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BMC Health Serv Res. 2018 Jan 25;18(1):42. doi: 10.1186/s12913-018-2856-9.

The use of external change agents to promote quality improvement and organizational change in healthcare organizations: a systematic review.

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Wisconsin Surgical Outcomes Research Program (WiSOR), University of Wisconsin-Madison, 600 Highland Ave, Madison, WI, 53792-1690, USA.
Department of Clinical Sciences, University of Kentucky College of Health Sciences, Room 209 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA.
Senior Academic Librarian, Ebling Library for the Health Sciences, University of Wisconsin- Madison, Madison, USA.
Department of Family Medicine, University of Wisconsin School of Medicine & Public Health, 1100 Delaplaine Ct, Madison, WI, 53715, USA.
Department of Family Medicine & Community Health, Research Scientist- Center for Health Enhancement Systems Studies, Department of Industrial & Systems Engineering, University of Wisconsin-Madison, 4115 Mechanical Engineering Building, 1513 University Avenue, Madison, WI, 53706, USA.



External change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare-specifically, in primary care settings.


We searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion.


Academic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes.


Our results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn't find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.


Academic detailing; External change agents; Organizational change; Practice facilitation; Quality improvement

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