An Argument for State-Driven Quality Collaboratives

The Sample Size Conundrum

A major challenge in quality improvement (QI) within the medical field is adequate sample size. To effect real change, not only do we need to amass large quantities of data for analysis, but also interventions require larger groups of patients and providers to recognize the effect of said intervention. With that, single-institution projects not only may fail to demonstrate change but also may have limited applicability outside of the individual practice. Opportunities for more robust data collection, analysis, and intervention—in terms of both numbers and resources—are necessary for continued advancement in surgical quality initiatives.

While we strive for large sample size, we must also ask “how large is too large?” Though increasing the number of collaborating institutions may increase the availability of data, it may also start to impinge on true collaboration. The most successful multisite collaborations require a culture of trust rather than competitiveness. Distrust prevents the dissemination of best practice from one institution to another, whereas a noncompetitive collegiality promotes partnership and sharing of ideas.[1] Some argue that trust can only exist when collaboration is between institutions that are familiar beyond name only. This may limit productive interactions on a national level and raises the argument for limiting participation to a region or state, as we see in the site-wide quality collaboratives. The limited number of participating hospitals within a region allows collegial relationships to develop with relative ease, and these relationships serve as the foundation for institutional trust.

The heterogeneity in practice patterns across a single state or region is impressive when you consider differences in patient populations, hospital resources, and physician preferences. With this, there will also be heterogeneity in patient outcomes—encompassing both positive and negative outliers. This represents a microcosm of medical practice across the United States. Given the proximity of the practices, it may also foster partnership and implementation of new quality-directed initiatives. In short, it is the ideal setting for QI collaboration.

Publication History

Article published online:
22 May 2023

• References

• 1 Campbell Jr D, Krapohl GL. Michigan Surgical Quality Collaborative: A Platform to Merge Surgery and Anesthesia Quality Initiatives. ASA Newsl 2014; 78 (12) 22-24
• 2 Campbell Jr DA, Kubus JJ, Henke PK, Hutton M, Englesbe MJ. The Michigan Surgical Quality Collaborative. The Michigan Surgical Quality Collaborative: a legacy of Shukri Khuri. Am J Surg 2009; 198 (05) S49-S55
• 3 Englesbe MJ, Dimick JB, Sonnenday CJ, Share DA, Campbell Jr DA. The Michigan Surgical Quality Collaborative. The Michigan surgical quality collaborative: will a statewide quality improvement initiative pay for itself?. Ann Surg 2007; 246 (06) 1100-1103
• 4 Hendren S, Fritze D, Banerjee M. et al. Antibiotic choice is independently associated with risk of surgical site infection after colectomy: a population-based cohort study. Ann Surg 2013; 257 (03) 469-475
• 5 Ferguson Jr TB. The Institute of Medicine committee report “best care at lower cost: the path to continuously learning health care.”. Circ Cardiovasc Qual Outcomes 2012; 5 (06) e93-e94
• 6 Vu JV, Collins SD, Seese E. et al. Evidence that a regional surgical collaborative can transform care: surgical site infection prevention practices for colectomy in Michigan. J Am Coll Surg 2018; 226 (01) 91-99
• 7 Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee JF, Englesbe MJ. Statewide implementation of postoperative opioid prescribing guidelines. N Engl J Med 2019; 381 (07) 680-682
• 8 Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality; . September 2004
• 9 Cohen AB, Restuccia JD, Shwartz M. et al. A survey of hospital quality improvement activities. Med Care Res Rev 2008; 65 (05) 571-595
• 10 Odell DD, Quinn CM, Matulewicz RS. et al. Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. J Am Coll Surg 2019; 229 (02) 175-183
• 11 Lussiez A, Eton R, Anderson M. et al. Heterogeneity in surgical quality improvement in Michigan. Ann Surg 2023; 277 (04) 612-618