Introduction
Unwarranted clinical variation (UCV) can be described as variation that can only be explained by differences in health system performance. There is a lack of clarity regarding how to define and identify UCV and, once identified, to determine whether it is sufficiently problematic to warrant action. As such, the implementation of systemic approaches to reducing UCV is challenging. A review of approaches to understand, identify, and address UCV was undertaken to determine how conceptual and theoretical frameworks currently attempt to define UCV, the approaches used to identify UCV, and the evidence of their effectiveness.

Design
Rapid evidence assessment (REA) methodology was used.

Data sources
A range of text words, synonyms, and subject headings were developed for the major concepts of unwarranted clinical variation, standards (and deviation from these standards), and health care environment. Two electronic databases (Medline and Pubmed) were searched from January 2006 to April 2017, in addition to hand searching of relevant journals, reference lists, and grey literature.

Data synthesis
Results were merged using reference‐management software (Endnote) and duplicates removed. Inclusion criteria were independently applied to potentially relevant articles by 3 reviewers. Findings were presented in a narrative synthesis to highlight key concepts addressed in the published literature.

Results
A total of 48 relevant publications were included in the review; 21 articles were identified as eligible from the database search, 4 from hand searching published work and 23 from the grey literature. The search process highlighted the voluminous literature reporting clinical variation internationally; yet, there is a dearth of evidence regarding systematic approaches to identifying or addressing UCV.

Conclusion
Wennberg's classification framework is commonly cited in relation to classifying variation, but no single approach is agreed upon to systematically expl...

The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.

The field of health informatics has generally been seen
as developing separately from the spatial sciences.
Geography, cartography, surveying and a variety of
applied disciplines make enormous use of spatial
technologies, concepts and methods in their work.
These technologies are increasingly pervasive and
central to our emerging ‘big data’ environment in
which locational data quality and accuracy are central.
Health informatics is also a field now going beyond
the traditional hospital environment, especially as
factors such as population ageing and rising chronic
disease require outreach programs of various kinds and
growing sophistication. In this scenario, we suggest
that health information technology (HIT) and the spatial
sciences are converging at a rapid rate such that health
informatics will become increasingly spatial in character
and function.
In this short piece, we explore some of the factors
leading to this convergence and suggest that it is
not quite as novel as it might at first seem. Medical
geography and medical informatics, for example,
have a deeper history than is commonly known by
many health professionals. Cartographic methods
have long been utilised in some areas of public health,
international health and epidemiology. Climate change
and the demographic transition are also leading to
much more engagement between these two fields
of practice and healthcare. Climate change because
the flow-on effects of rising temperatures, and water
levels, are hugely significant for human health, and the
demographic transition because health status is closely
correlated with both affluence and ageing. Obviously,
in our increasingly complex world, information
management is central to our capacity to cope with and
address new problems arising from these complexities.
Health information management as a skill and
knowledge base can only grow in importance as the
systemic problems we face (and contribute to) become
more tightly interwoven.

Knowledge translation and exchange (KTE) can enable evidence-informed road safety policy and practice by reducing the gap between what is known to be effective and what actually occurs. A quality improvement project, undertaken within a government policy frame, was implemented in 2015 to produce an enhanced KTE framework for road safety (the framework). Information was collected from 35 road safety stakeholders in the UK, the Netherlands, Norway and Sweden. Thirteen KTE facilitators were identified that covered research funding and production, the expertise of knowledge users and dissemination practices. The framework was subsequently developed, which separated facilitators seen as essential for a KTE system, from others perceived as aspirational due to their lesser influence and the considerable time and resources required for their implementation. The framework provides a heuristic device to enable policy agencies to holistically assess and improve current KTE systems for road safety, to encourage evidence-informed policy and practice.

