What is a QI collaborative?

A quality improvement collaborative (QIC) is defined as a structured framework that amalgamates groups of practitioners from different healthcare organizations to improve a specifically identified aspect of the quality of their service [1,2,3]. QICs facilitate multidisciplinary teams to implement evidence-based knowledge by learning from one another, collaborating, testing changes, and utilizing data driven changes. Using their collective experiences, QICs can accelerate the translation of evidence into practice, resulting in reduced unnecessary variation and improved clinical care and outcomes [4,5,6]. A QIC usually consists of policy leaders and health stakeholders working toward a common goal of improving performance on a well-defined quality measure or set of measures related to a safety issue or clinical outcome [7]. A QIC takes a multifaceted approach to quality improvement (QI) that involves five essential features- a target topic, clinical and quality improvement experts, multi-professional teams from multiple centers, a model for improvement, and a series of structured activities geared towards improvement [8]. Multidisciplinary teams include key stakeholders at the individual centers and across the centers, including patients and families [6, 9, 10].

Do QI collaboratives work?

QICs have reported significant improvements in targeted clinical processes and outcomes as described in a systematic review by Wells et al. [3]. Zamboni et al explored the relationship of QIC outcomes with context domains (health facility setting, project-specific factors, organizational and external factors) and mechanisms (intra- and inter- organizational changes). They reported that participation in a QIC improves knowledge, problem-solving skills, attitude, teamwork, shared leadership, and generates opportunities for capacity building [9]. They also identified that QIC outcomes are successful when the collaborative goals are aligned with national patient safety goals. Two other systematic reviews of QICs in healthcare have identified improvements in patient care and organizational performance [11, 12].

Success of a QIC depends on five general factors: the team’s ability to work together; their ability to learn and apply quality methods; the strategic importance of their work to their home organization; the culture of their home organization; and the type and degree of support from management [1]. Collective learning and an evidence-based approach help the collaborative models accelerate learning and process change amongst participating hospitals [2, 13].

However, QIC reports in adult literature have described limitations in design and methodologies for any conclusive evidence and the effects cannot be predicted with certainty [11, 12]. Often, it is difficult to disentangle the different components of an intervention or to assess interactions between longitudinal activities of the collaborative components. Hence, these encouraging results must be tempered by the limitations of persistent gaps in QIC design, quality of reporting, and publication bias.

Collaborative learning

The earliest QIC activities and methodology were first described by Northern New England Cardiovascular Disease Study Group, established in 1986 [14], and the Vermont Oxford Network, established in 1988 [15, 16]. This methodology for QIC became popularized as the Breakthrough Series developed by the Institute of Healthcare Improvement in 1995. Many examples in the literature of the QIC initiatives are based on the Breakthrough Series [13], a collaborative improvement model which outlines key elements including multidisciplinary teams working together to improve performance on a chosen topic supported by experts using evidence-based best practices [2]. QI Collaboratives have described improvement in a broad spectrum of topics in adults and children [17,18,19]. Furthermore, pediatric collaborative improvement networks have demonstrated improved outcomes for children and their families across multiple subspecialities [6, 20].

QI collaboratives in neonatology

There are several regional, national, and international collaborative networks established in neonatology. These include, but are not limited to, the California Perinatal Quality Care Collaborative (CPQCC), Ohio Perinatal Quality Collaborative (OPQC), Tennessee Initiative for Perinatal Quality Care (TIPQC); Children’s Hospital Neonatal Consortium (CHNC), The Pediatrix Center for Research, Education, Quality and Safety (CREQS), The National Network of Perinatal Quality Collaboratives (NNPQC), the Solutions for Patient Safety (SPS), and Vermont Oxford network (VON); Canadian Evidence-based Practice for Improving Quality (EPIQ) [21], Australia-New Zealand Neonatal Network (AZNN) [22], International Network for Evaluating Outcomes (iNeo) of neonates [23], and Chinese Neonatal Network (CHNN) [24].

