Abstract
BackgroundTo successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway. These practices are not always shared across organisations. Quality improvement collaboratives (QICs) offer a unique opportunity for key stakeholders from different organisations to share, learn and ‘take home’ best practice examples, to support local improvement efforts. This systematic review assessed the effectiveness of QICs in improving stroke care and explored the facilitators and barriers to implementing this approach.MethodsFive electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, and Cochrane Library) were searched up to June 2020, and reference lists of included studies and relevant reviews were screened. Studies conducted in an adult stroke care setting, which involved multi-professional stroke teams participating in a QIC, were included. Data was extracted by one reviewer and checked by a second. For overall effectiveness, a vote-counting method was used. Data regarding facilitators and barriers was extracted and mapped to the Consolidated Framework for Implementation Research (CFIR).ResultsTwenty papers describing twelve QICs used in stroke care were included. QICs varied in their setting, part of the stroke care pathway, and their improvement focus. QIC participation was associated with improvements in clinical processes, but improvements in patient and other outcomes were limited. Key facilitators were inter- and intra-organisational networking, feedback mechanisms, leadership engagement, and access to best practice examples. Key barriers were structural changes during the QIC’s active period, lack of organisational support or prioritisation of QIC activities, and insufficient time and resources to participate in QIC activities. Patient and carer involvement, and health inequalities, were rarely considered.ConclusionsQICs are associated with improving clinical processes in stroke care; however, their short-term nature means uncertainty remains as to whether they benefit patient outcomes. Evidence around using a QIC to achieve system-level change in stroke is equivocal. QIC implementation can be influenced by individual and organisational level factors, and future efforts to improve stroke care using a QIC should be informed by the facilitators and barriers identified. Future research is needed to explore the sustainability of improvements when QIC support is withdrawn.Trial registrationProtocol registered on PROSPERO (CRD42020193966).
Highlights
To successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway
Lowther et al Implementation Sci (2021) 16:95 level factors, and future efforts to improve stroke care using a quality improvement collaborative (QIC) should be informed by the facilitators and barriers identified
Study characteristics Twenty papers describing 12 QICs used in stroke care were included; four randomised controlled trials [21,22,23,24,25,26], four cross-sectional studies [27,28,29,30], three interrupted time series studies [31,32,33,34], four before-and-after studies [35,36,37,38], and two qualitative studies [39, 40]
Summary
To successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway. Reorganising stroke services and implementing changes at a system-level are increasingly being recognised as ways of enhancing coordination across the pathway, optimising care processes, and improving outcomes for stroke patients [3,4,5]. Implementing these transformative changes in stroke care is likely to involve a critical mass of stakeholders across different organisations and will require the application of effective quality improvement (QI) methodologies. Teams from different organisations are brought together in ‘learning sessions’
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