BMJ Qual Saf 21:621-623 doi:10.1136/bmjqs-2012-001065
  • Editorial

Evaluating the effect of a national collaborative: a cautionary tale

  1. Sanjay Saint1,3
  1. 1Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  2. 2Division of Nursing Business and Health Systems, School of Nursing, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Anne Sales, Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USA; salesann{at}

“There's something happening hereWhat it is ain't exactly clear…”—Buffalo Springfield

Improving the efficiency and quality of care that hospitalised patients receive is clearly important. The study by Glasgow and colleagues in this issue of BMJ Quality and Safety provides interesting insights into the summative outcomes of a large, national quality collaborative focused on reducing length of stay and discharging hospitalised patients before noon. Additionally, the authors included mortality and 30-day readmissions as secondary outcomes as part of their robust evaluation of a large mandatory collaborative (termed ‘FIX’) that occurred within the 130 hospitals that are part of the Veterans Health Administration (VHA). The findings of this ambitious study extend the literature evaluating quality-improvement projects. We applaud the authors on their achievement in reporting short-term outcomes of this large-scale initiative, and in going further to assess how any gains achieved in the initiative endured. Their innovative approach to measuring sustainability is an important step forward, and hopefully will encourage others with access to large systems with longitudinal data to continue metric development.

Their key finding was that less than half the hospitals showed improvement in the primary outcomes—length of stay and discharge before noon—beyond what would have been expected from trends unrelated to the initiative. However, even among hospitals that showed initial improvement, sustainability was difficult to achieve. Specifically, of the 130 hospitals participating in FIX, only 27 had both initial and sustained improvement in length of stay, while only 19 hospitals had both initial and sustained improvement in discharges before noon. Only five hospitals were able to sustain …

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