The external review of quality improvement in health care organizations: a qualitative study.

OBJECTIVE To explore the use of external approaches to quality improvement in health care organizations, through a descriptive evaluation of the process and impact of external reviews of clinical governance arrangements at health care provider organizations in the National Health Service (NHS) in England. DESIGN A qualitative study, involving the use of face-to-face and telephone interviews with senior managers and clinicians in health care provider organizations and with members of a regional clinical governance review team. SETTING The West Midlands region of England, in which there are 47 NHS trusts (health care provider organizations). STUDY PARTICIPANTS A total of 151 senior clinicians and managers at NHS trusts in the West Midlands and 12 members of a specially constituted regional clinical governance review team. INTERVENTION Clinical governance review visits which were undertaken by the regional clinical governance review team to all NHS trusts between April 1999 and February 2000. Interviews with senior managers and clinicians took place before and after the review visits had taken place; interviews with members of the clinical governance review team took place when they had undertaken most of their visits. RESULTS The prospect of external review produced mixed reactions in health care provider organizations, and preparing for such a review was a substantial and time-consuming task. The review itself was often productive, although differences in attitudes and expectations between health care provider organizations and review team members created tensions, especially when the results of the review were reported back. External reviews rarely generated wholly new knowledge, were more confirmatory than revelatory, and did not usually lead to major changes in policy, strategy or practice. CONCLUSIONS External review systems are widely used in health care to promote quality improvement in health care provider organizations, but their effectiveness is little researched and the optimal design of systems of external review is not well understood. More attention to the design and impact of external review would help to maximize its benefits and minimize costs and adverse effects.