I m p ro v i n g I n t e n s i v e C a re U n i t

Quality Using Collaborative

Networks
a b,c,
Sam R. Watson, MSA, MA, CPPS , Damon C. Scales, MD, PhD *

KEYWORDS
 Quality improvement  Cooperative behavior  Collaboration  Cost-effectiveness
 Patient safety  Critical care  Intensive care units  Health economics

KEY POINTS
 Collaborative intensive care unit networks have successfully improved quality across
entire health systems.
 These collaborative networks offer several advantages that include targeting a large
number of patients, sharing of resources between sites, and implementing common
measurement systems that can be used for audit and feedback or benchmarking.
 More research is needed to understand the mechanisms through which collaboratives
lead to improved care delivery, and to demonstrate their cost-effectiveness in comparison
with other approaches to system-level quality improvement.

INTRODUCTION

Critically ill patients require intensive monitoring and costly treatments. Despite
advances, however, mortality remains high. Unfortunately, delays often exist in the
publication and subsequent adoption of evidence-based practices. These delays
may contribute to morbidity and mortality, and waste resources.1–3 It is therefore vital
that such errors of omission are avoided in these patients, and that evidence-based
treatment is provided in a timely manner.
The challenge to the adoption of evidence-based best practice is twofold. First, the
effort necessary to cull the evidence, identify valid measures, and implement change

Financial disclosure: There was no funding source for this article. D.C.S. is supported by a New
Investigator Award from the Canadian Institutes for Health Research.
a
Michigan Health Association Keystone Centre, 6215 West St. Joseph Highway, Lansing, MI
48917, USA; b Interdepartmental Division of Critical Care, University of Toronto, Toronto,
Ontario, Canada; c Department of Critical Care Medicine, Sunnybrook Health Sciences Centre,
2075 Bayview Avenue, Room D108, Toronto, ON M4N 3M5, Canada
* Corresponding author. Department of Critical Care Medicine, Sunnybrook Health Sciences
Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N 3M5, Canada.
E-mail address: [Link]@[Link]

Crit Care Clin 29 (2013) 77–89

[Link] [Link]
0749-0704/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
78 Watson & Scales

can be significant, and in some cases may exceed the resources and abilities of indi-
vidual clinicians. Second, implementing evidence-based therapies often requires that
the behavior of clinicians be modified, and this requires effective strategies and often
considerable time and effort.4
In addition, there is a need to expedite the rate of quality improvement. The recent
report from the Institute of Medicine, Best Care at Lower Cost: The Path to Continu-
ously Learning Health Care in America, emphasized that there have been limited gains
in the improvement of quality and reduction of costs in health care, and highlighted the
need to increase the scale of improvement efforts.5 These challenges have motivated
clinicians, researchers, and policy makers to promote larger statewide or regional
quality-improvement campaigns over single-center quality initiatives.
There are many potential advantages to organizing health care centers to deliver
system-level interventions to improve quality.6 Most obviously, such approaches
are appealing to health care funding bodies because more patients can benefit from
the quality-improvement initiatives. Resources for quality improvement can be shared
across sites, and there may be opportunities to share successful strategies and
learning. Finally, accepted care practices can be standardized and common measure-
ment systems can be implemented, allowing for benchmarking across centers.
Many systems and structures have been proposed to improve intensive care unit
(ICU) quality across a system, for example, using telemedicine,7 public reporting of
quality measures, or creating reward-based or penalty-based pay-for-performance
(P4P) schemes.8,9 This article discusses the advantages and limitations of forming
collaborative networks of hospitals, which link institutions together with the aim of
improving quality across a system. Strategies that the authors consider important
for ensuring the success of these networks are outlined, and the importance of
ongoing evaluation to ensure that these networks achieve sustained impact and are
cost-effective are discussed. The article concludes with a review of areas perceived
to be important for future research.

WHAT IS AN ICU COLLABORATIVE NETWORK?

