Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies

Document Type : Review Article


1 Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands

2 Ministry of Health, Welfare, and Sport, The Hague, The Netherlands


A lack of knowledge exists on real world hospital strategies that seek to improve quality, while reducing or containing costs. The aim of this study is to identify hospitals that have implemented such strategies and determine factors influencing the implementation.

We searched PubMed, EMBASE, Web of Science, Cochrane Library and EconLit for case studies on hospitalwide strategies aiming to increase quality and reduce costs. Additionally, grey literature databases, Google and selected websites were searched. We used inductive coding to identify factors relating to implementation of the strategies.

The literature search identified 4198 papers, of which our included 17 papers describe 19 case studies from five countries, mostly from the United States. To accomplish their goals, hospitals use different management strategies, such as continuous quality improvement (CQI), clinical pathways, Lean, Six Sigma and value-based healthcare (VBHC). Reported effects on both quality and costs are predominantly positive. Factors identified to be relevant for implementation were categorized in eleven themes: (1) strategy, (2) leadership, (3) engagement, (4) reorganization, (5) finances, (6) data and information technology (IT), (7) projects, (8) support, (9) skill development, (10) culture, and (11) communication. Recurring barriers for implementation are a lack of physician engagement, insufficient financial support, and poor data collection.

Hospital strategies that explicitly aim to provide high quality care at low costs may be a promising option to bend the cost curve while improving quality. We found a limited amount of studies, and varying contexts across case studies. This underlines the importance of integrated evaluation research. When implementing a quality enhancing, cost reducing strategy, we recommend considering eleven conditions for successful implementation that we were able to derive from the literature.



Commentaries Published on this Paper

  • Linking Costs and Quality in Healthcare: Towards Sustainable Healthcare Systems; Comment on “Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies”

        Abstract | PDF


  • Ways to Improve Hospital Quality - A Health System Perspective; Comment on “Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies”

