• Maartje de Vos, Wilco Graafmans, Mieneke Kooistra, Bert Meijboom, Peter Van Der Voort, and Gert Westert.
• Department of Tranzo, University of Tilburg, Tilburg, the Netherlands. m.l.g.devos@uvt.nl
• Int J Qual Health Care. 2009 Apr 1; 21 (2): 119-29.

PurposeTo review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care.Data SourcesA systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008).Study SelectionHospital-based trials studying the effects of using quality indicators as a tool to improve quality of care.Data ExtractionTwo 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.ResultsA 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.ConclusionEffective 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.

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