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Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality

Closing the Quality Gap: Revisiting the State of the Science

Methods Research Reports

Investigators: , MM, , MD, MPH, and , MS.

Author Information
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 13-EHC041-EF

Structured Abstract


The United States devotes significant resources to health care, yet quality is often lacking. In 2004, the Agency for Healthcare Research and Quality launched a collection of evidence reports on quality improvement (QI) opportunities and strategies related to chronic conditions, practice areas, and cross-cutting priorities. This new Closing the Quality Gap series expands the topics examined and marshals the knowledge of eight Evidence-based Practice Centers (EPCs) to synthesize lessons learned and to advance the state of QI science.

Series topics:

The eight topics are: effectiveness of bundled payment programs, effectiveness of the patient-centered medical home, QI strategies to address health disparities, effectiveness of medication adherence interventions, effectiveness of public reporting, prevention of healthcare-associated infections, QI measurement of outcomes for people with disabilities, and health care and palliative care for patients with advanced and serious illness.

Data sources and review methods:

Each EPC conducted a systematic review of the peer-reviewed literature. Topic search strategies are available in the individual topic reports. This methods report relies on the final topic reports to highlight common lessons, identify implications for future systematic reviews of complex QI topics, and recommend next steps to advance the QI field.


The series collectively assessed the evidence across quality levers and various populations, interventions, outcomes, settings, and contexts. Various approaches were taken to analyze the evidence in meaningful ways for key audiences. The challenges across reports informed approaches for future reviews, including use of logic models, approaches to defining and searching for complex health care interventions, assessment of individual study quality and strength of evidence, meaningful synthesis, and methods for synthesis. Directions for future QI research include the role of systematic review to advance the field, consistent measurement, consistent and complete reporting, a focus on health, understanding of context, and development of a common lexicon for QI intervention.


In their innovative review of these complex topics, EPCs faced several common challenges, including difficulty in synthesizing the evidence due to heterogeneity in choice of outcomes measures; limited ability to draw conclusions due to weaknesses in study design and incomplete reporting; and difficulty applying traditional systematic review methods to the multifaceted, context-dependent, systems-level interventions typical of the QI field. Future research will be strengthened by consistent use of a core set of outcomes measures, more robust study designs, more complete reporting of intervention characteristics and contextual factors, and development of additional systematic review methods specific to the QI field.


Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10062-I. Prepared by: Stanford-UCSF Evidence-based Practice Center (operating under RAND Evidence-based Practice Center), Stanford, CA

Suggested citation:

McDonald KM, Chang C, Schultz E. Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality. Closing the Quality Gap: Revisiting the State of the Science. Methods Research Report. (Prepared by Stanford-UCSF Evidence-based Practice Center under Contract No. 290-2007-10062-I.) AHRQ Publication No. 13-EHC041-EF. Rockville, MD: Agency for Healthcare Research and Quality; February 2013.

This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10062-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.


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Bookshelf ID: NBK126724PMID: 23487867


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