Cover: What influences improvement processes in healthcare?

What influences improvement processes in healthcare?

A rapid evidence review

Published Sep 15, 2020

by Gemma-Claire Ali, Marlene Altenhofer, Emily Ryen Gloinson, Sonja Marjanovic

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Research Questions

  1. What factors influence quality improvement processes in healthcare?
  2. What are some of the themes and issues to explore in future research into the factors influencing quality improvement processes in healthcare?

Poor-quality healthcare has significant health-related and economic consequences for patients and the wider health system. Although many healthcare organisations are now engaging with improvement activity, the challenges associated with improving care quality remain considerable.

The field of improvement research has significant potential to contribute to a better understanding of how improvements in patient care can be achieved and sustained. It is an interdisciplinary academic field, and although the literature on quality improvement is broad and diverse, it is also fragmented. Many studies look at individual improvement models, approaches and interventions, and focus on understanding what works in relation to specific improvement aims. There is less consolidated and curated evidence on learning about the process of doing improvement. A better understanding of the nature of improvement processes and influences on them could inform both ongoing and future practice, by drawing out practical insights such as those related to the challenges faced by improvers and the strategies used to overcome them.

Against this context, The Healthcare Improvement Studies (THIS) Institute commissioned RAND Europe to conduct a rapid evidence review of the academic and grey literature, to draw out initial learning about what influences quality improvement processes in healthcare, and to inform potential themes to explore in future research.

Key Findings

We identified and reviewed 38 academic and 16 grey literature publications covering diverse improvement approaches. Some examples include Six Sigma, Lean, Business Process Reengineering, Plan-Do-Study-Act, clinical audits and feedback, quality improvement collaboratives and peer-learning communities, training and education interventions, and patient engagement and feedback-related interventions.

Key influences on improvement processes in healthcare

Based on the reviewed literature, six key factors influence the implementation of improvement efforts:

  • Leadership
  • Relationships and interactions that support an improvement culture
  • Skills and competencies
  • Use of data
  • Patient and public involvement, engagement and participation
  • Working as an interconnected system of individuals and organisations, influenced by internal and external contexts

This review also attempted to go beyond identifying these high-level influences by explaining what specific aspects of the influencing factors are important for quality improvement. The report provides a detailed analysis of influencing factors across the six categories outlined above, as well as summary tables for each.


  • Further research is needed to understand how challenges to implementing improvement can be addressed in practice, taking into consideration the interactions and interdependencies between different influences on improvement. Further research on the unintended consequences of improvement efforts is also needed, to ensure that any new improvement efforts can manage such risks.
  • The above insights should help improvement practitioners to recognise the issues that they need to consider in the design and implementation of improvement initiatives. They also highlight priority areas for the wider research community.

Research conducted by

This research was was commissioned by The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge and conducted by RAND Europe.

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