the observed outcomes (Berwick, 1998). In this approach, the gathering and monitoring of outcomes data are crucial to identifying and reducing inappropriate variations in outcomes. In some cases, cross-institutional collaborations have helped institutions develop effective quality improvement programs. Some programs use transparency—the public reporting of organizational performance in relation to benchmarks—as a means of enhancing accountability and promoting competition to improve the quality of care. Accreditation agencies and voluntary groups have also encouraged this quality improvement process, and some universities have applied quality improvement models to university administration. The University of Wisconsin, for example, has an office of quality improvement that supports process improvement activities in administrative as well as academic areas, and its website showcases examples of activities that are potentially relevant for conflict of interest programs (University of Wisconsin, 2008).

There are, of course, significant differences between quality improvement procedures and conflict of interest policies. Nonetheless, the mechanisms of collaboration, consensus building, and outcome measurement can usefully guide the relationships between outside supporting organizations and institutions directly involved in medical research, education, and practice.

Some supporting organizations have been able to promote a consensus on important and often contentious aspects of conflict of interest policies. As described in earlier chapters, AAMC convened a broad group of affected parties that made recommendations about financial ties with industry in medical education (AAMC, 2008c). The parties included academic medical centers, teaching hospitals, industry, professional organizations, government agencies, and consumer groups. AAMC and the Association of American Universities convened another consensus development process to develop recommendations for improving the adoption and implementation of conflict of interest policies in human subjects research (AAMC-AAU, 2008). Over time, these and other initiatives have forged agreement on goals and recommendations regarding a number of controversial issues. Such collaborative consensus-building activities can address the practical concerns of individuals and institutions affected and make recommendations more credible and acceptable.

Incentives

Supporting organizations can devise incentives for institutions to adopt and implement conflict of interest policies. An example of an incentive for change in institutional policies and practices is the policy of the National Library of Medicine mentioned in Chapter 3. It will not cite or index articles from certain types of company-sponsored journal supplements unless they



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