After the collaborative is over: what sustains quality improvement initiatives in primary care practices?

Multisite quality improvement (QI) initiatives, often known as collaboratives, involving primary care practices such as community health centers, academic practices, and managed care groups have been reported. Yet relatively little is known about the sustainability of these QI initiatives after the initial project, and frequently its funding, has ended. A series of practice characteristics that constitute critical elements for QI sustainability activities, as described in a Sustainability Pyramid Model, were proposed.

Approximately five months after the cessation of formalized activities of the final collaborative, 25 in-person interviews were conducted in 13 primary care practices that had participated in the three North Carolina Chronic Disease Management collaboratives, which initially involved 33 practices. Clinical outcomes were not considered.

Twelve of the 13 practices stated that the collaborative work resulted in improvement in one or more process and/or outcome clinical measures and those improvements have been continued. Five of the 13 practices reported that sustaining improvements had been a challenge since the collaboratives ended. Content analysis of the interviews indicated that the practices variously cited the practice characteristics, as included in the Sustainability Pyramid Model: regular meetings to study practice population data, leadership commitment, availability of infrastructure/staff support, pursuit of additional funding, publicity, and strategic partnerships.

Although the improvement activities initiated during the collaborative were sustained, the process of developing and implementing new QI activities appeared to be more challenging for almost half of the practices. The practices that could accomplish this ongoing new QI process had "institutionalized" their QI strategies--a finding with important implications for sustainability.