        Abstract | PDF



  1. Jeurissen P, Duran A, Saltman RB. Uncomfortable realities: the challenge of creating real change in Europe's consolidating hospital sector. BMC Health Serv Res. 2016;16 Suppl 2:168. doi:1186/s12913-016-1389-3
  2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516. doi:1001/jama.2012.362
  3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. doi:1377/hlthaff.27.3.759
  4. Stadhouders N, Kruse F, Tanke M, Koolman X, Jeurissen P. Effective healthcare cost-containment policies: a systematic review. Health Policy. 2019;123(1):71-79. doi:1016/j.healthpol.2018.10.015
  5. Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ. 2008;336(7659):1491-1494. doi:1136/bmj.39570.749884.BE
  6. Nuckols TK, Keeler E, Morton S, et al. Economic evaluation of quality improvement interventions designed to prevent hospital readmission: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(7):975-985. doi:1001/jamainternmed.2017.1136
  7. Øvretveit J. Does Improving Quality Save Money? A Review of Evidence of Which Improvements to Quality Reduce Costs to Health Service Providers. London: The Health Foundation; 2009:95.
  8. Garvin DA. What does “product quality” really mean? Sloan Manage Rev. 1984;25:25-43.
  9. Juran JM. A History of Managing for Quality: The Evolution, Trends, and Future Directions of Managing for Quality. Milwaukee, Wis: Asq Press; 1995.
  10. Zelman WN, Pink GH, Matthias CB. Use of the balanced scorecard in health care. J Health Care Finance. 2003;29(4):1-16.
  11. Chow CW, Ganulin D, Teknika O, Haddad K, Williamson J. The balanced scorecard: a potent tool for energizing and focusing healthcare organization management. J Healthc Manag. 1998;43(3):263-280.
  12. Hackman JR, Wageman R. Total quality management: empirical, conceptual, and practical issues. Adm Sci Q. 1995;40(2):309-342. doi:2307/2393640
  13. Øvretveit J. Total quality management in European healthcare. Int J Health Care Qual Assur. 2000;13(2):74-80. doi:1108/09526860010319523
  14. Leininger SM. Building clinical pathways. Orthop Nurs. 1998;17(3):75-77.
  15. De Bleser L, Depreitere R, De Waele K, Vanhaecht K, Vlayen J, Sermeus W. Defining pathways. J Nurs Manag. 2006;14(7):553-563. doi:1111/j.1365-2934.2006.00702.x
  16. Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care. 2005;17(2):141-146. doi:1093/intqhc/mzi016
  17. Black JR, Miller D, Sensel J. The Toyota Way to Healthcare Excellence: Increase Efficiency and Improve Quality with Lean. Vol 1. Chicago, IL: Health Administration Press; 2008.
  18. Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J. Lean thinking in healthcare: a realist review of the literature. Qual Saf Health Care. 2010;19(5):376-382. doi:1136/qshc.2009.037986
  19. Salah S, Rahim A, Carretero JA. The integration of six sigma and lean management. Int J Lean Six Sigma. 2010;1(3):249-274. doi:1108/20401461011075035
  20. Womack JP, Jones DT. Beyond Toyota: how to root out waste and pursue perfection. Harv Bus Rev. 1996;74(5):140-51.
  21. Buck C. Application of six sigma to reduce medical errors. In: Annual Quality Congress Proceedings-American Society for Quality Control. ASQ; 2001.
  22. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. Boston, Mass: Harvard Business School Press; 2006.
  23. Porter ME. A strategy for health care reform--toward a value-based system. N Engl J Med. 2009;361(2):109-112. doi:1056/NEJMp0904131
  24. de Koeijer R, Hazelzet J. Wat is nodig voor duurzame implementatie van Value Based Healthcare? Tijdschrift voor Arbeidsvraagstukken. 2017;33(2):199-213. doi:5117/2017.033.002.009
  25. Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements of patient-centred care? a narrative review and synthesis of the literature from health policy, medicine and nursing. J Adv Nurs. 2013;69(1):4-15. doi:1111/j.1365-2648.2012.06064.x
  26. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307(17):1801-1802. doi:1001/jama.2012.476
  27. Ekman I, Swedberg K, Taft C, et al. Person-centered care--ready for prime time. Eur J Cardiovasc Nurs. 2011;10(4):248-251. doi:1016/j.ejcnurse.2011.06.008
  28. Davis K, Drey N, Gould D. What are scoping studies? a review of the nursing literature. Int J Nurs Stud. 2009;46(10):1386-1400. doi:1016/j.ijnurstu.2009.02.010
  29. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. doi:1186/s12874-018-0611-x
  30. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. doi:1080/1364557032000119616
  31. Godin K, Stapleton J, Kirkpatrick SI, Hanning RM, Leatherdale ST. Applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in Canada. Syst Rev. 2015;4:138. doi:1186/s13643-015-0125-0
  32. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-473. doi:7326/m18-0850
  33. Strongwater SL. The change process and a clinical evaluation unit at University of Massachusetts Medical Center. Qual Manag Health Care. 1996;4(4):30-39. doi:1097/00019514-199604040-00005
