Quality improvement (QI) methods are foundational to pediatric practice, spanning process optimization, safety initiatives, and evidence-based care implementation. Many QI efforts occur at the local institutional level and can be adapted to other settings. As the QI field continues to evolve, we must consider additional strategies to reach more children. Collaborative QI facilitates access to resources that are not widely available, including subject matter and application experts, collective learning opportunities, accelerated knowledge dissemination, and implementation success.1 ,2 

In this issue of Pediatrics, 3 articles outline national QI collaboratives. Each initiative is supported by Value in Inpatient Pediatrics (VIP), an American Academy of Pediatrics–affiliated network. VIP supports multisite collaboratives in reaching health care systems that may not have the resources to perform projects independently.3  Prompted by the lack of high-quality evidence for routine use of high-flow nasal cannula (HFNC) to manage bronchiolitis and building on previous single-center studies, Byrd et al sought to reduce HFNC initiation and duration.4  They incorporated decision support tools to change institutional culture and designed toolkits to align with preexisting pathways, allowing for local system customization.4  McCulloh et al describe a collaboration to increase appropriate antibiotic therapy and duration for common bacterial infections.5  McDaniel et al describe a collaborative to improve American Academy of Pediatrics clinical practice guideline adherence for well-appearing febrile infants.6  They included family-centered educational tools, such as standardized discharge instructions and parent–provider discussion scripts.6 

As demonstrated by these 3 projects, collaborative QI requires ample financial and personnel resources, which in turn lead to several benefits. First, collaborative studies allow for generalizability to other health care systems and patient populations, as demonstrated by Byrd et al and McCulloh et al.’s studies, which included freestanding children’s hospitals in academic and community settings.4 ,5  Second, these studies can incorporate large comparison groups, as demonstrated by Byrd et al performing 2 arms, with each arm serving as a contemporaneous control for the other.4  Third, collaborative QI facilitates access to resources. McDaniel et al provided educational opportunities for study participants, including site meetings with QI experts, data analysis support, a webinar series, and clinician education.6  McDaniel et al and McCulloh et al used project-wide listservs for collaborative learning and troubleshooting.5 ,6  Finally, collaborative QI allows similar hospitals to compare and support local change, as demonstrated by McDaniel et al.6 

Although the impact of collaborative QI is substantial, many QI initiatives take place at the local level, leading to positive community outcomes while laying the groundwork for larger efforts. Local work allows for lessons to be learned at smaller scale and then applied to other settings, as recommended by the Model for Improvement.7  Local QI efforts are responsible for systemic changing that. Byrd et al demonstrated by building on the single-center study conducted by Siraj et al that trialed low-flow nasal cannula before HFNC and successfully reduced initiation rates.8  We must identify gaps between accepted best practice and local practice, craft appropriate aims, and design measurement strategies.1  These learnings can then be shared and scaled through collaborative QI.

As we continue to build on the successful efforts of the authors and participating centers described here, we can consider areas for continued growth. One important consideration for future QI success is to incorporate equity principles. The Institute for Healthcare Improvement Quintuple Aim outlines 5 aims for success, including health equity.9  As noted by Dr Kedar Mare, “without including equity as an explicit aim, our design choices will miss the opportunity to build equity into all that we do.”10  To eradicate health and health care disparities affecting minority communities, we must increase data to identify and address disparities, while providing incentives for the quality care of marginalized communities.11  Many theories, methods, and frameworks are available to assist improvement scientists as they approach their research questions with an equity lens.12  Agniel et al share a measurement framework that advances equity by expanding stratified reporting, focusing on 1 group at a time.13  Reichman et al propose an action-oriented approach, “Equity-Focused Quality Improvement”, to prevent the perpetuation and widening of existing disparities that may occur when equity is not centered in the conception and execution of improvement work.14 

Despite the widespread acknowledgment that equity is a foundational component to successful quality improvement, many studies are performed without an equity focus, evaluation of disparities, nor inclusion of family partners of commonly disempowered groups.15  These strategies are important steps toward equitable outcomes.16  When these elements are not reported, it is impossible to assess whether QI efforts led to equitable improvement or to perpetuation of harm to minority communities by widening unmeasured gaps. Some important resources for facilitating equity approaches, including access to data for stratification, may be facilitated by participation in collaborative QI with increased resources. However, a lack of resources is not justification to exclude equity in QI work. Every system will have different health and health care disparities that will require individualized approaches, in both single-center and multicenter QI. Transitioning equity-focused work to a broader level should be intuitive if equity is a core aim of all improvement work.

Both local and national collaborative QI are necessary as the field of improvement science matures. We commend the authors of these VIP initiatives for demonstrating the potential for collaboratives to advance QI methodology; it is up to all of us in the QI community to advance it yet further. We need to hold each other accountable for ensuring equity in our efforts, using QI principles effectively, and following sustainability beyond the initial phase. Local and collaborative QI efforts that do this effectively will reach more children, including the most vulnerable among them.

Drs Ridge and Statile drafted the commentary and reviewed it critically for important intellectual content; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

HFNC

high-flow nasal cannula

QI

quality improvement

VIP

Value in Inpatient Pediatrics

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