Robbert Huijsman and Richard

Objective To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care. Data sources Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases. Study selection Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes. Data synthesis Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processesor outcomesof care. Systematic reviewof these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect. Conclusions The evidence underlying quality improvementcollaboratives ispositivebut limitedand the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives. INTRODUCTION Stimulated by the concerted, ongoing efforts of the Institute of Medicine and other platforms which state that “reform around the margins is inadequate to address system ills” in quality of care, healthcare organisations in many countries are setting up quality improvement collaboratives. Multidisciplinary teams from various healthcare departments or organisations join forces for several months to work in a structured way to improve their provision of care. Quality improvement collaboratives are being used increasingly in the United States, Canada, Australia, and European countries. In northern European countries such as the United Kingdom and the Netherlands health authorities support nationwide quality programmes based on this strategy. Different types ofmultiorganisational collaboratives exist, the purpose of which are to improve care. The term quality improvement collaborative seems to be used for different multifaceted packages that focus on accelerating better outcomes. Quality improvement collaboratives are used in different clinical areas and organisational contexts and have been adopted by numerous large and small healthcare systems and individual clinics. These initiatives represent substantial investments of time, effort, and funding in the delivery of health care, although estimates of the total investment and applications of the collaborative are not available. The strength of the quality improvement collaborative seems to be the relatively efficient use of experts and peers and the exchange of best practices to facilitate and guide improvement. The earliest well documented activities of quality improvement collaboratives are those of the Northern New England Cardiovascular Disease Study Group, established in 1986, and the Vermont Oxford Network, established in 1988. Another well known approach is the Breakthrough Series developed by the Institute of Healthcare Improvement in 1995. Many of the present approaches of the quality improvement collaborative are based on those of the Breakthrough Series. A recent non-systematic review concluded that the collaborative methodology has important potential to improve outcomes for patients and to facilitate sustainability of quality improvement. Unfortunately this introduction to the collaborative methodology neither considers whether the evaluation of effectiveness is based on a controlled or an uncontrolled study design nor makes clear on what types of quality improvement collaborative the conclusions are based. Clear evidence of the effectiveness of the methods is lacking, despite the ongoing initiatives of the quality improvement collaborative reflecting different multifaceted intervention packages, the growing number of published papers, good face validity of the model, and facilitators claiming thatmanyprofessionals appreciate taking part in a collaborative for both professional and organisational development. Little is known about the Dutch Institute for Healthcare Improvement, PO Box 20064, 3502 LB Utrecht, Netherlands Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen Institute of Health Policy and Management, Erasmus MC, University Medical Centre Rotterdam Correspondence to: LMTSchouten [email protected] doi:10.1136/bmj.39570.749884.BE BMJ | ONLINE FIRST | bmj.com page 1 of 9 on 30 June 2008 bmj.com Downloaded from