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MEDICINE IN SMALL DOSES

The objective of a Quality Improvement Collaboratives (QIC) is to improve patient care by bringing together experts in clinical and performance improvement from various health-care organizations across a region or country by focussing on a structured approach to a particular clinical problem or discipline. The strategy being that teams of clinicians working together are more likely to be effective than those working in isolation. Examples of some of the more successful QIC include the North England Cardiovascular Disease Study Group and the US Veteran Affairs National Quality Improvement Program. The two most commonly used models are the Vermont Oxford Network (VON), established in 1988 which tend to focus on one domain, in the case of VON, improving the quality and safety of medical care for new born infants and their families (www.vtoxford. org, www.nicq.org), and the Breakthrough Series, established in 1995 (www.success-works.com.au/BPEP/bsc.html), developed initially by the Institute of Health Care Improvement, which uses a method covering a wide range of topics and disciplines, from primary health care to adverse events in hospitals (Lindenauer. BMJ 2008; 336: 1448–9). Schouten et al. (BMJ 2008; 336: 1491–4) conducted a systematic review to evaluate the effectiveness of QIC and found nine studies that showed moderate positive results. Seven showing an effect on some of the selected outcome measures, but two showing no significant effect. The difficulty in performing such a systematic review is that the application of standard and traditional biomedical research methods may not be appropriate to evaluate QIC. The more realistic approach may be to use qualitative research methods and to evaluate the strategies of members of the team, for example the role of executive sponsors and the roles of the doctors and nurses gaining support of their colleagues and how information and technology were used, as pointed out by Lindenauer. An alternative way of evaluating these collaboratives may be to look at specific study groups that have been successful and used these as a guide for the planning of other collaboratives. A simple example of how a QICmay improve the process but not necessarily the outcome would be the analysis of postoperative wound infections of inpatients undergoing major surgery, in which compliance for giving the correct prophylactic antibiotics at the time of incision may improve without necessarily reducing the incidence of wound infection. This discordance between improving processes without improving outcomes is a dilemma that future QIC will need to address before this process will gain universal acceptance.