Understanding The Components Of Quality Improvement Collaboratives: A Systematic Literature

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Determinants of success of quality improvement collaboratives: what does the literature show. The
qualitative analysis evaluated the study design, year, country, context, target for improvement, health
services, duration of intervention, number of particip. They can be a context for building
understanding and relationships between regional coordinating organisations and general practices.
What this study adds Collaboratives can be useful in general practice for improving target topics,
developing practices and providers, developing the health system and building quality improvement
capacity. APHCRI centre of research excellence in primary health care Microsystems, 2014.
Therefore, we identified two domains for analysis of mechanisms of change: we postulated that QIC
outcomes may be generated by mechanisms activated within each organisation (intra-organisational
mechanisms) and through their collaboration (inter-organisational mechanisms). These were related
to savings in the health care system and did not consider broader costs and benefits such as lost
productivity, non-medical patient costs and carer time. It is not clear from the current research which
factors promote success. Previous reviews of QICs have noted that the literature reporting them
appears to be subject to positive biases of successful participants. 2 It is possible that the research
projects included in this review are overly positive about QICs due to selection bias in the samples
interviewed and confirmation bias in the individuals themselves. Full texts of studies identified by
abstract and title screen as having met the inclusion criteria were obtained and reviewed
independently (LdlP and GR). All major reviews noted that the literature was limited in quality.
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
Outcomes included building skills and knowledge, and changes to motivation. How and under what
circumstances do quality improvement collaboratives lead to better outcomes. Care should be taken
with implementation to maximise effectiveness in achieving all four outcomes. These roles suggest
that QICs are well matched to the improvement needs of general practice. Collaborate. Collaborating
1. to work, one with another; cooperate, as on a literary work: They collaborated on a novel.
Bethesda: USAID Health Care Improvement Project; 2008. Additional file 2. Table 1 Overview of
studies data extraction: a modified version of JBI data extraction form describing nine aspects of
each of the eight studies included in the review. Five were considered good quality and favoured the
establishment of QICs as cost-effective implementation methods. The influence of context on the
effectiveness of hospital quality improvement strategies: a review of systematic reviews. The
enablers and barriers for the uptake, use and spread of primary health care Collaboratives in
Australia. Costs of quality improvement: a survey of four acute care hospitals. Understanding the
components of quality improvement Collaboratives: a systematic literature review. High-quality
health systems in the Sustainable Development Goals era: time for a revolution. They can also
develop knowledge and motivation in providers, build systems and team work in local practice
organisations, and improve support at a system level. The enablers and barriers for the uptake, use
and spread of primary health care Collaboratives in Australia. Evidence for the impact of quality
improvement collaboratives: systematic review. BMJ. 2008;336(7659):1491. Article. Additional file
5. Table 3 JBI Dominance Ranking Matrix: a three by three dominance ranking matrix (DRM) tool to
classify the cost-effectiveness results of the included studies as dominant and favoured, unclear or
rejected. Adequacy and appropriateness of external support, functionality of quality improvement
teams, leadership characteristics and alignment with national systems and priorities may influence
outcomes of quality improvement collaboratives, but the strength and quality of the evidence is weak.
Results Study selection The search identified 8505 citations and after removing duplicates, 3481
titles and abstracts were reviewed. IHI’s Collaborative Model for Achieving Breakthrough
Improvement A Breakthrough Series Collaborative is a short-term (6- to 15-month) learning system
that brings together a large number of teams from hospitals or clinics to seek improvement in a
focused topic area. Reference lists of included papers were reviewed to identify additional papers.
We generated a preliminary coding framework for context and mechanism data in MS Excel.