  34. Jabbal J, Lewis M. Approaches to Better Value in the NHS: Improving Quality and Cost. The King's Fund; 2018.
  35. Blanchard JC, Rudin RS. Improving hospital efficiency through data-driven management: a case study of health first, Florida. Rand Health Q. 2016;5(4):2.
  36. van den Heuvel J, Does RJ, Bogers AJ, Berg M. Implementing six sigma in the Netherlands. Jt Comm J Qual Patient Saf. 2006;32(7):393-399. doi:1016/s1553-7250(06)32051-x
  37. Meliones J. Saving money, saving lives. Harv Bus Rev. 2000;78(6):57-62, 64, 66-57.
  38. van Leersum N, Bennemeer P, Otten M, Visser S, Klink A, Kremer JAM. Cure for increasing health care costs: the Bernhoven case as driver of new standards of appropriate care. Health Policy. 2019;123(3):306-311. doi:1016/j.healthpol.2019.01.002
  39. Chatfield SC, Volpicelli FM, Adler NM, et al. Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre. BMJ Qual Saf. 2019;28(6):449-458. doi:1136/bmjqs-2018-009068
  40. Reynolds J, Roble D. Combining pay for performance with gainsharing. Healthc Financ Manage. 2006;60(11):50-55.
  41. Nilsson K, Bååthe F, Erichsen Andersson A, Sandoff M. Value-based healthcare as a trigger for improvement initiatives. Leadersh Health Serv (Bradf Engl). 2017;30(4):364-377. doi:1108/lhs-09-2016-0045
  42. Niemeijer GC, Trip A, de Jong LJ, Wendt KW, Does RJ. Impact of 5 years of lean six sigma in a University Medical Center. Qual Manag Health Care. 2012;21(4):262-268. doi:1097/QMH.0b013e31826e74b7
  43. Barnabè F, Guercini J, Perna MD. Assessing performance and value-creation capabilities in lean healthcare: insights from a case study. Public Money Manag. 2019;39(7):503-511. doi:1080/09540962.2019.1598197
  44. Kuhn B, Lehn C. Value-based reimbursement: the banner health network experience. Front Health Serv Manage. 2015;32(2):17-31.
  45. Rees C. How Hospitals Can Save 18 Percent in Direct Costs. Children's Hospital Association; 2014.
  46. Birk S. Quality, cost efficiency, the new quality-cost imperative: systemwide improvements can yield financial gains. World Hosp Health Serv. 2010;46(2):16-19.
  47. Kirkman-Liff B. The structure, processes, and outcomes of Banner Health's corporate-wide strategy to improve health care quality. Qual Manag Health Care. 2004;13(4):264-277. doi:1097/00019514-200410000-00008
  48. Li SA, Jeffs L, Barwick M, Stevens B. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Syst Rev. 2018;7(1):72. doi:1186/s13643-018-0734-5
  49. Kotter JP. Leading Change. Harvard Business Press; 2012.
  50. Rogers EM. Diffusion of Innovations. Simon & Schuster; 2010.
  51. Andrews R, Boyne GA, Law J, Walker RM. Strategy formulation, strategy content and performance. Public Manag Rev. 2009;11(1):1-22. doi:1080/14719030802489989
  52. Swanwick T, McKimm J. What is clinical leadership…and why is it important? Clin Teach. 2011;8(1):22-26. doi:1111/j.1743-498X.2010.00423.x
  53. Øvretveit J, Staines A. Sustained improvement? findings from an independent case study of the Jönköping quality program. Qual Manag Health Care. 2007;16(1):68-83. doi:1097/00019514-200701000-00009
  54. Matthews MR, Miller C, Stroebel RJ, Bunkers KS. Making the paradigm shift from siloed population health management to an enterprise-wide approach. Popul Health Manag. 2017;20(4):255-261. doi:1089/pop.2016.0064
  55. Nilsson K, Bååthe F, Erichsen Andersson A, Sandoff M. Value-based healthcare as a trigger for improvement initiatives. Leadersh Health Serv (Bradf Engl). 2017;30(4):364-377. doi:1108/lhs-09-2016-0045
  56. Mosadeghrad AM, Ferdosi M. Leadership, job satisfaction and organizational commitment in healthcare sector: proposing and testing a model. Mater Sociomed. 2013;25(2):121-126. doi:5455/msm.2013.25.121-126
  57. Cliff B. Patient-centered care: the role of healthcare leadership. J Healthc Manag. 2012;57(6):381-383.
  58. Waring JJ, Bishop S. Lean healthcare: rhetoric, ritual and resistance. Soc Sci Med. 2010;71(7):1332-1340. doi:1016/j.socscimed.2010.06.028
  59. Oborn E, Barrett M, Racko G. Knowledge translation in healthcare: incorporating theories of learning and knowledge from the management literature. J Health Organ Manag. 2013;27(4):412-431. doi:1108/jhom-01-2012-0004
  60. Andersen H, Røvik KA. Lost in translation: a case-study of the travel of lean thinking in a hospital. BMC Health Serv Res. 2015;15:401. doi:1186/s12913-015-1081-z
  61. Hildebrandt H, Hermann C, Knittel R, Richter-Reichhelm M, Siegel A, Witzenrath W. Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract. Int J Integr Care. 2010;10:e046. doi:5334/ijic.539

Articles in Press, Corrected Proof
Available Online from 08 December 2021
  • Receive Date: 24 December 2020
  • Revise Date: 02 November 2021
  • Accept Date: 07 December 2021
  • First Publish Date: 08 December 2021