A collaborative network consists of multiple teams located in health care facilities in

different geographic areas, or in different units within the same organization, working
together to solve a practice gap.10 Quality-improvement initiatives that involve more
than one center are appealing for several reasons, in particular because the sharing
of information and resources should create efficiencies while eliminating redun-
dancies. The proposed advantage of the collaborative approach is predicated on
the idea that learning from the successes of others and sharing of information between
institutions or teams is more likely to lead to improvements in care through a group
effort.11–13 In other words, a collaborative network of hospitals or units working
together would be expected to achieve better outcomes and faster results in
quality-improvement initiatives than if they were working on the same initiatives
alone.14 In the last decade there have been several of these large-scale collaborative
networks in the critical care environment, many claiming highly successful results.15,16

EXAMPLES IN CRITICAL CARE

A search was made of the available literature to identify collaborative networks that have
been used to improve quality of care in ICUs. To identify potential publications, OVID
Medline from 1996 to October 2012 was searched using the keyword “collaborative”
combined with the medical subject headings “Critical Care” (243 citations) or “Intensive
Care Units” (288 citations). From these, 17 publications describing multicentered
 Improving ICU Quality Using Collaborative Networks 79

collaborative networks targeting quality improvement in adult or pediatric ICUs were

identified (Table 1). The number of centers involved ranged from 5 to 114. The most
commonly used methods of dissemination were face-to-face workshops and telecon-
ferences. A wide range of clinical practices were targeted by these collaborative
networks, although the most frequently tackled problems were prevention of catheter-
related bloodstream infections and ventilator-associated pneumonia (VAP).
Arguably the most well-known example of an ICU collaborative network is the Mich-
igan Health and Hospital Association (MHA) Keystone Center’s Keystone ICU project,
in which the participants in the collaborative received standardized information on
interventions and collected data using standard measures.16 In addition, they
addressed teamwork and patient-safety climate. Through face-to-face meetings
and regular teleconferences, the ICU teams were able to learn collectively and share
their individual experiences in the implementation of the interventions. Institutional
performance data were shared anonymously, allowing the local ICU to compare itself
against the entire collaborative.17 The initiative involved more than 120 ICUs from
around the state of Michigan, as well as 5 out-of-state ICUs. Of note, the collaborative
linked the application of evidence-based medical interventions with the socioadaptive
framework of improving teamwork and patient-safety culture. It focused on reducing 2
hospital-associated infections, central line–associated bloodstream infections
(CLABSI), and VAP.16,18 The MHA Keystone network was able to achieve sustainable
reductions in both of these preventable complications.19
Similarly, 23 ICUs in all 11 acute care hospitals in Rhode Island formed a collabora-
tive network to reduce ICU-related complications.20 This collaborative model was
associated with statewide reductions in CLABSI and VAP. The Veterans Affairs Mid-
west Care Network also developed a collaborative network involving 9 hospitals,
and targeted these same preventable infections; this approach led to improved adop-
tion and decreased infection rates in 8 of these hospitals.21 A similar approach has
been reported in pediatric ICUs.22
These collaboratives have typically reported success by documenting sustained
reductions in preventable complications over time, or increased adherence to targeted
care practices. More recently, some collaboratives have used more rigorous evalua-
tions that are less vulnerable to confounding attributable to secular trends, using, for
example, cluster randomization or interrupted time series. The results of these evalu-
ations have not always been consistent; some collaborative approaches have yielded
modest gains, whereas others have failed to show benefit. In Ontario, Canada, a collab-
orative involving 15 community ICUs (the Ontario ICU Best Practices Project) achieved
modest improvements in adherence to 6 quality-process measures, especially when
baseline compliance was low.23 A multifaceted intervention to improve end-of-life
care that was delivered to 6 active hospitals did not lead to improved family-
reported or nurse-reported quality of dying in comparison with 6 control hospitals.24
These results have led to recommendations that the implementation of future collab-
orative networks should use more rigorous evaluations, especially considering that
improvements in some of the more commonly targeted complications, for example
CLABSI and VAP, have been observed over time in regions without active large-
scale quality-improvement initiatives.25,26

ESSENTIAL ELEMENTS OF A COLLABORATIVE

Implementation science is a new and evolving field, with a paucity of research directed
at understanding critical factors in the successful implementation of large-scale
collaboratives.25,27 However, from the experience of the Keystone ICU project and
 80
Watson & Scales
Table 1
Characteristics of critical care collaborative networks

