How collaborative are quality improvement collaboratives: a qualitative study in stroke care

Abstract

BackgroundQuality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration. This literature has been relatively neglected in evaluations of QICs, even though they are founded on principles of co-operation and sharing.MethodsWe interviewed 32 professionals in hospitals that participated in Stroke 90:10, conducted a focus group with the QIC faculty team, and reviewed purposively sampled documents including reports and newsletters. Analysis was based on a modified form of Framework Analysis, combining sensitizing constructs derived from the literature and new, empirically derived thematic categories.ResultsImprovements in stroke care were attributed to QIC participation by many professionals. They described how the QIC fostered a sense of community and increased attention to stroke care within their organizations. However, participants’ experiences of the QIC varied. Starting positions were different; some organizations were achieving higher levels of performance than others before the QIC began, and some had more pre-existing experience of quality improvement methods. Some participants had more to learn, others more to teach. Some evidence of free-riding was found. Benchmarking improvement was variously experienced as friendly rivalry or as time-consuming and stressful. Participants’ competitive desire to demonstrate success sometimes conflicted with collaborative aims; some experienced competing organizational pressures or saw the QIC as duplication of effort. Experiences of inter-organizational collaboration were influenced by variations in intra-organizational support.ConclusionsCollaboration is not the only mode of behavior likely to occur within a QIC. Our study revealed a mixed picture of collaboration, free-riding and competition. QICs should learn from work on the challenges of collective action; set realistic goals; account for context; ensure sufficient time and resources are made available; and carefully manage the collaborative to mitigate the risks of collaborative inertia and unhelpful competitive or anti-cooperative behaviors. Individual organizations should assess the costs and benefits of collaboration as a means of attaining quality improvement.

A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators

“…A single-site study using a Six Sigma approach to improve door-to-needle times, however, has shown sustained improvements over time, suggesting that sustainability may also be more achievable in a single hospital setting rather than across a hospital system 24. As in other studies, our data confirm the smaller but significant and sustained effect of data feedback alone to improve performance, especially in sites that are organised and motivated to change and when external system mandates for improvement exist, although in a qualitative analysis of response to data sharing in collaboratives, not all participants find benchmarking of data to be a positive experience 25. Although more work to tease out the differential effects of various implementation strategies on specific types of indicators is needed, our finding that time and baseline performance were most consistently associated with early and sustained improvement suggest that these factors should be clearly documented and included when evaluating the effect of any new quality improvement programme.…”

Can Learning Collaboratives Support Implementation by Rewiring Professional Networks?

“…First, LCs facilitate interactions directly between participants and faculty content experts during the in-person learning sessions, conference calls, and team consultations (Carter et al, 2014). Faculty content experts are a direct source of technical information about new practices and implementation strategies and thus, are critical for promoting successful implementation.…”

“…In other studies, opportunities for participants to interact and learn from expert faculty and other participants were perceived as the most helpful LC features (Carter, Ozieranski, McNicol, Power, & Dixon-Woods, 2014; Ebert, Amaya-Jackson, Markiewicz, Kisiel, & Fairbank, 2011; Nembhard, 2009), and the inter-organizational contacts, specifically, were significantly associated with improved team performance (Nembhard, 2011). However, the overall evidence of LCs’ effectiveness in improving care quality and implementing treatment innovations is mixed (Schouten, Hulscher, van Everdingen, Huijsman, & Grol, 2008), and little is known about whether LCs “rewire” social networks in a way that supports implementation.…”

To RCT or not to RCT? The ongoing saga of randomised trials in quality improvement

“…In addition to the ecosystem, the behaviours and motivations of teams entering improvement collaboratives appear to be as important as the environmental context. For example, in Stroke 90:10 negative and positive behaviours from teams were present in equal measure with observations of social loafing and freeriding 4 5. These behaviours go some way to explaining the likelihood of a team to ‘benefit’ from the improvement intervention as designed and currently are best investigated through qualitative research methods such as ethnography and semistructured interview.…”