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Open Access Research article

Exploring the black box of quality improvement collaboratives: modelling relations between conditions, applied changes and outcomes

Michel LA Dückers1*, Peter Spreeuwenberg1, Cordula Wagner12 and Peter P Groenewegen13

Author Affiliations

1 NIVEL - Netherlands Institute for Health Services Research, Utrecht, the Netherlands

2 EMGO Institute for Health and Care Research, Free University Medical Centre, Amsterdam, the Netherlands

3 Department of Sociology, Department of Human Geography, Utrecht University, Utrecht, the Netherlands

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Implementation Science 2009, 4:74  doi:10.1186/1748-5908-4-74

Published: 17 November 2009

Abstract

Introduction

Despite the popularity of quality improvement collaboratives (QICs) in different healthcare settings, relatively little is known about the implementation process. The objective of the current study is to learn more about relations between relevant conditions for successful implementation of QICs, applied changes, perceived successes, and actual outcomes.

Methods

Twenty-four Dutch hospitals participated in a dissemination programme based on QICs. A questionnaire was sent to 237 leaders of teams who joined 18 different QICs to measure changes in working methods and activities, overall perceived success, team organisation, and supportive conditions. Actual outcomes were extracted from a database with team performance indicator data. Multi-level analyses were conducted to test a number of hypothesised relations within the cross-classified hierarchical structure in which teams are nested within QICs and hospitals.

Results

Organisational and external change agent support is related positively to the number of changed working methods and activities that, if increased, lead to higher perceived success and indicator outcomes scores. Direct and indirect positive relations between conditions and perceived success could be confirmed. Relations between conditions and actual outcomes are weak. Multi-level analyses reveal significant differences in organisational support between hospitals. The relation between perceived successes and actual outcomes is present at QIC level but not at team level.

Discussion

Several of the expected relations between conditions, applied changes and outcomes, and perceived successes could be verified. However, because QICs vary in topic, approach, complexity, and promised advantages, further research is required: first, to understand why some QIC innovations fit better within the context of the units where they are implemented; second, to assess the influence of perceived success and actual outcomes on the further dissemination of projects over new patient groups.