The study aim was to investigate the understandings and concerns of stakeholders regarding the evolution of health service accreditation programs in Australia. Stakeholder representatives from programs in the primary, acute and aged care sectors participated in semi-structured interviews. Across 2011-12 there were 47 group and individual interviews involving 258 participants. Interviews lasted, on average, 1 h, and were digitally recorded and transcribed. Transcriptions were analysed using textual referencing software. Four significant issues were considered to have directed the evolution of accreditation programs: altering underlying program philosophies; shifting of program content focus and details; different surveying expectations and experiences and the influence of external contextual factors upon accreditation programs. Three accreditation program models were noted by participants: regulatory compliance; continuous quality improvement and a hybrid model, incorporating elements of these two. Respondents noted the compatibility or incommensurability of the first two models. Participation in a program was reportedly experienced as ranging on a survey continuum from "malicious compliance" to "performance audits" to "quality improvement journeys". Wider contextual factors, in particular, political and community expectations, and associated media reporting, were considered significant influences on the operation and evolution of programs. A hybrid accreditation model was noted to have evolved. The hybrid model promotes minimum standards and continuous quality improvement, through examining the structure and processes of organisations and the outcomes of care. The hybrid model appears to be directing organisational and professional attention to enhance their safety cultures. Copyright © 2015 John Wiley & Sons, Ltd.

Accrediting health care organizations against standards is a recognized safety and quality intervention. The credibility of an accreditation programme relies on surveying reliability. We investigated accreditation survey coordinators' perceptions of reliability issues and their continued relevancy, during a period of national accreditation reform.In 2013 and 2014, questionnaire surveys were developed using survey coordinators' feedback of their experiences and concerns regarding the accreditation process. Each year, a purpose-designed questionnaire survey was administered during the accrediting agency survey coordinator training days.Participants reported that survey reliability was informed by five categories of issues: the management of the accreditation process, including standards and health care organizational issues; surveyor workforce management; survey coordinator role; survey team; and individual surveyors. A new accreditation system and programme did not alter the factors reported to shape survey reliability. However, across the reform period, there was a noted change within each category of the specific issues that were of concern. Furthermore, consensus between coordinators that existed in 2013 appears to have diminished in 2014. Across all categories, in 2014 there was greater diversity of opinion than in 2013.The known challenges to the reliability of an accreditation programme retained their potency and relevancy during a period of reform. The diversity of opinion identified across the coordinator workforce could potentially place the credibility and reliability of the new scheme at risk. The study highlights that reliability of an accreditation scheme is an ongoing achievement, not a one-off attainment.

Effective nursing leadership is necessary for the delivery of safe, high quality healthcare. Yet experience and research tells us that nursing leaders are commonly unprepared for their roles. Take The Lead (TTL), a large-scale, multifaceted professional development program was initiated in New South Wales, Australia, to strengthen the capacity of Nursing/Midwifery Unit Managers (N/MUMs). The aim of this study was to examine the effects of TTL on job performance, nursing leadership and patient experience.Nursing/Midwifery Unit Managers (n = 30) and managers of N/MUMs (n = 30) who had completed the TTL program were interviewed between August and December 2010. The semi-structured interviews included a combination of open-ended questions and questions that required respondents to rate statements using a Likert scale. Data from the open-ended questions were thematically analysed to identify and categorise key concepts. The responses to the Likert items were analysed via descriptive statistics.Nursing/Midwifery Unit Managers' participation in TTL engendered improvements in job performance and leadership skills, as well as some improvement in patients' experiences of care. The program facilitated role clarification and helped foster peer-support and learning networks, which were perceived to provide ongoing professional and personal benefits to participants.Our study revealed a consensus about the beneficial outcomes of TTL among those involved with the program. It supports the significant and ongoing value of widely implemented, multifaceted nursing leadership development programs and demonstrates that participants value their informal interactions as highly as they do the formal content. These findings have implications for delivery mode of similar professional development programs.

To examine how consumer engagement (CE) can be promoted through Australian accreditation programmes.A nation-wide qualitative study completed in 2012.All eight Australian States and Territories.Two-hundred and fifty-eight healthcare stakeholders from the acute, primary and aged care sectors.Forty-seven individual and group interviews were undertaken. Questions elicited views on the dimensions and utility of CE promotion by accreditation programmes.Healthcare stakeholders' views on the dimensions and utility of CE promotion by accreditation programmes.Four mechanisms of CE promotion were identified. Two involved requirements for health service organizations to meet CE-related standards related to consumer experience and satisfaction surveys, and consumer participation in organizational governance processes. Two mechanisms for promoting CE through accreditation processes were also identified, concerning consumer participation in the development and revision of standards, and the implementation of accreditation surveys. Accreditation programmes were viewed as important drivers of CE, yet concerns were raised regarding the organizational investments needed to meet programmes' requirements.Accreditation programmes use diverse mechanisms as levers for change to promote CE in healthcare. These mechanisms and their inter-relationships require careful consideration by accreditation agencies and health policymakers to maximize their potential benefits, while maintaining stakeholder engagement in programmes.

