Organizational interventions to implement improvements in patient care: a structured review of reviews

BACKGROUND Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement. OBJECTIVE To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care. DESIGN Structured review of published reviews of rigorous evaluations. DATA SOURCES Published reviews of studies on organizational interventions. REVIEW METHODS Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003. Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings. RESULTS A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain. CONCLUSION There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.