BMJ Qual Saf 20:344-350 doi:10.1136/bmjqs.2010.047159
  • Original research

Creating effective quality-improvement collaboratives: a multiple case study

Open Access
  1. Roland A Bal
  1. Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  1. Correspondence to Mathilde M H Strating, Institute of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands; strating{at}
  1. Contributors APN and MMHS formulated the research question of this article and developed the questionnaire. MMHS carried out the study, performed the statistical analyses and drafted the manuscript. AN advised on the analyses. APN, TZ-J and RAB formulated the overall research questions and overall study design of the evaluation, and critically revised the manuscript. All authors read and approved the final manuscript. All authors 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.

  • Accepted 20 December 2010
  • Published Online First 26 January 2011


Objective To explore whether differences between collaboratives with respect to type of topic, type of targets, measures (systems) are also reflected in the degree of effectiveness.

Study setting 182 teams from long-term healthcare organisation developed improvement initiatives in seven quality-improvement collaboratives (QICs) focusing on patient safety and autonomy.

Study design Multiple case before–after study.

Data collection 75 team leaders completed a written questionnaire at the end of each QIC on achievability and degree of challenge of targets and measurability of progress. Main outcome indicators were collaborative-specific measures (such as prevalence of pressure ulcers).

Principal findings The degree of effectiveness and percentage of teams realising targets varied between collaboratives. Collaboratives also varied widely in perceived measurability (F=6.798 and p=0.000) and with respect to formulating achievable targets (F=6.566 and p=0.000). The Problem Behaviour collaborative scored significantly lower than all other collaboratives on both dimensions. The collaborative on Autonomy and control scored significantly lower on measurability than the other collaboratives. Topics for which there are best practices and evidence of effective interventions do not necessarily score higher on effectiveness, measurability, achievable and challenging targets.

Conclusions The effectiveness of a QIC is associated with the efforts of programme managers to create conditions that provide insight into which changes in processes of care and in client outcomes have been made. Measurability is not an inherent property of the improvement topic. Rather, creating measurability and formulating challenging and achievable targets is one of the crucial tasks for programme managers of QICs.


  • Funding The Care for Better programme and the evaluation study are funded by The Netherlands Organisation for Health Research and Development (ZonMw grantnr 5942). The researchers of the evaluation study are independent from this funding organisation.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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