Health systems are changing at variable rates. Periods of significant change can create new challenges or amplify existing barriers to accreditation program credibility and reliability. The purpose of this paper is to examine, during the transition to a new Australian accreditation scheme and standards, challenges to health service accreditation survey reliability, the salience of the issues and strategies to manage threats to survey reliability.Across 2013-2014, a two-phase, multi-method study was conducted, involving five research activities (two questionnaire surveys and three group discussions). This paper reports data from the transcribed group discussions involving 100 participants, which was subject to content and thematic analysis. Participants were accreditation survey coordinators employed by the Australian Council on Healthcare Standards.Six significant issues influencing survey reliability were reported: accreditation program governance and philosophy; accrediting agency management of the accreditation process, including the program's framework; survey coordinators; survey team dynamics; individual surveyors; and healthcare organizations' approach to accreditation. A change in governance arrangements promoted reliability with an independent authority and a new set of standards, endorsed by Federal and State governments. However, potential reliability threats were introduced by having multiple accrediting agencies approved to survey against the new national standards. Challenges that existed prior to the reformed system remain.Capturing lessons and challenges from healthcare reforms is necessary if improvements are to be realized. The study provides practical and theoretical strategies to promote reliability in accreditation programs.

Agencies promoting national health-care accreditation reform to improve the quality of care and safety of patients are largely working without specific blueprints that can increase the likelihood of success.This study investigated the development and implementation of the Australian Health Service Safety and Quality Accreditation Scheme and National Safety and Quality Health Service Standards (the Scheme), their expected benefits, and challenges and facilitators to implementation.A multimethod study was conducted using document analysis, observation and interviews. Data sources were eight government reports, 25 h of observation and 34 interviews with 197 diverse stakeholders.Development of the Scheme was achieved through extensive consultation conducted over a prolonged period, that is, from 2000 onwards. Participants, prior to implementation, believed the Scheme would produce benefits at multiple levels of the health system. The Scheme offered a national framework to promote patient-centred care, allowing organizations to engage and coordinate professionals' quality improvement activities. Significant challenges are apparent, including developing and maintaining stakeholder understanding of the Scheme's requirements. Risks must also be addressed. The standardized application of, and reliable assessment against, the standards must be achieved to maintain credibility with the Scheme. Government employment of effective stakeholder engagement strategies, such as structured consultation processes, was viewed as necessary for successful, sustainable implementation.The Australian experience demonstrates that national accreditation reform can engender widespread stakeholder support, but implementation challenges must be overcome. In particular, the fundamental role of continued stakeholder engagement increases the likelihood that such reforms are taken up and spread across health systems.

Background: Service accreditation is a structured process of recognising and promoting performance and adherence to standards. Typically, accreditation agencies either receive standards from an authorized body or develop new and upgrade existing standard

BACKGROUND: Despite the acute impact of road trauma involving novice drivers, there have been few efforts to identify the main factors influencing the novice driver policy agenda. Increasing the transparency of such policy dynamics may help inform future novice driver policy agenda-setting processes, as well as those in other public health settings. METHODS: Forty interviews were conducted between 2007 and 2009 with individuals involved in novice driver policy debates and processes in four Australian states. RESULTS: An increasing body of positive evaluations from other jurisdictions was seen to provide an initial stimulus for Australian novice driver policy activities. The dissemination of evidence by researchers, lobbying and advocacy by other influential stakeholders, and media reporting of multiple-fatality novice driver crashes were seen as other factors central to policy agenda setting. CONCLUSIONS: Australian graduated driver licensing (GDL) policy initiatives may only be acted upon once adequate political support is identified in terms of community demand for action and public acceptance of GDL policy in neighboring states. As such, researcher encouragement of community support for unpopular evidence-based policies during windows of opportunity for policy reform may act as an influential agenda-setting force.