In this review, we aim is to evaluate national QI collaboratives primarily based in US (described below in alphabetical order). We will discuss the QI framework used by these collaboratives and provide examples of specific outcomes that their studies addressed.

Children’s Hospital Neonatal Consortium

The Children’s Hospital Neonatal Consortium (CHNC) provides a platform in QI for participating children’s hospital neonatal intensive care units (NICUs) by means of Collaborative Initiatives for Quality Improvement (CIQI) [25, 26]. This platform provides leadership, collaborative structure, resource access, QI education, team feedback, data driven change, and several other resources to assist participating institutions in completing QI projects. CIQI Steering Committee is a multi-disciplinary group of QI leaders involving physicians, nurses, and advanced practice clinicians which provides oversight of the CHNC CIQI Program. A CIQI Program Manager is responsible for operations, data management, and coordination of QI activities. At the local level a project planning and management team together with faculty advisors help oversee the collaborative efforts.

Children’s Hospitals Solutions for Patient Safety

Launched in 2009, Children’s Hospitals Solutions for Patient Safety (SPS) [27] was founded as a partnership between providers and the business community to improve quality and reduce costs. The mission is to work to eliminate serious patient harm from children’s hospitals by partnering with families and frontline staff. The tenets that are the driving force for SPS include executive leadership, focus on outcomes through HRO concepts and QI methodologies, focus on sharing successes and failures transparently, learning from one another instead of competing, “All Teach, All Learn” principle, and finally a commitment to building a “culture of safety”. SPS aims to decrease rates of the most common serious patient and employee harms, to identify and eliminate safety disparities, and to create robust learning systems for ambulatory safety. The network has now grown to include 140+ children’s hospitals across US and Canada.

National Institute for Children’s Health Quality

National Institute for Children’s Health Quality (NICHQ) [28] is committed to achieving better health outcomes for children and their families. It is a mission driven non-profit organization that focuses on providing equitable change for the health of children and their families. The National Network of Perinatal Quality Collaboratives (NNPQC) [29] provides resources and expertise to state-based perinatal quality collaboratives to improve maternal and infant health outcomes, particularly within marginalized populations disproportionately affected by adverse perinatal outcomes.

Pediatrix- center for research, education, quality and safety

With the goal to utilize evidence-based medicine to advance clinical care, the Pediatrix Center for Research, Education, Quality, and Safety (CREQS) engages in clinical research, education, continuous quality improvement, and safety initiatives. The specific objectives of CREQS are to contribute to better patient outcomes and reduce long-term healthcare costs. Pediatrix also provides [30, 31] a High Reliability Organization (HRO) program that combines characteristics of HROs with Six Sigma, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), and Crew Resource Management.

Vermont Oxford Network

The Vermont Oxford Network (VON) [32] is a nonprofit voluntary collaboration of health care professionals and families at more than 1400 member hospitals, primarily in the United States, working together as an interdisciplinary community to improve the quality, safety, and value of care for newborn infants and their families. iNICQ is an Internet-Based Newborn Improvement Collaborative for Quality coordinated by VON which brings teams together by using local and collective data to guide improvement on a designated topic. Participating centers are supported with access to expert faculty, VON measurement and reporting, an interactive online toolkit of evidence-based practices, modules, and online classrooms. Newborn Improvement Collaborative for Quality (NICQ) are groups of 8–10 teams that work together creating a culture of collaboration allowing for data-transparency, data-driven and evidence-based approaches, and rigorous quality improvement methodology to achieve and sustain improvement. Each homeroom faculty consists of a QI leader, a family/parent leader, and a NICU clinician. The VON NICQ collaborative includes families as partners to ensure that the family perspective is represented, valued, and enhanced during each improvement cycle.

