Clinical Orthopaedics and Related Research®

, Volume 470, Issue 4, pp 1006–1016

The Use of Three Strategies to Improve Quality of Care at a National Level

Symposium: Value Based Healthcare

DOI: 10.1007/s11999-011-2083-8

Cite this article as:
So, J.P.P. & Wright, J.G. Clin Orthop Relat Res (2012) 470: 1006. doi:10.1007/s11999-011-2083-8



Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial.


The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries.


We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size.


Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results.


Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  1. 1.The Hospital for Sick ChildrenTorontoCanada
  2. 2.Division of Orthopaedic SurgeryChild Health Evaluative SciencesToronto Canada
  3. 3.The Hospital for Sick Children and University of TorontoTorontoCanada

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