INTRODUCTION
Participation in quality improvement (QI) collaboratives has helped hospitals improve outcomes and decrease costs.1,2 As such, state-level surgical QI collaboratives have become increasingly common. However, the optimal design of an effective collaborative and their key drivers of success remain unclear. Our objective was to create a conceptual model of a surgical QI collaborative to facilitate the development, implementation, and systematic evaluation of the Illinois Surgical Quality Improvement Collaborative (ISQIC).
METHODS
A multi-disciplinary, multi-institutional team of ISQIC researchers conducted a literature review and expanded and adapted key components of existing models of healthcare QI to create a conceptual model for a surgical QI collaborative.3,4 Feedback from leaders in QI, hospital administrators, clinical frontline staff, and quality researchers guided the evolution of the model through multiple iterations until final consensus was reached. Institutional review board approval was not required, as this research did not involve human subjects.
RESULTS
The conceptual model’s foundation consists of surgical QI needs that stimulate system and process changes that, in turn, result in improved outcomes. The model is cyclical to account for the iterative nature of the system and process changes made in response to QI needs. Surgical QI collaboratives can facilitate QI through initiatives that support 3 key domains of surgical QI: the hospital, the QI team, and the perioperative microsystem (e.g., operating room, intensive care unit). Inter-related sub-domains contain the key components of surgical QI that may benefit from collaborative support (Figure 1).
Figure 1:
Conceptual mode of a surgical QI collaborative. The overarching influence of the collaborative (purple) is depicted as operating on the Hospital, Surgical QI Team, and Peri-Operative Microsystem domains of surgical QI.
At the hospital level, institutional leadership, QI support and capacity, QI characteristics, and hospital culture are essential for success. At the QI team level, the dynamics, attributes, and composition of the team are paramount. Last, within the perioperative microsystem level, environment, culture, and staff leadership are similarly fundamental to QI success. Components of each domain and examples of collaborative support are provided in the Table.
Table 1:
Key components of the sub-domains and examples of mechanisms of support for each sub-domain that can be offered by QI collaboratives within the three domains of surgical QI: Hospital, Surgical QI Team, and Peri-Operative Microsystem.
| SUB-DOMAINS | EXAMPLES OF COLLABORATIVE SUPPORT |
|---|---|
| Hospital | |
|
Hospital QI Leadership • Hospital Board of Directors • Chief of Surgery • Surgical Quality Champion |
Board engagement initiatives, administrator resource toolkit, public relations toolkits |
|
QI Support and Capacity • Infrastructure/Resources • Financial • Workforce QI Focus |
Data collection infrastructure (NSQIP participation), coordinating center, performance reports, pilot grants |
|
Hospital QI Characteristics • Physician Compensation Model • Organizational QI Maturity |
Physician participation stipends, assessment of readiness to change |
|
Hospital QI Culture • Surgical Culture • QI Culture |
Collaboration with other hospitals, hospital-specific QI projects, performance bonuses |
| Surgical QI Team | |
|
Surgical QI Team Dynamic • Decision-Making Process • Team Norms/Power Structure • Team QI Skill |
Team QI curriculum, QI toolkit, assessment of QI knowledge |
|
Surgical QI Team Attributes • Physician Involvement • QI Experience • Previous Collaboration |
Surgical QI case studies, statewide QI projects, hospital-specific QI projects, collaboration and networking with other hospitals, physician participation |
|
Surgical QI Team Composition • Team Leadership • Key Stakeholders • Team Diversity |
Leadership training, project management training, mentorship by surgical QI expert, inclusion of surgeon, clinical abstractor, performance improvement coach, key stakeholders, and frontline providers |
| Peri-Operative Microsystem | |
|
QI Environment • Staff QI Capability • Staff QI Motivation |
Site visits and interviews, sharing performance reports, performance incentive awards |
|
QI Culture • Shared Culture across Microsystems • Workforce Engagement |
Site visits, best practice guidelines, encouraged participation in QI initiatives, Safety Attitudes Questionnaire (SAQ) |
|
Staff Leaders • Nursing Management Support and Engagement • Ancillary Staff Management’ Support and Engagement • Physicians’ Support/Engagement |
Site visits, audits, performance feedback, surgeon-level risk-adjusted comparative data |
DISCUSSION
This conceptual model provides a formal framework for the development and systematic evaluation of surgical QI collaboratives. Though previous QI collaboratives have had success in improving quality, the mechanisms underlying this success remain unclear. Surgical QI is complex with many inter-related components and processes, impeding assessment of individual collaborative support mechanisms. By depicting the key drivers of surgical QI and their inter-relatedness, this model provides a framework for collaborative QI that facilitates the generation, implementation, and evaluation of collaborative interventions.
Conceptual models of healthcare QI have been previously described, but these models do not integrate QI collaborative influence on institutional drivers of success.3,5,6 Although created for ISQIC, the underlying components and relationships of this model can be applied to other QI collaboratives. As a result, this model may serve as a valuable tool for implementing and evaluating interventions in new or well-established collaboratives.
Of note, this model is adapted from existing models for healthcare QI with modifications made by consensus expert opinion. Given the paucity of data regarding the interplay between QI collaboratives and institutional QI, the individual components and relationships of this conceptual model are still in need of validation. Additionally, this model may fail to capture all inherent complexities of surgical QI in participating hospitals. However, this model cab provide an organized conceptual framework that facilitates the systematic evaluation of QI collaborative interventions.
The success of QI collaboratives is contingent upon the ability to facilitate QI within participating institutions beyond that which could be accomplished in the absence of collaborative support. It is imperative for QI collaboratives to evaluate the efficacy of each intervention to prevent resources from being allocated to ineffective support mechanisms. This conceptual model has facilitated our ongoing evaluation of ISQIC and can be similarly used by others. Such evaluations can provide valuable insight into the mechanisms underlying successful collaborative QI and help to optimize the efficacy of QI collaboratives in healthcare.
ACKNOWLEDGMENTS
MWW, CAM, and KYB had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The authors of this manuscript have no conflicts of interest to disclose. Research reported in this publication was supported by Blue Cross Blue Shield of Illinois, Health Care Service Corporation, and the Agency for Healthcare Research and Quality (R01HS024516-01, PI: Karl Y. Bilimoria, MD MS). MWW’s was supported by the National Institute of General Medical Sciences of the National Institutes of Health (1F32GM113513-01, PI: Michael W. Wandling, MD) and CAM’s was supported by the Agency for Healthcare Research and Quality (T-32 HS 000078, PI: Jane L. Holl, MD MPH). The funding organizations for this project were not involved in the design or conduct of the study, the collection, management, analysis, or interpretation of the data, the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication.
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