LAUSR

A major challenge in quality improvement (QI) within the medical field is adequate sample size. To effect real change, not only do we need to amass large quantities of data for analysis, but also interventions require larger groups of patients and providers to recognize the effect of said intervention. With that, single-institution projects not only may fail to demonstrate change but also may have limited applicability outside of the individual practice. Opportunities for more robust data collection, analysis, and intervention—in terms of both numbers and resources—are necessary for continued advancement in surgical quality initiatives. While we strive for large sample size, we must also ask “how large is too large?” Though increasing the number of collaborating institutions may increase the availability of data, it may also start to impinge on true collaboration. The most successful multisite collaborations require a culture of trust rather than competitiveness. Distrust prevents the dissemination of best practice from one institution to another, whereas a noncompetitive collegiality promotes partnership and sharing of ideas.1 Some argue that trust can only exist when collaboration is between institutions that are familiar beyond name only. This may limit productive interactions on a national level and raises the argument for limiting participation to a region or state, as we see in the site-wide quality collaboratives. The limited number of participating hospitals within a region allows collegial relationships to develop with relative ease, and these relationships serve as the foundation for institutional trust. The heterogeneity in practice patterns across a single state or region is impressive when you consider differences in patient populations, hospital resources, and physician preferences. With this, there will also be heterogeneity in patient outcomes—encompassing both positive and negative outliers. This represents a microcosm of medical practice across the United States. Given the proximity of the practices, it may also foster partnership and implementation of new quality-directed initiatives. In short, it is the ideal setting for QI collaboration.