title: Optimising the community-based approach to healthcare improvement: Comparative case studies of the clinical community model in practice.
abstract: Community-based approaches to healthcare improvement are receiving increasing attention. Such approaches could offer an infrastructure for efficient knowledge-sharing and a potent means of influencing behaviours, but their potential is yet to be optimised. After briefly reviewing challenges to community-based approaches, we describe in detail the clinical community model. Through exploring clinical communities in practice, we seek to identify practical lessons for optimising this community-based approach to healthcare improvement. Through comparative case studies based on secondary analysis, we examine two contrasting examples of clinical communities in practice - the USA-based Michigan Keystone ICU programme, and the UK-based Improving Lung Cancer Outcomes Project. We focus on three main issues. First, both cases were successful in mobilising diverse communities: favourable starting conditions, core teams with personal credibility, reputable institutional backing and embeddedness in wider networks were important. Second, top-down input to organise regular meetings, minimise conflict and empower those at risk of marginalisation helped establish a strong sense of community and reciprocal ties, while intervention components and measures common to the whole community strengthened peer-norming effects. Third, to drive implementation, technical expertise and responsiveness from the core team were important, but so too were 'hard tactics' (e.g. strict limits on local customisation); these were more easily deployed where the intervention was standardised across the community and a strong evidence-base existed. Contrary to the idea of self-organising communities, our cases make clear that vertical and horizontal forces depend on each other synergistically for their effectiveness. We offer practical lessons for establishing an effective balance of horizontal and vertical influences, and for identifying the types of quality problems most amenable to community-based improvement.
authors.affiliation: Cambridge Centre for Health Services Research, University of Cambridge, UK; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, USA. Electronic address: eaveling@hsph.harvard.edu.
authors.forename: Emma-Louise
authors.initials: EL
authors.lastname: Aveling
authors.affiliation: Department of Health Sciences, University of Leicester, UK.
authors.forename: Graham
authors.initials: G
authors.lastname: Martin
authors.affiliation: NIHR Biomedical Research Unit in Nutrition, Diet and Lifestyle at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, UK.
authors.forename: Georgia
authors.initials: G
authors.lastname: Herbert
authors.affiliation: Department of Health Sciences, University of Leicester, UK.
authors.forename: Natalie
authors.initials: N
authors.lastname: Armstrong
mesh_terms: D016022:Case-Control Studies; D019058:Community Networks / Q000592:standards* / Q000639:trends; D003695:Delivery of Health Care / Q000379:methods* / Q000592:standards; D006801:Humans; D007398:Interpersonal Relations; D058996:Quality Improvement
keywords: Case study; Clinical community; Community-based; Improvement; UK; USA