title: Obstacles to collaborative quality improvement: the case of ambulatory general medical care.
abstract: OBJECTIVE
  To assess the effectiveness of inter-site collaboration and report-card style feedback of quality measures on quality improvement in the outpatient setting and to identify major barriers to improvement.
  
  
  METHODS
  A collaborative quality improvement effort consisting of a large cross-sectional data collection effort (chart reviews and patient surveys), feedback of comparative quality of care data to improvement teams, and collaboration between sites.
  
  
  METHODS
  Eleven primary care sites in the Boston area.
  
  
  METHODS
  Quality improvement teams at each site with physician leaders.
  
  
  METHODS
  Education about techniques of rapid-cycle quality improvement, coaching of on-site teams, and report-card style feedback of comparative site-specific quality of care data.
  
  
  RESULTS
  Multiple quality improvement projects were undertaken through this collaboration. However, though we were careful to educate teams on methods of continuous quality improvement and to name specific clinical leaders, the degree of collaboration and quality improvement fell short of expectations. Major impediments to improvement included lack of team members' time and resources, lack of incentives, and unempowered team leadership. The primary obstacle to collaboration was the diversity of sites and inability of teams to create interventions that were relevant to other sites.
  
  
  CONCLUSIONS
  Despite ample quality of care data, quality improvement education, and a structured collaborative process, achieving quality improvement in the ambulatory setting is still a difficult challenge. Organizations need to find ways of overcoming the obstacles faced by improvement teams in order to maximize quality improvement.
authors.affiliation: Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
authors.forename: T K
authors.initials: TK
authors.lastname: Gandhi
authors.forename: A L
authors.initials: AL
authors.lastname: Puopolo
authors.forename: P
authors.initials: P
authors.lastname: Dasse
authors.forename: J S
authors.initials: JS
authors.lastname: Haas
authors.forename: H R
authors.initials: HR
authors.lastname: Burstin
authors.forename: E F
authors.initials: EF
authors.lastname: Cook
authors.forename: T A
authors.initials: TA
authors.lastname: Brennan
mesh_terms: D000553:Ambulatory Care / Q000592:standards*; D019985:Benchmarking; D001900:Boston; D003299:Cooperative Behavior; D003430:Cross-Sectional Studies; D005246:Feedback; D006302:Health Services Research; D006801:Humans; D007324:Institutional Management Teams; D007373:Interinstitutional Relations; D008332:Management Quality Circles; D011320:Primary Health Care / Q000592:standards*; D017749:Total Quality Management / Q000458:organization & administration*