Approach and outcomes of QI collaboratives in neonatology

Table 1 shows some examples from each of the 5 collaboratives described. We identified papers that described improvement work within each QIC and did not include individual team reports, or case reports. In addition, we chose a sample of convenience, up to 6 for each QIC that represents different methodologies and various types of clinical issues that QICs have addressed. This sample serves as a representation of the work of each OIC. The number of centers varies based on the size of the collaborative. The number of centers in each of the QIC publications varies from 7 to 330. These collaboratives demonstrate a wide range of topics have been addressed via QIC in neonatology. A clearly defined aim statement was identified for most of these QIC initiatives. However, the operational definitions for outcome, process, and balancing measures have not always been defined in these projects. Although all manuscripts have reported a collective improvement by the collaborative, it is apparent that not all the individual participating centers demonstrate improvement. Some centers contribute more data than others to the outcomes leading to overall improvement in the collaborative. In our evaluation, we identified only one QIC which addressed the economic implications of a QIC, specifically on low-birth-weight infants (NIC/Q- Neonatal Intensive Care Collaborative Quality).

Table 1 Examples of QI papers published from each of the 5 collaboratives.

The implementation and mechanism of impact of a QIC varies widely and are briefly summarized here. CHNC utilizes the Model for improvement [33] methodology in their QI efforts. The collaborative provides best practices through clinical practice recommendations, but each center develops their own tools to conduct the project. IHI Breakthrough Series Collaborative Framework [13] concepts are used through regularly scheduled monthly meetings and huddles which provide opportunity to educate, share challenges, find solutions, report progress and data. Shared learning helps each center achieve their goals. CHNC also successfully utilized orchestrated testing [34], an application of planned experimentation that allows simultaneous examination of multiple practices (bundle elements) to determine which intervention or combination of interventions are the most effective. This technique has been used to reduce central line–associated bloodstream infections [35, 36].

100,000 Babies Campaign, first launched by Pediatrix in 2007, utilizes a QI infrastructure based on the Kotter organizational change model [37, 38]. QI projects in this collaborative utilize electronic health records- Pediatrix BabySteps Clinical Data Warehouse which provides a valuable resource for population and outcomes data [39]. The 100,000 Babies Campaign used QualitySteps [39, 40], a system developed by Pediatrix to assist development of project design, worksheets, and annotated run charts for CQI projects. This program continues to provide QI opportunities through its version 2.0.

NICHQ developed a change package and provided technical assistance to incorporate QI principles to improve the systems of care for premature babies during the Neonatal Outcomes Improvement Projects (2007–2010) in several states to reduce the burden of mortality and morbidity associated with premature birth and low birth weight. Some of the neonatal related initiatives by the organization includes but not limited to Best Fed Beginnings [41], a national QI initiative to help increase the number of “Baby-Friendly” designated hospitals in the United States; Infant Mortality Collaborative Improvement and Innovation Network, safe sleep, smoking cessation, social determinants of health, perinatal regionalization, and NewSTEPs 360, a national collaboration that aims to improve newborn screening programs.

The SPS network utilizes QI Science & HRO Concepts to drive the culture to reduce harm. SPS has developed change packages that inform best practices to reduce Hospital Acquired Conditions (HACs) such as Central line associated blood stream infections, unplanned extubations, adverse drug events, pressure injuries, and others. The change packages also include measurement strategy, care bundles, toolkits, and action items to inform improvement. Another key element SPS incorporates is partnering with and engaging patients and families in their QI initiatives.

VON utilizes the Model for Improvement [33] and experience-based co-design in their QI efforts. VON develops toolkits that consist of change ideas and evidence based potential better practices that are available to the teams. The term “potentially better practices” indicates that a practice is not considered better or best until adapted, tested, and shown to work in the local context. VON QI collaborative provides resources including clinical examples, measurement plans and reporting, foundational QI resources, consultation and collaboration with care experts and other teams. Teams test and implement evidence-based changes and apply continuous measurement to demonstrate improved outcomes. The collaborative uses the approach Learn + Measure + Share = Improve. Online courses related to QI foundations, VON Grand rounds and webinars provide evidence-based education to participating centers.