Fig. 42.1
ISQIC conceptual model
The Nuts and Bolts of a Quality Improvement Collaborative
The common characteristics of QI Collaboratives have been well described [2, 10] and emphasize collaborative learning, support, and exchange of insights among different health care organizations [11]. Ayers and colleagues identified guidelines for developing a successful learning collaborative, based on qualitative interviews with key informants from ten established learning collaboratives [1]. Table 42.1 outlines their findings which could be used as structural guidelines for developing a successful learning collaborative.
Table 42.1
Key components of a successful learning collaborative
Component | Description |
|---|---|
Mission and target population | Clear and achievable mission Tangible goals |
Membership | Strategies for membership (application, invitation, etc.) |
Defined roles | • Clinical Leader or “Champion” (e.g., knowledgeable of improvement processes, ability to integrate spirit of collaborative learning with everyday practice, willingness to share) • Project Manager (e.g., coordinates communication, organizes and facilitates meetings, project expertise) • Data Analyst (e.g., transforms data into useful information) |
Technology | Develop data management and communication systems across member organizations to enable collection, aggregation, and analysis of the data |
Funding | Identify and select sources (e.g., membership dues, private organizations, research institutions) |
Governance | Establish multidisciplinary decision-making body to guide Collaborative process |
Contractual issues | Establish and articulate policies addressing confidentiality, data ownership by organization submitting data, publication/presentation process and rights, and participant responsibilities |
Meetings | Convene regular, formal face-to-face meetings |
In the simplest terms, the ultimate goal of a collaborative is learning. Beyond the structural components outlined in Table 42.1, Gauthier [24] suggests several conditions for successful collaborative learning across organizational boundaries:
Participants should have similar maturity level on the learning continuum (e.g., with some experience of quality improvement techniques and vision building);
Senior executives and line managers need to commit to a multiyear program and to involve themselves personally in the learning sessions;
Participants agree to a noncompetitive environment to create a safe setting for sharing all relevant experiences;
A core team of facilitators combining general and specialized skills should be involved in and between the meetings to help structure a cumulative learning experience and increasingly involve the participants in designing and co-leading the sessions;
There must be a willingness to experiment in content and format from session to session, and a commitment to dialogue and collaboration;
Participants should be encouraged to take time for exchanges between the learning sessions (social networking, site visits, etc.)
A focus on personal development and on challenging one’s mental models should be adopted from the beginning and sustained throughout the multiyear program.
Similarly, [25] describes four general categories of collaborative success factors: topics chosen for improvement, participant and team characteristics, skills of facilitator and expert advisors, and ensuring ways to maximize spread of ideas. Greenhalgh et al. elaborate that these success factors result from:
- 1.
Clearly focused important topics that address clear gaps between current and best practice.
- 2.
Highly motivated participants who clearly understand individual and corporate goals in a supportive organizational culture.
- 3.
Effective teams and team leadership whose goals are in alignment with those of the organization.
- 4.
Facilitation by credible expert, who provide adequate support outside as well as through the learning events.
- 5.
Maximizing the spread of ideas through networking between teams and other mechanisms ([6], p. 167).
Once the collaborative is established, there is a general process of that guides the flow of collaborative work in which participants agree to work together over a number of months to share ideas and knowledge. They set specific goals and measure progress toward meeting those goals. Through facilitated sessions, participants share techniques for creating organizational change and implementing rapid-cycle, iterative tests of change at the microsystem level [6, 26].
The functioning of a QIC can be tied to an effective team structure and strong leadership. For example, in describing the successful application of a QIC using the IHI Breakthrough series in 40 US hospitals to reduce adverse drug events Leape et al. (2000) identified strong leadership and team work among their most important success factors: “Success in making significant changes was associated with strong leadership, effective processes and appropriate choice of intervention. Successful teams were able to define, clearly state and relentlessly pursue their aims, and then chose practical interventions and moved early into changing a process” [27]. As the leader of the collaborative team, the Champion has a unique role in the QIC. Champions persistently support new ideas; and have persistence to fight both resistance and/or indifference to promote the acceptance of a new idea or to achieve project goals [6]. A different type of leader—the boundary spanner—have influence across organizational and other boundaries, acting as bridges to connect people and ideas [6, 28].
Evaluation
Intuitively, the collaborative model seems to be an effective way to learn and engage front line clinicians in designing and implementing change. What’s the catch? Mainly, creating and running a collaborative is expensive and difficult to measure using traditional epidemiological methods. Mittman and others note that QICs are arguably the most important response yet to the health “quality chasm,” and call for rigorous mixed-method evaluation to identify factors which determine their success [29].
The evaluation of QI collaboratives poses substantial challenges given the multitude of changes occurring simultaneously and the existence of concurrent external and internal stimuli to improve care [30]. Further knowledge of the basic components of effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives [10].
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