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Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies
  1. Valerie M Vaughn1,2,3,
  2. Sanjay Saint1,2,3,
  3. Sarah L Krein1,2,3,
  4. Jane H Forman2,3,
  5. Jennifer Meddings1,2,3,4,
  6. Jessica Ameling1,3,
  7. Suzanne Winter1,3,
  8. Whitney Townsend5,
  9. Vineet Chopra1,2,3
  1. 1 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
  2. 2 Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  3. 3 Patient Safety Enhancement Program, Ann Arbor Veterans Affairs Medical Center/University of Michigan, Ann Arbor, Michigan, USA
  4. 4 Departmentof Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
  5. 5 Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Valerie M Vaughn, Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; valmv{at}


Background Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.

Methods Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.

Results Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

Conclusions Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.

Systematic review registration PROSPERO: CRD42017067367.

  • quality improvement
  • healthcare quality improvement
  • patient safety
  • qualitative research
  • leadership

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  • Contributors As first author of this study, I take responsibility for the integrity of this work as a whole. We certify that all authors have seen and approved the manuscript. Each author has contributed significantly to it.

  • Funding This study was supported by Centers for Disease Control and Prevention (Contract Number: 200-2015-88275).

  • Disclaimer The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Veterans Affairs.

  • Competing interests SS has received fees for serving on advisory boards for Doximity and Jvion. JM has received honoraria for lectures and teaching related to prevention and value-based purchasing policies involving catheter-associated urinary tract infection and hospital-acquired pressure ulcers. She has also received honoraria from RAND Corporation/AHRQ for preparation of an AHRQ Chapter update on prevention of catheter-associated UTI.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Coding data from this qualitative review are available upon request to the corresponding author, VMV, at

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