BMJ Qual Saf doi:10.1136/bmjqs-2011-000243
  • Original research

Findings from a national improvement collaborative: are improvements sustained?

  1. Peter J Kaboli2,4,5
  1. 1The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Healthcare System, Iowa City, Iowa, USA
  2. 2Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa, USA
  3. 3VHA High Reliability Systems and Consultation, Fort Meade, South Dakota, USA
  4. 4VA Office of Rural Health (ORH), Veterans Rural Health Resource Center–Central Region, Iowa City VA Healthcare System, Iowa City, Iowa, USA
  5. 5The Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
  1. Correspondence to Justin M Glasgow, Iowa City VA Healthcare System, 601 Highway 6 West, Mailstop 152, Iowa City, IA 52246-2208, USA; justin.glasgow{at}
  1. Contributors All authors have contributed and met the requirements of authorship for this article by assisting in data interpretation, draft editing and revising, and final approval of this version.

  • Accepted 24 February 2012
  • Published Online First 4 April 2012


Background Despite considerable efforts to improve healthcare quality and patient safety, broad measures of patient outcomes show little improvement. Many factors, including limited programme evaluations and understanding of whether quality improvement (QI) efforts are sustained, potentially contribute to the lack of widespread improvements in quality. This study examines whether hospitals participating in a Veterans Health Affairs QI collaborative have made and then sustained improvements.

Methods Separate patient-level risk-adjusted time-series models for two primary outcomes (hospital length of stay (LOS) and rate of discharges before noon) as well as three secondary outcomes (30-day all-cause hospital readmission, in-hospital mortality and 30-day mortality). The models considered 2 years of pre-intervention data, 1 year of data to measure improvements and then 2 years of post-intervention data to see whether improvements were sustained.

Results Among 130 Veterans Affairs hospitals, 35% and 46% exhibited improvements beyond baseline trends on LOS and discharges before noon, respectively. 60% of improving LOS hospitals exhibited sustained improvements, but only 32% for discharges by noon. Additional subgroup analyses by hospital size and region found a similar performance across most groups.

Conclusions This quasi-experimental evaluation found lower rates of improvements than normally reported in studies of QI collaboratives. The most striking observation was that a majority of hospitals increased their rates of discharges before noon, but after completing the collaborative their performance declined. Future work needs to qualitatively and quantitatively assess what organisational features distinguish those hospitals that can improve and sustain quality.


  • This manuscript is not under review elsewhere and there is no prior publication of the manuscript's contents. The preliminary results of this manuscript were presented at the National VA Health Services Research and Development Research Meeting, Washington, DC, February 2011, and the Society of General Internal Medicine Annual Meeting, Phoenix, AZ, May 2011. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. The authors report no conflict of interest in regards to this study.

  • Funding The work reported here was supported by a TL1 award from the University of Iowa Institute for Clinical and Translational Science (5TL1 RR024981-03) and the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (HSR&D) Service through the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center (HFP 04-149).

  • Competing interests None.

  • Ethics approval University of Iowa Institutional Review Board and the Iowa City VA Healthcare System Research and Development Committee.

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

  • Data sharing statement Available to researchers with VA accreditation.

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