Methods of Dissemination
Number of Centers Geography of (Face-to-Face Workshops,
Collaborative Participating Collaborative Key Interventions Teleconference, etc)
The Canadian ICU Collaborative39,40 50 National (Canada) 1. Transfusions Face-to-face workshops
2. Ventilator-associated pneumonia Teleconference
prevention
3. High-risk medications
4. Sepsis
5. Cardiac arrests
6. Central line–associated bloodstream
infection prevention
On The CUSP: STOP BSI, Hawaii41 16 State/Provincial Central line–associated bloodstream Face-to-face workshops
(Hawaii, USA) infection prevention Web content
Teleconference
Vermont Oxford Network: 114 National (USA) Evidence-based surfactant treatment for Face-to-face workshops
promotion of evidence based preterm infants of 23–29 wk gestation Web content
surfactant treatment for preterm Teleconference
infants of 23–29 wk gestation42
Vermont Oxford Network43 10 National (USA) 1. Nosocomial infection Face-to-face workshops
2. Chronic lung disease
Network-Based Pilot Program to 5 Regional (New York/ 1. Identify family’s cardiopulmonary Face-to-face workshops
Improve Palliative Care in the New Jersey, USA resuscitation preference Teleconference
Intensive Care Unit44 VA hospitals) 2. Offer the patient and family social
work support and spiritual support
3. Conduct an interdisciplinary family
meeting to discuss the patient’s and/
or family diagnosis, prognosis, goals
of care
The Ohio Perinatal Quality 20 State/Provincial 1. Promotion of ultrasound Face-to-face workshops
Collaborative45 (Ohio, USA) confirmation of gestational age Teleconference
<20 wk
2. Promotion and adoption of
American College of Obstetricians
and Gynecologists schedule
3. Birth criteria
4. Dating criteria optimal
5. Specific indication for scheduled
birth
6. Documented discussion of risks and
benefits of scheduled birth
7. Improved obstetric-pediatric
communication

Improving ICU Quality Using Collaborative Networks

8. Culture of safety
Keystone ICU16 72 State/Provincial 1. Central line–associated bloodstream Face-to-face workshops
(Michigan, USA) infection prevention Web content
2. Ventilator-associated pneumonia Teleconference
prevention
3. Comprehensive unit-based safety
program
Integrating a multidisciplinary 8 National (USA) Progressive mobility Face-to-face workshops
mobility program into intensive Toolkits
care practice46 Teleconference
Neonatal Intensive Care Quality 9 National (USA) 1. Vitamin A supplementation Face-to-face workshops
Improvement Collaborative 2000: 2. Decrease fluid administration Web content
ALI47 3. Postextubation CPAP Teleconference
4. Permissive hypercarbia Site visits
5. Decrease dexamethasone
6. Prophylactic surfactant delivery
room NCPAP
7. High-frequency ventilation or low-
VT ventilation
8. Gentle ventilation in the delivery
room

(continued on next page)

81
 82
Watson & Scales
Table 1
(continued )
Methods of Dissemination
Number of Centers Geography of (Face-to-Face Workshops,
Collaborative Participating Collaborative Key Interventions Teleconference, etc)
Vermont Oxford Neonatal 6 National (USA) Nosocomial infection prevention Face-to-face workshops
Evidence-Based Quality Teleconference
Improvement Collaborative48
A statewide quality-improvement 13 State/Provincial Central line–associated bloodstream Face-to-face workshops
collaborative to reduce neonatal (California, USA) infection prevention Web content
central line–associated Teleconference
bloodstream infections49 Site visits
The Ontario ICU Clinical Best 15 State/Provincial 1. Prevention of ventilator-associated Video conference
Practices Project23 (Ontario, Canada) pneumonia Web content
2. Prophylaxis against deep vein Annual face-to-face
thrombosis workshops
3. Daily spontaneous breathing trials
4. Prevention of catheter-related
bloodstream infections
5. Early enteral feeding Initiation of
enteral feeds within 48 h of ICU
admission
6. Decubitus ulcer prevention
 Child Health Corporation of 20 National (USA) 1. Prevention practices (eg, SBAR and Face-to-face workshops
America multicenter mock codes) Web content
collaborative50 2. Detection practices (eg, pediatric Teleconference
early warning system)
3. Correction practices (eg, algorithms
for shock, respiratory distress,
neurologic changes)
Child Health Corporation of 26 National (USA) Central line–associated bloodstream Face-to-face workshops
America multicenter infection prevention Web content
collaborative22 Teleconference
The Rhode Island ICU 11 State/Provincial 1. Central line–associated bloodstream Face-to-face workshops
Collaborative51 (Rhode Island, USA) infection prevention Web content
2. Ventilator-associated pneumonia Teleconference
prevention

