NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

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 [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Feb.

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

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 [Internet].

Show details

Appendix DTaxonomy of Quality Improvement Strategies

In this methods report, we discuss results for intervention-focused topics with respect to the taxonomy of quality improvement (QI) strategies developed for the original Closing the Quality Gap series. Below, we provide details of that taxonomy, abstracted from the original series report. Further details, including examples of each type, may be found in the original Closing the Quality Gap series overview and methodology report.1

  1. Provider reminder systems—The investigators defined a reminder system as any patient- or clinical encounter-specific information provided orally, in writing, or by computer intended to prompt a clinician to recall information or intended to prompt consideration of a specific process of care (e.g., “This patient last underwent screening mammography 3 years ago”). The reminder also may include information prompting the clinician to follow evidence-based care recommendations (e.g., to make medication adjustments or to order appropriate screening tests). The phrase “clinical encounter-specific” in the definition serves to distinguish reminder systems from audit and feedback, whereby clinicians typically receive performance summaries relative to a process or outcome of care spanning multiple encounters (e.g., all patients with type 2 diabetes seen by the clinician during the past 6 months).
  2. Facilitated relay of clinical data to providers—“Facilitated relay” is used to describe the transfer of clinical information collected directly from patients and relayed to the provider in instances where the data are not generally collected during a patient visit or using some format other than the existing local medical record system (e.g., the telephone transmission of a patient's blood pressure measurements from a specialist's office). The Effective Practice and Organisation of Care (EPOC) group uses the term “patient mediated” to describe such interventions,2 but the authors regard the label “facilitated relay” as more descriptive. Some overlap with provider reminder systems was expected, but the strategies were kept separate at the abstraction stage. This decision allowed for the possibility that the data could be subsequently analyzed with and without collapsing the two strategies.
  3. Audit and feedback—The researchers defined audit and feedback as any summary of clinical performance for health care providers or institutions performed for a specific period of time and reported either publicly or confidentially to the clinician or institution (e.g., the percentage of a provider's patients who achieved or did not achieve some clinical target, such as blood pressure or HbA1c control over a certain period). “Benchmarking” is a term referring to the provision of performance data from institutions or providers regarded as leaders in the field. These data serve as performance targets for other providers and institutions. The authors included benchmarking as a type of audit and feedback, so long as local data were provided for comparison with the benchmark data.
  4. Provider education—“Provider education” is used to describe a variety of interventions including educational workshops; meetings such as traditional Continuing Medical Education (CME); lectures (in person or computer based); and educational outreach visits (by a trained representative who meets with providers in their practice settings to disseminate information with the intent of changing the providers' practice). The same term also is used to describe the distribution of educational materials (electronically published or printed clinical practice guidelines and audio-visual materials). The investigators further captured information about the intensity (i.e., duration and number of educational sessions) and format (i.e., lectures delivered live, via teleconference, or prerecorded) in a free-text mode for each of these substrategies. Early plans to capture these and other predictors in a structured form were abandoned after the authors and their technical advisors agreed the judgments were too subjective. This was due in large part to a relative lack of detail surrounding the interventions in the vast majority of studies.
  5. Patient education—This strategy is centered on in-person patient education, either individually or as part of a group or community, and through the introduction of print or audio-visual educational materials. Patient education may be the sole component of a particular quality improvement strategy, or it can be one part of a multifaceted QI strategy. It should be noted that the authors evaluated only those strategies in which patient education was regarded as one component of a multifaceted strategy. A future volume in this series may address the topic of patient education as a single intervention, along with its relative effects on a variety of chronic diseases.
  6. Promotion of self-management—This strategy includes the distribution of materials (e.g., devices for blood pressure or glucose self-monitoring) or access to a resource that enhances the patients' ability to manage their condition, the communication of useful clinical data to the patient (e.g., most recent HbA1c or lipid panel levels), or followup phone calls from the provider to the patient, with recommended adjustments to care. The authors expected some overlap with regard to patient education (strategy 5) and patient reminders (strategy 7). They elected to keep the strategies separate at the abstraction stage to allow for the possibility that the data could be analyzed after the fact, with and without collapsing the two strategies.
  7. Patient reminders—This term is used to define any effort directed by providers toward patients that encourages them to keep appointments or adhere to other aspects of the self-management of their condition.
  8. Organizational change—This strategy included any intervention having features consistent with at least one of the following descriptions, each of which represents a substrategy of organizational change that was abstracted for incorporation in the analysis:
    1. Disease management or case management: The coordination of assessment, treatment, and referrals by a person or multidisciplinary team in collaboration with, or supplementary to, the primary care provider.
    2. Team or personnel changes: Adding new members to a treatment team (e.g., adding a diabetes nurse, a clinical pharmacist, or a nutritionist to a clinical practice); creating multidisciplinary teams within a practice or revising the roles of existing team members (e.g., giving a clinic nurse a more active role in patient management); or simply adding more nurses, pharmacists, or physicians to a clinical setting.
    3. Communications, case discussions, and the exchange of treatment information between distant health professionals (e.g., telemedicine).
    4. Total Quality Management (TQM) or Continuous Quality Improvement (CQI) techniques for measuring quality problems, designing interventions, and implementation of interventions, along with process remeasurements.
    5. Changes in medical records systems: Adopting improved office technology (e.g., computer-based records, patient tracking systems).
    Although the definition used for this strategy (organizational change) is consistent with prior reviews, the authors recognized the potential heterogeneity of included interventions and accordingly planned to analyze this strategy with respect to the aforementioned substrategies.
  9. Financial, regulatory, or legislative incentives—This strategy encompassed any intervention having features consistent with at least one of the following descriptions:
    1. Positive or negative financial incentives directed at providers (e.g., regarding adherence to some process of care or achievement of a target patient outcome).
    2. Positive or negative financial incentives directed at patients.
    3. Systemwide changes in reimbursement (e.g., capitation, prospective payment, shift from fee-for-service to salary).
    4. Changes to provider licensure requirements.
    5. Changes to institutional accreditation requirements.


Shojania KG, McDonald KM, Wachter RM, et al. Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. Rockville, MD: Agency for Healthcare Research and Quality; 2004. Series Overview and Methodology. (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290-02-0017). AHRQ Publication No. 04-0051-1. www​
Effective Practice and Organisation of Care Group (EPOC). The Data Collection Checklist, Section 2.1.1. [January 16, 2013]. http://epoc​.cochrane​.org/sites/epoc.cochrane​.org/files/uploads​/datacollectionchecklist.pdf.
Bookshelf ID: NBK126726


  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (688K)

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...