gms | German Medical Science

Background: Variance and errors in health care are unfortunately commonplace. Evidence-based or best practice care produce superior outcomes if uniformly and consistently implemented.

Objectives: 1. To evaluate systematic reviews on change techniques in health care 2. To compare successful improvement projects at one large health care organization to evidence-based recommendations for process improvement.

Methods: We searched the Cochrane Database of Systematic Reviews, the Cochrane EPOC site and other major databases for systematic reviews and guidelines on provider and organizational change and quality improvement implementation. We analyzed SR methods and compared the strengths of evidence. We then compared the synthesis to programs at Kaiser Permanente that have significantly reduced mortality from myocardial infarction, stroke and sepsis and morbidity from medication errors, pneumonia, pressure ulcers and hospital acquired infections.

Results: There are few systematic reviews in these areas. One comprehensive review included a survey and analysis of the organizational behavior literature, providing a multidimensional view of organizational change and uptake of innovations. The Kaiser programs incorporated many of these best practices for change.

Discussion: Studies of complex interventions that involve leadership behavior are methodologically difficult. The evidence grading system used in the major SR followed WHO criteria that were different than systems used to appraise clinical trials. Nonetheless, the recommended techniques supported actual improvements in care.

Implications for guideline developers/users: An implementation framework should be part of evidence-based guidelines to ensure active uptake and adoption. Guideline recommendations should be clinically specific and sequenced to best care for major health problems.