Improving ICU Quality Using Collaborative Networks

3. Comprehensive unit-based safety
program
A statewide collaborative to 19 State/Provincial Central line–associated bloodstream Face-to-face workshops
decrease NICU central (New York, USA) infection prevention
line–associated bloodstream
infections52
A collaborative to reduce 18 National (Thailand) Ventilator-associated pneumonia National and regional
ventilator-associated prevention face-to-face workshops
pneumonia in Thailand53

Abbreviations: CPAP, continuous positive airway pressure; ICU, intensive care unit; NCPAP, nasal CPAP; NICU, neonatal ICU; SBAR, Situation/Background/Assess-
ment/Recommendation; VA, Veterans Administration; VT, tidal volume.

83
84 Watson & Scales

the Ontario ICU Best Practices Project, there are several essential elements that
contribute to the success and sustainability of these networks.
First, tasking a central body with summarizing the available evidence and identifying
the interventions that are most likely to result in a change in clinician behavior reduces
the burden on individual facilities and busy clinicians.4 The synthesis of evidence into
a useful and practical intervention can be resource intensive, and in many cases may
exceed the capability of many hospitals, especially nonacademic facilities.
Second, developing a limited set of standardized measures that are linked to the inter-
vention and desired outcome is a critical aspect of the collaborative process. Without
credible measures, clinicians are less likely to believe that the interventions are effective.
Furthermore, choosing measures that can be directly linked to the targeted practices
ensures that participants can associate their efforts with meaningful improvements.
Focusing on only a limited (rather than exhaustive) set of valid measures helps to limit
the resources that are required for data collection; if data-collection efforts become
overly burdensome, this can detract from the intended focus of the collaborative.
Third, a successful collaborative will engage frontline clinicians and address quality
targets that are clinically important and relevant. Ensuring that participating ICUs have
an opportunity to provide input and contribute to the overall approach that is adopted
will increase the likelihood of buy-in; if an intervention is perceived to have limited
value to the physicians involved, they are less likely to participate or be supportive.
Some collaboratives have engaged frontline clinicians with face-to-face educational
sessions, whereas others have used telemedicine; the comparative effectiveness of
each should be a topic of future research.
Developing partnerships with payers can also create advantages. For example, in
Michigan the largest commercial payer began to include the Keystone ICU project
in its P4P incentive, and this added additional incentives to participation. The Blue
Cross Blue Shield of Michigan (BCBSM) first provided financial incentives to hospitals
in the collaborative that submitted data. This incentive encouraged those organiza-
tions that may have been less likely to participate to report data on a regular basis.
The incentive was subsequently switched from a pay-for-participation to a P4P
scheme, in which hospitals were rewarded only when there was improved adoption
of processes that were linked to the outcomes.
Centralized support for the collection and reporting of data is a core element of
a collaborative quality-improvement initiative. A system of audit and feedback helps
to maintain the credibility of the intervention and monitor its ongoing effectiveness,
and to convince stakeholders that resources could not be better directed elsewhere.
In Michigan, data submitted to the project management team were reported back
within a 6-week time frame. The rapid reporting of the ICUs’ performance, along
with a comparison with other ICUs in the project, provided timely feedback to the
frontline teams and was perceived to be important for maintaining engagement. Simi-
larly, in the Ontario ICU quality-improvement collaborative, timely audit-feedback of
comparative performance information was cited by participants as being the most
important driver of change through “friendly competition.” Furthermore, the compar-
isons with other participating ICUs were deemed to increase communication within
ICUs and elicit support from hospital leadership.23,28
The optimal size, geography, and scope of a large-scale collaborative remain
unknown. State-level or other regionalization may offer some advantages (eg,
fostering healthy competition between sites) that may be difficult to achieve with
much larger initiatives such as the Institute for Healthcare Improvement 100,000 Lives
Campaign.29 Such competition has been found to be a key element contributing to the
success of some collaboratives.28
 Improving ICU Quality Using Collaborative Networks 85