Introduction to Quality Improvement and Health Information Technology. Lecture b. Additional file
3. Table 2a CHEERS Checklist of included economic evaluation studies: A completed checklist of
24 items used to assess the methodological quality of all included studies in the review. Articles were
assessed for quality using a threshold approach based on the criteria described by Dixon-Woods. Two
authors independently reviewed citations and full text papers. Available from:. Hong QN PP,
Fabregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, Gagnon, M-P GF, Nicolau B,
O’Cathain A, Rousseau M-C, Vedel I. A major reported role for QICs was the establishment of
systems to collect, feed back and respond to improvement data in general practice. We saved that
family unnecessary visits and tests—that was a result of having a coordinator to help right the ship a
little bit. (physician champion, practice 4) (McAllister et al 30 ) Some reported that teams had
become more patient-centred through changes such as joint goal setting with patients and providing
patients with more choices. With increasing pressure on the healthcare system to deliver evidence-
based practice with scarce resources, there is a need to evaluate the cost-effectiveness of healthcare
improvement and knowledge translation strategies. An intervention was rejected if, relative to its
comparator, it either (i) was more expensive and less effective, (ii) was more expensive and just as
effective or (iii) cost the same but was less effective. Peer interaction was seen as effective in
reducing isolation, increasing motivation and increasing learning. Our search of the grey literature
was an important step given the variety of ways in which healthcare improvements are reported.
Regional-level data were reported as leveraging the competitive nature of clinicians through critical
comparison. Charles M Kilo 1999 What is a quality improvement collaborative. Then, from the
qualitative evidence, we extracted supportive or dissonant data on the same factors. The search
strategy was developed for MEDLINE using medical subject search headings (MeSH) and text
words and then adapted for use with the other databases. Objectives:. Upon completion of this
module the student will be able to: Describe the role of the nurse in quality improvement.
Mechanisms, contexts and points of contention: operationalizing realist-informed research for
complex health interventions. Using small tests of change to improve PMTCT services in northern
Nigeria: experiences from implementation of a continuous quality improvement and breakthrough
series program. They therefore need to be assessed against specific priorities for health improvements
and expenditure. Development of a key concept in realist evaluation. Eleven of 12 practices
developed formalized QI team processes including active parent partner participation. (McAllister et
al 30 ) Oregon collaborative organisers had parents give presentations at collaborative meetings,
which they told us received practices’ highest ratings in meeting evaluations. (Burton et al 37 )
Theme 2. Four studies provided a cost per patient of establishment of the QIC. Which elements of
improvement collaboratives are most effective. This is an open access article distributed in
accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this work non-commercially, and license
their derivative works on different terms, provided the original work is properly cited, appropriate
credit is given, any changes made indicated, and the use is non-commercial. See. Download Free
PDF View PDF Implementation Science How and under what circumstances do quality
improvement collaboratives lead to better outcomes. Collaborate. Collaborating 1. to work, one with
another; cooperate, as on a literary work: They collaborated on a novel.
Two authors (LdlP and GR) independently screened titles and abstracts based on the inclusion
criteria detailed in the review protocol. Patients in QI Some teams included patients in QI efforts
through sharing of outcome data and targets. Implementing a stepped-care approach in primary care:
results of a qualitative study. Providers highly valued provision of time for improvement activities
and the opportunity to meet with peers. This study compared clinic level coaching, group telephone
calls to clinicians, face to face learning sessions and a combination of these elements to see which
methods were more effective. Evaluation of quality improvement programmes. (Quality
Improvement Research). APHCRI centre of research excellence in primary health care Microsystems,
2014. Studies reported the inclusion of patients in QI activities, increased QI skills in practice team
members, the creation of a QI culture in participating practices and the creation of QI capacity at a
regional level. Determinants of success of quality improvement collaboratives: what does the
literature show. Effects included improved relationships between team members, empowerment of
non-physicians to work to their scope of practice and redistribution of tasks. Participants explained
how increasing patient involvement and supporting self-management seemed to improve patient
knowledge, adherence to treatment, and skills in self-management. (Harris et al 27 ) Reported patient
experience outcomes were often related to improved access to care. We explored how QIC outcomes
may be generated and found that health professionals’ participation in QIC activities may improve
their knowledge, problem-solving skills and attitude; team work; shared leadership and the
development of habits for improvement. The methodology used in the review has ensured the
inclusion of most qualitative literature dealing with the topic. References ? The Breakthrough
Series:IHI’s Collaborative Model for Achieving Breakthrough Improvement. Context matters:
practitioner perspectives on immunization delivery quality improvement efforts. They did not address
item 13, related to estimating costs via a model-based evaluation, items 15 and 16, the choice of
model or assumptions or item 20, how uncertainty was addressed. Differences between reviewer’s
results were resolved by discussion and when necessary in consultation with a third review author
(MC). A detailed break-down of costs of QICs may assist in identifying elements of greatest cost
and alternatives that may be effective for cost savings to the quality improvement process. A model
for improvement which involves setting clear, measurable targets, collecting data and testing changes
quickly on a small scale to advance reinvention and learning by doing. A new typology for
understanding context: qualitative exploration of the model for understanding success in quality
(MUSIQ). These changes align strongly with international recommendations for primary care reform.