One of the most effective measures to reduce crashes amongst young drivers is the implementation
of a comprehensive Graduated Licensing Scheme (GLS). Yet while all Australian jurisdictions have
some form of GLS in place, young drivers remain over-represented in crashes on Australian roads.
This indicates that improvements to GLS models in each jurisdiction would be beneficial.
The Centre for Road Safety in Transport for New South Wales, on behalf of the Austroads Road
Safety Taskforce, commissioned road safety consultants Eric Howard and Anne Harris to develop
an evidence-informed GLS policy framework that can be applied across all Australian jurisdictions.
The project involved a review of current Australian GLS arrangements, a discussion paper outlining
key research findings and extensive consultation with road safety and licensing representatives from
all jurisdictions.
The framework identifies fundamental GLS components to guide, rather than prescribe, the
implementation of increasingly effective GLS models across Australia. The GLS components relate
to key areas of focus that contribute to young driver crashes including age, experience, risk taking
and licensing access and support. The framework outlines the features of progressively more
comprehensive GLS models that address these issues (i.e. standard, enhanced and exemplar models)
to account for the varied starting points across Australia and enable jurisdictions to make
improvements gradually.
The Australian GLS Policy Framework was approved by the Transport Ministers of every
jurisdiction. The success of this project demonstrates how policy agencies can take action together
to reduce Australian road trauma, even when jurisdictions’ current policies differ considerably.

Preface
This preface was written by the Australian Commission on Safety and Quality in Health Care
(the Commission) to provide context and background to the report which follows, Patient
Journey and Tracer Methodologies: Literature review. The Commission contracted the
University of Technology Sydney (UTS) to prepare the literature review, as part of the review
of the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
Background
The Commission’s role is to lead and coordinate national improvements in the safety and
quality of health care. The Commission works in partnership with the Australian Government,
state and territory governments and the private sector to achieve a safe and high-quality,
sustainable health system. In doing so, the Commission also works closely with patients,
carers, clinicians, managers, policymakers and healthcare organisations.
The Commission developed the National Safety and Quality Health Service (NSQHS)
Standards in consultation with the Australian Government, state and territory governments,
technical experts and stakeholders. They aim to protect the public from harm and to improve
the quality of health service provision.
To become accredited, health service organisations must pass assessments to show they
have implemented the NSQHS Standards. The assessments are conducted by independent
accrediting agencies, approved by the Commission, as part of the AHSSQA Scheme.
However, state and territory regulators and chief executives of health service organisations
have raised concerns about several aspects of the accreditation process.
The Commission is undertaking a review to update and improve the accreditation process. In
May 2017, the Commission contracted four literature reviews to provide an evidence base to
inform the Commission’s review of the AHSSQA Scheme. The reviews explored the
potential use of the following methods to improve the veracity of health service
organisations:
• Attestation by a governing bo...

Preface
This preface was written by the Australian Commission on Safety and Quality in Health Care
(the Commission) to provide context and background to the report which follows, Attestation
by Governing Bodies: Literature review. The Commission contracted the University of
Technology Sydney (UTS) to prepare the literature review, as part of the review of the
Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme.
Background
The Commission’s role is to lead and coordinate national improvements in the safety and
quality of health care. The Commission works in partnership with the Australian Government,
state and territory governments and the private sector to achieve a safe and high-quality,
sustainable health system. In doing so, the Commission also works closely with patients,
carers, clinicians, managers, policymakers and healthcare organisations.
The Commission is responsible under the National Health Reform Act 2011 for the
formulation of standards relating to healthcare safety and quality matters and for formulating
and coordinating national models of accreditation for health service organisations.
The Commission developed the National Safety and Quality Health Service (NSQHS)
Standards in consultation with the Australian Government, state and territory governments,
technical experts and stakeholders. They aim to protect the public from harm and to improve
the quality of health service provision.
To become accredited, health service organisations must pass assessments to show they
have implemented the NSQHS Standards. The assessments are conducted by independent
accrediting agencies approved by the Commission as part of the AHSSQA Scheme.
However, state and territory regulators and chief executives of health service organisations
have raised concerns about several aspects of the accreditation process.
The Commission is undertaking a review to update and improve the accreditation process. In
May 2017, the Commission contracted four literat...