• Quality improvement
• quality improvement collaboratives
• diabetes care
• primary care
• clinical outcomes
• chronic disease management
• cost effectiveness
• diabetes mellitus
• risk management

The potential of quality improvement collaboratives (QICs) to improve the quality of primary healthcare is widely recognised. However, despite wide use, the evidence base to support QICs is surprisingly modest.1 In this issue of the journal, Knight et al 2 provide useful information suggesting that QICs in Australia had a positive impact on diabetes care. They present convincing data showing improvement trends over the years these QICs were active. However, establishing a causal link is challenging in the absence of a randomised control or comparison group. Although several group-randomised trials of QICs for diabetes care have shown positive results,3 others have failed to improve care, and many have improved only test rates but not key aspects of care such as glucose or blood pressure (BP) control.4 While we all have high hopes for QICs, the jury is still out on their effectiveness for diabetes care and care of other specific medical conditions.

As we ponder these mixed results, an important question is how to maximise the benefit of future QICs. What we have learnt about QICs so far suggests several opportunities to improve the effectiveness of QICs as we move forward with our eyes on the goal of improved quality of primary care services. I posit that a shortcoming of many QICs to date is that they often seek to implement spontaneous ideas or insights provided by practitioner participants in QICs. While such an approach has much to recommend it, many participants may not be aware that, over the last 30 years, many ‘common sense’ approaches to care improvement have been tested and found wanting5 ,6—in some cases even leading to worse care outcomes than no intervention at all.7 Examples of this ‘spontaneous combustion’ approach to QICs are not hard to find.4 , …