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Systematic review

Quality Collaboratives as a Tool in Quality Improvement – A Summary of Research and Experiences

  • Year: 2011
  • By: Norwegian Knowledge Centre for the Health Services
  • Authors Bakke T, Udness E, Harboe I.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-438-5

Participation in quality collaboratives is one of the tools that are used to improve quality in the health care services. The purpose of such collaboratives is to increase competence in different areas, and to improve the quality of the services.


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Key message

Participation in quality collaboratives is one of the tools that are used to improve quality in the health care services. The purpose of such collaboratives is to increase competence in different areas, and to improve the quality of the services. The core is joint education and training across professions, departments and organizations. This is in line with the goals of the National health and care services plan (2011 – 2015) 

Main findings

  • The evidence underlying quality collaboratives is positive but limited. Weaknesses in study design means that one can not determine if the reported improvements are a result of participation in collaboratives, or due to other factors.
  • Experience from quality collaboratives in Norway and other countries indicates that participation has increased the quality of the services. In some collaboratives before and after measurements indicate major improvements. However, it is difficult to document that the improvements are mainly due to participation in collaboratives, or because of other factors.
  • Experience from collaboratives show that many participants experience professional and organizational development, and that participation provides a breeding ground for increased collaboration with other organizations.

Research points to some success criteria necessary to achieve the goals of collaboratives. These include: Engagement by management and staff, an organizational culture who promotes quality improvement, and access to accurate and complete data about the quality of the services. Experiences from collaboratives supports the conclusion that these factors are of great importance.

Summary

Background

Quality collaboratives are being used to share knowledge and to improve quality in the health care services in Norway and internationally. 

Objective

The objective of this project has been to find answers to the following questions:
1. Can collaboratives contribute to quality improvement in the health care services through mutual learning across different health professions/departments / organizations?
2. What success criteria and critical factors are identified using collaboratives as a tool in quality improvement?

Method

The Search strategy consisted of three elements:
1. Systematic literature search in relevant databases.
2. Search in relevant Norwegian and international websites.
3. Acquiring experience about collaboratives through structured dialogue and through experts.

The literature search for systematic reviews was conducted in September 2011. The search in relevant Norwegian and international websites was conducted in the summer of 2011 and ended 31 August. References were screened by two persons individually. Systematic reviews about the effect of collaboratives in the health care services were included. Quality assessment was made by two people individually, in accordance to the methods of The Norwegian Knowledge Centre for the Health Services (NOKC) ( www.epoc.cochrane.org ).

Results

We identified a total of 113 references. 88 of these were the result of systematic search. In addition, we found 24 Norwegian reports and one scientific article. Of the 88 references in the systematic search, two references were considered potentially relevant and ordered in full text: Schouten et al 2008: Evidence for the impact of quality improvement collaborative: systematic review, and Fung-Kee-Fung et al 2009: Regional Collaborations as a Tool for Quality Improvements in Surgery. Both of the selected references turned out to be relevant and were included in the project.

Through a supplementary search in Medline we found a systematic review: Boonyasai et al 2007: Effectiveness of Teaching Quality Improvement to Clinicians. This review looks at the effectiveness of training health professionals in quality improvement, and was included because such training is central in many collaboratives. 

A supplementary search on the webpage of the journal Implementation Science led to the discovery of a systematic review from 2011: White et al: What is the value and impact of quality and safety team? A scoping review. This review was also included on the basis of the purpose of the project - to collect as much knowledge about collaboratives as possible. The systematic reviews were of moderate quality.

The systematic reviews report positive but limited effect of organizing quality improvement as collaboratives. This means that participation in such collaboratives might contribute to better quality in the health care services. However, because of weaknesses in the studies included in the systematic review, we cannot determine if the reported improvements are a result of participation in the collaboratives, or due to other factors. At the present time the effect of participation in such collaboratives cannot be predicted with great accuracy.

A review of reports on collaboratives in Norway and other countries shows that the quality in the health care services has increased. In some reports before and after measurements indicate some major improvements. However, it is difficult to find documentation that shows that the improvements are due to participation in collaboratives, or because of other factors. Many participants express positive experiences. These experiences are, among other things, a sense of professional and organizational development, greater understanding of each other's profession within the team and within one’s own organization. In addition, participation creates a breeding ground for increased collaboration with other organizations. 

Discussion

Norway’s Coordination Reform put strong emphasis on increased collaboration in the health care services for the benefit of the patients. The reform is challenging the individual focus on human resource development, education and training. These tasks must now be adapted to the goals in the reform. This message is also underlined by The World Health Organization (WHO): The main focus of expertise must be on collaboration - how the various professions and organizations can and must work together with users /patients and their families to ensure high quality in services. In this way of thinking, collaboration becomes a value in its self. Collaboratives combine development of skills across profession, departments and organizations, with training in systematic quality improvement. Collaboratives thus to a large extent meet the new requirements for professional development, with a shift from individual focus to joint and cross-sectoral development of knowledge.

Some challenges have emerged; improvements are not documented; teams drop out during the process; participation can be expensive. There can be a lack of planning and a lack of anchoring before and during the intervention. There is no evidence that the improvements are sustained over time. It is possible to do something about these issues, for example through a focus on the success criteria that have been identified.

Conclusion

Evidence from systematic reviews shows that collaboratives can have a positive, but limited effect on quality improvement. It is therefore possible that participation contributes to better quality in the health care services. Experience from collaboratives in Norway and other countries indicates that participation has increased the quality. In some collaboratives before and after measurements indicate major improvements. However, it is difficult to document that the improvements are due to participation in collaboratives, or other factors. Studies of collaboratives show that many participants experience professional and organizational development, and that participation provides a breeding ground for increased collaboration with other organizations. However, it is difficult to document that the improvements are due to participation in collaboratives, or other factors. Planning and implementation of collaboratives should build on the research and experience that exists in relation to success criteria. Where adopted, collaboratives should be followed by research and rigorously evaluation.

Need for further research

Participation in collaboratives can require large investments of both time and resources. This suggests that more research is needed: What mechanisms are responsible for what effect? Are there specific elements that must be in place to increase the opportunities to achieve improvements through collaboratives? Does participation in collaboratives work for some organizations and not for others? New studies to determine the effect of collaboratives must be designed in a manner that allows them avoid the methodological weaknesses found in many of the existing studies.