Finally, the collaborative network cannot focus solely on the clinical processes and
outcomes. It must have a component that actually addresses changing the behavior of
clinicians. Collectively these behaviors, referred to as the ICU’s culture, are influenced
by the perspectives and attitudes of the clinical staff toward patient safety and team-
work. In the Keystone ICU project, the application of interventions that specifically
addressed how teams worked together to solve problems, prevent harm, and commu-
nicate with each other were applied alongside the technical interventions to prevent
CLABSI and VAP. The use of tools to foster and develop teamwork, such as daily goals
and “learning from defects,” were used to foster an environment where physicians and
nurses, as well as other members of the care team, respected the input of each other
in the provision of care.30–32 There is much emerging literature demonstrating that
improved teamwork and safety culture lead to better outcomes for patients.33,34

EVALUATING BENEFITS AND UNINTENDED CONSEQUENCES

The authors believe that more research is needed to evaluate the effectiveness of ICU
collaborative networks, and also to better understand which factors contribute to their
success or failure. To date, most large-scale quality-improvement interventions
including collaboratives have been evaluated using the before-after study design or
analyses of administrative data. Although these offer advantages because they are
simple and feasible, they can be vulnerable to confounding even when sophisticated
time-series analyses are used.35,36 Collaboratives are increasingly being studied using
more rigorous study designs, for example, cluster randomized trials23; these
approaches can help account for temporal trends that may have been unrelated to
the intervention.25 A challenge in cluster randomized trials for studying collaboratives
is that they require some hospitals to receive no intervention if randomized to a control
arm. The Ontario collaborative overcame this challenge by using an “active control
group,” so that each group of ICUs received the active behavior-change intervention
targeting one care practice and simultaneously acted as a control group for the other
group of ICUs that received the active behavior-change intervention targeting
a different care practice. Stepped-wedge randomization is another approach to eval-
uating large-scale quality-improvement initiatives that is becoming increasingly used
to evaluate collaborative networks.37,38 This study design involves randomizing
groups to receive the intervention at different time points and in sequence; groups
that have not yet received the intervention remain as “controls” until a time point
that is predefined by the randomization scheme. This approach has appeal because
it ensures that all groups will receive the quality-improvement intervention by the
end of the evaluation, and can make the roll-out more manageable. However, as
with cluster randomized trials, a disadvantage is that many hospitals will not be part
of the collaborative at the start of the implementation.

FUTURE RESEARCH

The success of collaborative projects such as the Keystone ICU project has
compelled many regions and jurisdictions to consider similar large-scale quality-
improvement initiatives. However, much remains to be learned about the effectiveness
of these collaboratives and their mechanisms of action. For example, what makes
some collaborative networks more effective than others? Are some care practices
and behaviors more amenable to change using collaboratives? Are these collaborative
networks cost-effective, especially compared with multiple single-unit quality-
improvement initiatives or other approaches to improving care across a system?
These and other questions outlined in Box 1 highlight the many knowledge gaps
86 Watson & Scales

Box 1
Questions for future research involving ICU collaborative networks

Research on the Effectiveness of Collaborative Networks

What makes some collaborative networks more effective than others?
How sustainable are the improvements that can be achieved using collaborative networks?
Are collaborative networks cost-effective compared with multiple single-unit quality-
improvement initiatives, and in comparison with other system-level quality-improvement
initiatives (eg, public reporting or P4P)?
Research on How Collaborative Networks Change Behavior
Are some care practices and behaviors more amenable to change using collaborative networks?
What components of a quality-improvement intervention are most suited to use in
a collaborative network (eg, education, reminders, audit-feedback, and so forth)?
Does competition versus cooperation lead to more effective uptake and adoption, and foster
change in behavior?
How much contact is required between frontline clinicians and the coordinating center, or
project leaders?
Which members of the health care team and/or administration need to be involved to make
a collaborative most successful?
What improvement knowledge do frontline providers engaged in the project need?
Can telemedicine connections between geographically separated ICUs achieve the same
degree of motivation among participants as face-to-face meetings?

that persist. There are great opportunities for further research to explore these issues
and to ensure that these collaborative networks, which typically involve many hospi-
tals, clinicians, and resources, can achieve their goals of improving system-level
quality and becoming cost-effective.

SUMMARY

Collaborative ICU networks have successfully improved quality across entire health
systems. These networks offer several advantages that include targeting a large
number of patients, sharing of resources between sites, and implementing common
measurement systems that can be used for audit and feedback or benchmarking.
More research is needed to understand the mechanisms through which collaboratives
lead to improved delivery of care and to demonstrate their cost-effectiveness in
comparison with other approaches to system-level quality improvement.

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