Assessment of generalizability The currency and year of studies was converted to US dollars for
2018 using the Eurostat-OECD purchasing power parities data base for Euros and the World Bank
deflator data base for US dollar updates. They are adaptable within complex healthcare systems and
offer a way to scale up implementation across many different organisations. Download citation
Received: 25 July 2019 Accepted: 12 February 2020 Published: 02 March 2020 DOI: Share this
article Anyone you share the following link with will be able to read this content: Get shareable link
Sorry, a shareable link is not currently available for this article. We generated a preliminary coding
framework for context and mechanism data in MS Excel. Weaknesses While this review is
methodologically sound, constrained resources challenged the handling of a large amount of data. Of
particular note was the frequent comment that participation in QICs initiated practice meetings. The
research team elected to focus on qualitative studies and qualitative components of mixed-methods
studies. Promoting best practice in general practitioner management of osteoarthritis of the hip and
knee: arthritis and musculoskeletal quality improvement (AMQuIP) program. Mechanisms, contexts
and points of contention: operationalizing realist-informed research for complex health interventions.
Most studies were rated as medium quality (53%) with low ratings attributed to all internal and
external programme reviews (Additional file 3 ). Assessment of generalizability The currency and
year of studies was converted to US dollars for 2018 using the Eurostat-OECD purchasing power
parities data base for Euros and the World Bank deflator data base for US dollar updates. We
identified 15 studies containing data on context of which 8 quantitatively tested the association
between a single contextual factor and outcomes. Realising the potential of primary health care
2020, 2020. Reference lists of included studies were scanned for potentially eligible studies. Care
should be taken with implementation to maximise effectiveness in achieving all four outcomes.
Weaknesses While this review is methodologically sound, constrained resources challenged the
handling of a large amount of data. We included quantitative studies that used full economic
evaluation (i.e. cost-effectiveness, cost-utility analysis, cost-benefit analysis, cost-consequences
analysis); partial economic evaluations (i.e. cost analyses, cost descriptions, cost outcome
descriptions, cost minimisation studies); and randomised trials reporting estimates of resource use or
costs associated with implementation or improvement. These studies were conducted in different
countries or across states, with different infrastructure costs and resources. However, variations in
effectiveness, costs and elements of the method within studies, indicated that caution is needed. The
same group 3 found that aspects of teamwork and participation in specific collaborative activities
were associated with improvement success. IHI White Paper 2003 A quality improvement
collaborative is A quality improvement methodology that “brings together groups of practitioners
from different healthcare organisations to work in a structured way to improve one aspect of the
quality of their service. A strength of this review is the rigorous and systematic method used to
identify studies and synthesise data. Under mechanisms, we identified themes under the two
framework domains using thematic analysis. However, qualitative evidence from programme reviews
and mixed-methods process evaluations of QIC programmes suggests that negative perceptions of
the adequacy of available resources, low staff morale and limited availability of relevant clinical
skills may contribute to negative perceptions of organisational readiness, particularly in LMIC
settings. They have been widely used in a broad range of healthcare settings. This review analysed
qualitative literature and as such collated the views of subjects included in the original studies as
well as the findings of the authors of those studies. Evaluating health care collaboratives: the
experience of the quality assurance project. A protocol is available at the PROSPERO international
register of systematic reviews ( ). Although most of the studies captured only medical costs, most
considered that societal effects of health improvements may increase the cost-effectiveness due to
improved quality of life (QoL). Results We screened 962 abstracts of which 88 met the inclusion
criteria, and we retained 32 for analysis. Important views may have been missed in those studies.
