Physicians today are confronted with increasing demand to ensure and improve care of their patients. A variety of approaches claim to provide solutions to the problems of health care delivery. These approaches represent different perspectives on optimal care and the best method for improving care. By summarizing recent reviews and debates in this field, this article critically reflects on the value of some of the approaches that have gained popularity during the last decades: evidence-based medicine and clinical practice guidelines, professional development, assessment and accountability, patient empowerment, and total quality management. Evidence regarding the impact and feasibility of the various approaches is mixed or simply lacking. In particular, the health care community lacks an understanding of which approaches are most appropriate for what types of improvement in what settings and of the determinants of successful performance change. Given the complexity of improvement and change in patient care, it is not realistic to expect that one approach can solve all the problems in health care delivery. None of the popular models for improving clinical performance appear to be superior. Therefore, bridges must be built and models must be integrated to be truly effective.
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