title: Opening the black box of quality improvement collaboratives: an Actor-Network theory approach.
abstract: BACKGROUND
  Quality improvement collaboratives are often labeled as black boxes because effect studies usually do not describe exactly how the results were obtained. In this article we propose a way of opening such a black box, by taking up a dynamic perspective based on Actor-Network Theory. We thereby analyze how the problematisation process and the measurement practices are constructed. Findings from this analysis may have consequences for future evaluation studies of collaboratives.
  
  
  METHODS
  In an ethnographic design we probed two projects within a larger quality improvement collaborative on long term mental health care and care for the intellectually disabled. Ethnographic observations were made at nine national conferences. Furthermore we conducted six case studies involving participating teams. Additionally, we interviewed the two program leaders of the overall projects.
  
  
  RESULTS
  In one project the problematisation seemed to undergo a shift of focus away from the one suggested by the project leaders. In the other we observed multiple roles of the measurement instrument used. The instrument did not only measure effects of the improvement actions but also changed these actions and affected the actors involved.
  
  
  CONCLUSIONS
  Effectiveness statistics ideally should be complemented with an analysis of the construction of the collaborative and the improvement practices. Effect studies of collaboratives could benefit from a mixed methods research design that combines quantitative and qualitative methods.
authors.affiliation: Department of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands. broer@bmg.eur.nl
authors.forename: Tineke
authors.initials: T
authors.lastname: Broer
authors.forename: Anna P
authors.initials: AP
authors.lastname: Nieboer
authors.forename: Roland A
authors.initials: RA
authors.lastname: Bal
mesh_terms: D003299:Cooperative Behavior; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006268:Health Facilities / Q000592:standards; D006801:Humans; D007373:Interinstitutional Relations; D007400:Interprofessional Relations; D008297:Male; D001523:Mental Disorders / Q000175:diagnosis / Q000628:therapy*; D017146:Models, Organizational; D009426:Netherlands; D009936:Organizational Innovation; D015397:Program Evaluation; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D058996:Quality Improvement / Q000458:organization & administration*; D012107:Research Design; D012944:Social Support; D017749:Total Quality Management / Q000458:organization & administration
references.citation: Ann Intern Med. 2004 Jun 1;140(11):897-901
references.pmid: 15172904
references.citation: Jt Comm J Qual Saf. 2003 Feb;29(2):85-93
references.pmid: 12616923
references.citation: Qual Health Res. 2002 Sep;12(7):966-81
references.pmid: 12214681
references.citation: Soc Sci Med. 2010 May;70(9):1285-94
references.pmid: 20185218
references.citation: Qual Saf Health Care. 2002 Sep;11(3):270-5
references.pmid: 12486994
references.citation: BMJ. 2008 Jun 28;336(7659):1491-4
references.pmid: 18577559
references.citation: BMC Health Serv Res. 2009 Sep 26;9:175
references.pmid: 19781101
references.citation: Soc Sci Med. 2009 Dec;69(12):1713-21
references.pmid: 19833425