What are the Barriers and Facilitators to the Implementation and/or Success of Quality Improvement and Risk Management in Hospitals: A Systematic Literature Review

Background:Most of the research papers and literature reviews on barriers and facilitators of quality and safety improvement programs and actions in hospitals failed to have a comprehensive approach, in particular regarding the individual factors, which in a daily practice appear to be key. The objective is to list comprehensively these factors and to organize them in relevant categories. Methods:This systematic literature review examines, organizes and summarizes current literature on the association between hospital-level, department-level and individual-level and implementation and/or success of horizontal quality improvement and risk management programs and actions in hospitals. The search covered the medical, social and human sciences literature based on all ranges of approaches, quantitative, qualitative and mixed. Inclusion criteria were publication period between 1990 and 2012 in English and French, association between one or several factors and a quality/safety improvement action/program implementation and/or success, use of a structured quantitative and/or qualitative methodology. Critical appraisal was made by two independent readers using a structured grid. A multidisciplinary team (sociologists, researchers in management and in quality and safety, hospital director and chief medical officer) classified the factors into categories. Results:Among 30,615 references, 23 articles were analyzed in depth, six literature reviews and17 original articles; 11 of which used a qualitative methodology, four a mixed methodology and two a quantitative methodology. None of these original articles was included in the bibliographies of the 6 literature reviews. In all, 73 facilitating factors and 58 factors barriers were retrieved. Factors associated with management and leadership, and organizational factors (related to the organization of work in general and not with the organization of the project itself), seemed to hold an important role. The quality management system followed the same trend, with more facilitating factors than barriers. Conversely, the interactional and individual factors were more often barriers. The most frequent factors referring to the individual level were “trivialization” (low perceived importance of risk), denial of reality, of the patient's feelings, and lack of skills or knowledge. Conclusion:While implementing quality/safety actions, it is probably just as important to take the barriers into account as facilitators; however, they are possibly more difficult to identify than the facilitators as they are apparently more often psychosocial in nature or relate to interactions between professionals.