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To bridge the gap between scientific evidence and patient care we need an in‐depth understanding of the barriers and incentives to achieving change in practice. Various theories and models for change point to a multitude of factors that may affect the successful implementation of evidence. However, the evidence for their value in the field is still limited. When planning complex changes in practice, potential barriers at various levels need to be addressed. Planning needs to take into account the nature of the innovation; characteristics of the professionals and patients involved; and the social, organisational, economic and political context.

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A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.Keywords: Theories, quality improvement, health care. S ometimes new scientific findings, best practices, or clinical guidelines are easily implemented in practice. Most of the time, however, improving patient care is not easy, particularly if an innovation requires complex changes in clinical routines, better collaboration among disciplines, changes in patients' behavior, or changes in the organization of care. To date, the majority of health care improvements have been targeted at factors related to individual professionals, particularly their knowledge, routines, or attitudes (Grimshaw et al.Address correspondence to: Richard Grol, Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre (UMCN), KWAZO 117, PO Box 9101, 6500 HB Nijmegen, the Netherlands (email: R.Grol@kwazo.umcn.nl). The Milbank Quarterly, Vol. 85, No. 1, 2007 (pp. 93-138) 94R. Grol, M. Bosch, M. Hulscher, M. Eccles, and M. Wensing 2004), although improvement may be impeded by a much broader range of economic, administrative, and organizational factors or those relating to patients' beliefs or behavior.Because the interaction of factors at multiple levels may influence the success or failure of quality-improvement interventions (Ferlie and Shortell 2001;Grol 1997;Shortell et al. 2000), an understanding of these factors (the obstacles and incentives for change) is crucial to an effective intervention (Grol and Grimshaw 2003;Grol and Wensing 2004;van Bokhoven, Kok, and van der Weijden 2003). An understanding of the theoretical assumptions and hypotheses behind these factors is necessary as well, as it enables the consideration of theory-based interventions for quality improvement. Currently, however, the specific model or approach is usually based on implicit (and potentially biased) personal beliefs about human behavior and change (Grol 1997).In this article we summarize and recommend a set of theories regarding change in health care and argue for a more systematic use of theories in planning and evaluating changes in clinical practice, by following and extending previous overviews of theories (e.g., Ashford 1998;Greenhalgh et al. 2004;Kitson, Harvey, and McCormack 1998;Michie et al. 2005;Robertson, Baker, and Hearnshaw 1996). The Complexity ...

Objective To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care. Data sources Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases. Study selection Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes. Data synthesis Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect. Conclusions The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.

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Objective: To determine which attributes of clinical practice guidelines influence the use of guidelines in decision making in clinical practice. Design: Observational study relating the use of 47 different recommendations from 10 national clinical guidelines to 12 different attributes of clinical guidelines-for example, evidence based, controversial, concrete. Setting: General practice in the Netherlands. Subjects: 61 general practitioners who made 12 880 decisions in their contacts with patients. Main outcome measures: Compliance of decisions with clinical guidelines according to the attribute of the guideline. Results: Recommendations were followed in, on average, 61% (7915/12 880) of the decisions. Controversial recommendations were followed in 35% (886/2497) of decisions and non-controversial recommendations in 68% (7029/10 383) of decisions. Vague and non-specific recommendations were followed in 36% (826/2280) of decisions and clear recommendations in 67% (7089/10 600) of decisions. Recommendations that demanded a change in existing practice routines were followed in 44% (1278/2912) of decisions and those that did not in 67% (6637/9968) of decisions. Evidence based recommendations were used more than recommendations for practice that were not based on research evidence (71% (2745/3841) v 57% (5170/9039)). Conclusions: People and organisations setting evidence based clinical practice guidelines should take into account some of the other important attributes of effective recommendations for clinical practice.