Table 1 Components of the quality improvement collaborative intervention

In the Netherlands, access to care is easily available and almost fully reimbursable. Although the care for people with diabetes type 2 was mainly concentrated in primary care in the last decades, people with diabetes now receive care in primary, secondary or tertiary level care settings, The integrated care strategy intends to develop a model of care that will provide an appropriate structure to deliver the full range of health, personal, and social services and initiatives to improve the organization, management, and integration or coordination of primary generalist care and secondary specialist care services for diabetes (including diabetes specialist nurses, dieticians, podiatrists, and specialist support). Guidelines on care and prevention are amply available but not fully implemented. As part of an alliance between the Dutch Institute for Healthcare Improvement and the College of Health Insurances to improve chronic care in an integrated care setting, a national quality improvement collaborative (QIC) based on the Breakthrough Series http://www.ihi.org was set up to encourage high quality in integrated diabetes care in the Netherlands. This voluntary quality improvement strategy was designed to bring together and support multiprofessional diabetes teams from primary care and outpatient hospital clinics.

Expert meeting

In the preparation phase, an expert meeting of 30 national diabetes experts including general practitioners, diabetologists, specialized diabetes nurses, dieticians, podiatrists, members of the Dutch Diabetes Federation, and other patient organizations was organized. The purpose was to gain insight into current diabetes care barriers and facilitators. The experts listed 12 barriers and facilitators on the patient, professional, and organizational levels.

Expert panel and change concepts

Following the expert meeting, an expert panel representing five national diabetes experts and two quality improvement experts was installed to facilitate and support the participating provider teams. The expert panel prepared a package of ideas (change concepts) for closing the gap between best and actual practice. The package was based on national and international diabetes guidelines, field surveys, personal experience, and the barriers and facilitators mentioned in the expert meeting.

Recruitment of participants

Letters of invitation

In 2004, letters of invitation were sent to invite diabetes provider teams in outpatient hospital clinics and general practices nationwide to participate in a diabetes QIC on in 2005.

Invitational meeting

In addition, two invitational meetings were organized to inform teams about the goals and structure of the project. The participating teams each had to pay a fee of €23.750 Euro to cover project management costs.

Start

Kick-off

Before the kick-off meeting, the participating multidisciplinary provider teams were asked to collect some baseline data and to describe the current diabetes practice to identify 'performance gaps' in their practice. In the national kick-off meeting, the teams were provided with materials and information (package of change). The kick-off session provided information about the change package and quality improvement techniques. The topics included setting aims, the use of measurement and small, incremental tests of change.

Execution phase

Learning Sessions

The teams attended three learning sessions about the change package, quality improvement methods, and reporting their experiences, changes, and results for their targets.

Plan Do Study Act (PDSA) cycles

Between meetings, the team members recruited other providers from their respective organizations (participating hospitals and general practices) to implement selected changes and measure progress in their own organizations. They used a PDSA change testing method to plan, implement, and evaluate many small changes in quick succession (the rapid cycle improvement method). The expert panel supported the teams by means site visits, conference calls, e-mail 'listserv' discussion groups, and feedback.