Strengths This study presents qualitative evidence of the role of QICs drawn from participants and
implementers of QICs in general practice. Implementing a stepped-care approach in primary care:
results of a qualitative study. Realist synthesis: illustrating the method for implementation research.
Review of Australian health economic evaluation - 245 interventions: what can we say about cost
effectiveness. Understanding the components of quality improvement Collaboratives: a systematic
literature review. The coding of qualitative data is necessarily a subjective process. The enablers and
barriers for the uptake, use and spread of primary health care Collaboratives in Australia. This
demonstrated that differences that can be achieved in both effectiveness and cost by the choice of
how education or support was provided to clinicians.
Structure evaluation- physical facilities, resources, equipment. We explored how QIC outcomes may
be generated and found that health professionals’ participation in QIC activities may improve their
knowledge, problem-solving skills and attitude; team work; shared leadership and the development
of habits for improvement. Funding The authors have not declared a specific grant for this research
from any funding agency in the public, commercial or not-for-profit sectors. Another author (GR)
checked the extraction for accuracy. Perspectives on implementing quality improvement
collaboratives effectively: qualitative findings from the CHIPRA quality demonstration grant
program. Methods We built an initial conceptual framework to drive our enquiry, focusing on three
context domains: health facility setting; project-specific factors; wider organisational and external
factors; and two further domains pertaining to mechanisms: intra-organisational and inter-
organisational changes. After removal of duplicates (370), 962 abstracts were screened of which 88
met the inclusion criteria. The WHO and the Organisation for Economic Cooperation and
Development have identified a pressing need for a primary care-led transformation of health
systems. 11 12 They call for a reorientation of primary care to become more person centred,
multidisciplinary and population based. Provider impact appeared to be greatest on the small
improvement teams delegated to attend the activities of the QIC. The improvement guide: a practical
approach to enhancing organizational performance: Wiley; 2009. Collaboratives appear to provide
outcomes strategic for improving general practice, which is important for efficient, effective health
systems. How this study affects practice Future implementations should be cognisant of their
potential impact beyond target topics and consider how to optimise impact in all four areas. It was
noted that participation in a QIC could also have adverse effects causing fatigue and, in some cases,
undermining confidence in QI strategies. Most that are included in this review show cost savings or
improvement in healthcare process and patient outcomes across acute, long term care and chronic
conditions. Results We screened 962 abstracts of which 88 met the inclusion criteria, and we
retained 32 for analysis. The influence of context on the effectiveness of hospital quality
improvement strategies: a review of systematic reviews. Peterson A, Gudbjornsdottir S, Lofgren U-
B, et al. Some studies also reported enhanced enjoyment of work and success in making change.
Care should be taken with implementation to maximise effectiveness in achieving all four outcomes.
Further research is needed to determine whether certain contextual factors related to capacity should
be a precondition to the quality improvement collaborative approach and to test the emerging
programme theory using rigorous research designs. The enablers and barriers for the uptake, use and
spread of primary health care Collaboratives in Australia. Findings: Of 1367 abstracts identified, 23
papers (reporting on 26 collaboratives) provided information on potential determinants and their
relationship with effectiveness. Identification of interventions which can impact general practices is
crucial as health systems seek to become more efficient, effective and equitable through improved
primary care. KZ and JS discussed the initial programme theory with two quality improvement
experts acknowledged at the end of this paper. This is presented in Table 2a (Additional file 3 ). Peer
interaction was seen as effective in reducing isolation, increasing motivation and increasing learning.
