How can organizations improve their operating processes and hence performance? Experts advise organizations to leverage front-line staff knowledge about existing organizational processes via collaboration among front-line staff and between front-line staff and managers. Collaboration refers to individuals working together to achieve a common goal via information-sharing, joint decision-making, and coordination of activities. We tested the effectiveness of this strategy in 23 hospital neonatal intensive care units (NICUs) that participated in a quality improvement collaborative sponsored by the Vermont Oxford Network (VON) during 2002 and 2003. NICUs provide care to premature infants and infants with complications. As part of the collaborative, they worked to implement potentially better practices to improve patient outcomes.

We hypothesized that improved patient outcomes would be associated with higher levels of collaboration in three types of activities: (1) unit management (shared governance), (2) routine production (team meetings and collaborative communication), and (3) process improvement (selection of improvement projects and use of “learn-how” activities such as dry-runs). We tested our hypotheses at the patient-level (N = 1061) with population-averaged, logistic regression models to account for the correlation between infants treated in the same NICU and our binary outcome variable, 2004 patient mortality. To assess risk-adjusted improvement in mortality over the course of the collaborative, we controlled for NICU’s 2001 risk-adjusted mortality rate.

Contrary to our hypothesis, shared governance was significantly associated with an increased chance of mortality (Odds Ratio (OR) = 1.70; 95% confidence interval (CI) = 1.08 to 2.68; p = .02). Our other two hypotheses received partial support. Collaboration in routine production as reflected in collaborative communication was associated with reduced chance of mortality (OR = .74; 95% CI = .53-1.02; p=.06), but team meetings had no effect on mortality. Similarly, collaboration in process improvement as reflected by the use of learn-how was associated with a decreased chance of mortality (OR = .59; 95% CI = .36-.97, p =.04), but shared project identification was not. In sum, we found no evidence to support a positive relationship between collaboration in unit management and better performance; instead, we found the opposite. We did find some support for a positive relationship between reduced mortality and the more “active” forms of collaboration in routine production and process improvement.

Our results support the recommendation that organizations leverage front-line staff’s knowledge via multiple forms of collaboration (Institute of Medicine 2004). However, they show that not all forms of collaboration are helpful. Shared governance may interfere with performance improvement by adding time-consuming steps to change processes or diverting staff’s attention from core functions. Also, obtaining consensus across staff and managers may result in less-effective compromise solutions. On the positive side, collaboration in routine production and process improvement may solve two common problems: fragmented service delivery (Institute of Medicine 2004) and new process implementation failure (Cabana et al. 1999). Collaborative communication may facilitate better outcomes by enabling effective coordinated responses to changing conditions. Learn-how may help overcome resistance to change because staff adapt new practices to their setting. We hope this concrete knowledge about the effectiveness of different types of collaboration aids other organizations striving to improve performance.
 

References:

Cabana, M. D., C. S. Rand, N. R. Powe, A. W. Wu, M. H. Wilson, P. A. Abboud, and et al. 1999. “Why don't physicians follow clinical practice guidelines? A framework for improvement.” JAMA 282(15):1458-65.

Institute of Medicine. 2004. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, D.C.: National Academy Press.

 

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Posted on January 21, 2008