Table 1

Example topics and the basis for their inclusion

Motivation for inclusion
Problematic improvements
 ChecklistsDeceptively simple, but often require other more substantive changes (teamwork, workflow, attention to design issues)1 2 4
 Incident reportingMakes sense in principle as a means of capturing incidents worth investigating to identify system problem, but misapplied in practice as a source of trend data and pie charts
 Standardised hospital mortality ratiosThe title of one commentary says it all: ‘a bad idea that just won't go away’13
 Targeting ‘low hanging fruit’Meant to refer to improvement targets that will not require much effort to achieve worthwhile gains. In practice, these fruit are often further out of reach than they at first appear (or are not as worth picking as one might have thought)
 Audit and feedback of performance (‘report cards’)A large literature shows modest benefits. Probably more substantial improvements are possible. But, feedback initiatives routinely occur with little consideration of what seems to work best (eg, that feedback should occur from a supervisor or respected colleague, should occur frequently, and be accompanied by a goal or action plan14)
Problematic problems
 FallsMost falls produce no injury; interventions that reduce fall-related injuries remain elusive, and focusing on fall rates risks reducing mobilisation8
 InterruptionsNot all interruptions are bad and simply counting them all serves little purpose. The desirability of preventing an interruption depends on a complex interplay between the content of the interruption, the task being performed, and the potential for recovery strategies, among others9 10
 Readmission ratesWidely targeted and make sense in principle, but the proportion of preventable readmissions is probably much lower than generally stated, especially when one considers preventability by a hospital level as opposed to changes that might occur in the whole health system
 Hand hygiene complianceHospitals invest considerable time measuring and attempting to improve rates of hand hygiene compliance. We do not know the threshold rate at which tangible infection control benefits begin to occur. And, hand hygiene audits almost certainly overestimate performance15
 ‘Low value care’Inappropriate or low value medical care is common and makes good sense to target.16 The problem is that the easy cases are not common. It is unusual to have an aspect of medical care that is usually inappropriate and also consumes substantial resources