This demonstrated that differences that can be achieved in both effectiveness and cost by the choice
of how education or support was provided to clinicians. Structure evaluation- physical facilities,
resources, equipment. While the application of QIC has grown in LMICs, evidence remains
dominated by experiences from high-income settings: only 9 out of 32 studies were from a LMIC
setting of which 4 were in the grey literature (Table 2 ). We see three key opportunities to fill this
theoretical gap. After screening and quality assessment, 33 articles, representing 26 projects, were
included ( online supplemental appendix 2 ).
We saved that family unnecessary visits and tests—that was a result of having a coordinator to help
right the ship a little bit. (physician champion, practice 4) (McAllister et al 30 ) Some reported that
teams had become more patient-centred through changes such as joint goal setting with patients and
providing patients with more choices. Consistent identification of costs and description of the
elements applied in QICs would better inform decisions for their use and may reduce perceived
barriers. The purpose is to inform implementers and participants about the utility of using or
participating in QICs in general practice. They identified cost savings and improvement in health
outcomes for patients in both acute care and chronic condition management. Improving health
worker performance: an ongoing challenge for meeting the sustainable development goals. QICs
were funded in most studies by national agencies with specialist healthcare improvement staff
involved in developing the collaborative, engaging participants and providing education, guidance
and support for the duration. The most common and highly valued impact on motivation reported
was from interaction with peers. Two authors independently reviewed citations and full text papers.
The collaborative on Autonomy and control scored significantly lower on measurability than the
other collaboratives. Double review of papers in our research team minimised subjectivity of
interpretation and allowed a deep reflection on the role of the factors that appeared under both
dimensions. These studies are considered here in relation to cost effectiveness and cost savings
achieved for the use of QICs across a range of health conditions and countries. This study did not
collect patient outcomes but focussed on three primary process outcomes: waiting time, retention of
patients and annual numbers of new patients. This qualitative systematic review is the first to focus
on their role in the unique and strategic context of general practice. The contribution of primary care
systems to health outcomes within organization for economic cooperation and development (OECD)
countries, 1970-1998. Four studies provided a cost per patient of establishment of the QIC. A major
reported role for QICs was the establishment of systems to collect, feed back and respond to
improvement data in general practice. Resources such as guideline flow sheets either developed by
QIC participant or by regional organisations were disseminated. Full texts of studies identified by
abstract and title screen as having met the inclusion criteria were obtained and reviewed
independently (LdlP and GR). Download citation Received: 25 July 2019 Accepted: 12 February
2020 Published: 02 March 2020 DOI: Share this article Anyone you share the following link with
will be able to read this content: Get shareable link Sorry, a shareable link is not currently available
for this article. All included studies reported having received ethical clearance. IHI’s Collaborative
Model for Achieving Breakthrough Improvement A Breakthrough Series Collaborative is a short-
term (6- to 15-month) learning system that brings together a large number of teams from hospitals or
clinics to seek improvement in a focused topic area. Informing implementation of quality
improvement in Australian primary care. Mechanisms, contexts and points of contention:
operationalizing realist-informed research for complex health interventions. Procedures for blood
pressure measurement at home. (Peterson et al 47 ) QI knowledge and skills Respondents described
satisfaction from gaining QI knowledge and skills which enabled them to change the way they
provide care. Care should be taken to optimise implementation of the collaborative to take these
factors into account. We also thank Will Warburton at the Health Foundation, London, UK, for his
input in refining research questions in the light of QIC experience in the UK and the Safe Care
Saving Lives implementation team from ACCESS Health International for their reflections on the
implementation of a quality improvement collaborative, which helped refine the theory of change.
After removal of duplicates (370), 962 abstracts were screened of which 88 met the inclusion
criteria. Previous systematic reviews reported positive effects on target outcomes, but the role of
context and mechanism of change is underexplored. Results 15 qualitative and 18 mixed-methods
studies of QICs in general practice were included. They did not address item 13, related to estimating
costs via a model-based evaluation, items 15 and 16, the choice of model or assumptions or item 20,
how uncertainty was addressed.