Assessing the impact of continuous quality improvement on clinical practice: What it will take to accelerate progress

The literature on continuous quality improvement (CQI) has produced some ev idence, based on nonrandomized studies, that its clinical application can i mprove outcomes of care while reducing casts. Its effectiveness is enhanced by a nucleus of physician involvement, individual practitioner feedback, a nd a supportive organizational culture. The few randomized studies, however , suggest no impact of CQI on clinical outcomes and no evidence to dare of organization-wide improvement in clinical performance. Further, most studie s address misuse issues and avoid examining overuse or underuse of services . The clinical application of CQI is more likely to have a pervasive impact when it takes place within a supportive regulatory and competitive environ ment, when it is aligned with financial incentives, and when it is under th e direction of an organizational leadership that is committed to integratin g all aspects of the work.