Using Quality Indicators to Improve Hospital Care: A Review of the Literature

Maartje De Vos; Wilco Graafmans; Mieneke Kooistra; Bert Meijboom; Peter Van Der Voort; Gert Westert


Int J Qual Health Care. 2009;21(2):119-129. 

In This Article

Abstract and Introduction


Purpose: To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care.
Data Sources: A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008).
Study Selection: Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care.
Data Extraction: Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care.
Results: A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan.
Conclusion: Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.


With increasing frequency, hospitals in various countries report and monitor indicator data in order to improve the quality of care.[1–4] Quality indicators aim to detect sub-optimal care either in structure, process or outcome, and can be used as a tool to guide the process of quality improvement in health care.[5] Monitoring the health care quality makes hospital care more transparent for physicians, hospitals and patients. Furthermore, it provides information to target quality improvement initiatives. However, collection of indicator data also implies an administrative burden for physicians and hospitals; therefore, the use of this information should be optimized. It is unclear which implementation strategy for quality indicators is optimal, and what effects can be achieved when quality improvement is guided by indicator information.

The implementation of quality indicators as a tool to assist quality improvement requires effective communication strategies and the removal of hindrances.[6] Evidence suggests that audit and feedback based on indicator data can be effective in changing health care professional practice.[7,8] Monitoring the indicator data may also help to target specific quality improvement initiatives such as educational programs and development of protocols.

The effect of monitoring indicator data to promote quality improvement, and ultimately patient care, has been demonstrated in specific situations. For example, in the Bradford Teaching Hospital in the United Kingdom, feedback of mortality rates resulted in the reduction of the standardized mortality rate from 0.95 to 0.75.[9]

At present, no clear overview is available about strategies for implementing indicators and the effects on quality of care in hospitals. Some reviews do address the issue of implementation of indicators, but do not focus on hospital care.[10,11] Another review of the literature has a limited focus on audit and feedback as implementation strategies.[8] With respect to the effectiveness of using indicators to promote quality improvement, previous reviews have focused on specific diseases or medical disciplines, e.g. pneumonia or cardiac surgery.[12,13] In our review, we focus on hospital care in general, and take into account all possible implementation strategies described in the literature. The purpose of our study is firstly to review the literature concerning strategies for implementing quality indicators, and secondly to examine their effectiveness in improving the quality of hospital care.


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