible that time and money that could be used for patient care is currently wasted on some strategies. There is a strong case for more independent and scientific research.
  7. Fuller reviews of the evidence for particular strategies than were possible in this report should be carried out.