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Table 5 Inter-organisational mechanisms of change

From: How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review

Themes (No. studies)

Evidence synthesis

Quality of Evidence [ref.]

Description of relationship QIC component–mechanism–outcome

Contextual enablers of mechanism (or barriers)

Quantitative and mixed methods

Qualitative and review

QIC component

Mechanism of change

Outcome

Shared community of practice (N = 7)

Collaboration with other hospitals

• Sense of community reinforced or created

• Increased motivation, by supporting reframing of improvement topic as desirable, urgent and achievable

Health workers motivated and empowered to take action towards common goal

• Settings where a community of practice amongst clinicians exists or can be developed

• Barrier: external pressures on hospitals incentivising competition v. collaboration.

Medium [46, 67,68,69]

Low [17, 50, 63]; medium [67, 69]

Platform for capacity building (N = 5)

Collaboration with other hospitals

• Platform to refine skills for improvement provided

• Definition of standard care processes facilitated

 

• Settings with quality-focused HR systems, e.g. incorporating quality objectives in professional development and performance appraisals

• Barrier: high performing hospitals have less to gain from collaboration

• Barrier: Collaboration can be undermined by free-riding (not all facilities contribute equally) and social loafing (leaving it to others to support low performing hospitals)

Medium [51, 67,68,69,70]

Low [51]; medium [67, 69, 70]

Demonstration role (N = 3)

Collaboration with other hospitals

• Feasibility of improving outcome of focus is demonstrated

Increased engagement in QIC

• Supportive leadership

• External support to disseminate success stories

• Barrier: Large hospitals may have less to gain from collaboration

Medium [71]

Low [51, 63]

Friendly competition (N = 6)

Collaboration with other hospitals

• Reputational gain from improvement (or conversely risk of non-improvement) at individual and organisational level achieved.

• Access to others’ data and benchmarking for internal gains enabled.

Normative pressures to conform (change practice and improve) created.

• Open sharing of data on mutual performance

• Alignment with institutional priorities (lack of which contributes to perception that collaboration is stressful and time-consuming)

• Geographically dense professional network

• Non-hierarchical teams facilitating decentralised decision making

• Barrier: competition for financial incentives linked to quality criteria

Medium [47, 66]

Low [17, 63]; medium [69]; high [72]