International Quality Improvement Collaborative

The International Quality Improvement Collaborative for Congenital Heart Disease (IQIC): Improving care in low- and middle-income countries provides benchmarking data for health care professionals and guides quality improvement efforts. The decrease in morbidity and mortality rates at participating sites is significant. Children’s HeartLink partner hospitals participating in IQIC demonstrate even more improvement in quality. (See details below.) Today all of our partners are expected to participate in the collaborative.

The IQIC was launched in 2008 by representatives from Boston Children’s Hospital and several nongovernmental organizations, including Children’s HeartLink. The IQIC:

  • collects information about site-specific outcomes following congenital heart surgery
  • determines patient and procedural predictors of site-specific outcomes
  • uses quality improvement methodology and collaboration between programs in developed and developing countries to reduce mortality in the developing world

The Database

There are over 75,000 surgical cases from 56 sites in 24 countries entered in the IQIC database.

Clinical outcomes tracked in the database include:

  • in-hospital and 30-day mortality
  • surgical site and bloodstream infections
  • nutritional status

Quality Improvement Component

The quality improvement component is based on three key drivers of mortality:

  • team-based practice
  • reduction of surgical site infections and bacterial sepsis
  • safe perioperative practice

IQIC partners participate in monthly webinars hosted by a multidisciplinary team from Boston Children’s Hospital.

  • The webinars facilitate didactic and participatory learning, and provide a collaborative learning experience that can be adapted for individual sites.
  • The modules include an overview of the problem, learning objectives, application and problem solving through case studies, implementation and evaluation tools.
  • The curriculum also includes advanced nursing content.

Evaluation and Reporting

Boston Children’s Hospital sends teams to visit each site on an annual basis to ensure validity of the data and conduct a source verification of a sample of data that has been entered by each site into the database.

Sites that pass the data audit receive an annual benchmarking report that allows them to track individual progress and compare their results to their IQIC partners. These reports can be used to evaluate program performance and drive quality improvement at each site. Results from the 2015 annual data analysis showed that the quality of IQIC data has improved, with over 84% of sites passing the data audit to be included in the aggregate analysis.

Improvements at Participating Sites

  • IQIC data show that participating institutions realized significantly lower rates of post-surgical infection and mortality since joining the collaborative. (Jenkins et al. 2014 Reducing Mortality and Infections after Congenital Heart Surgery in the Developing World. Pediatrics, 134(5):e1422-30)
  • While case complexity has remained relatively constant since 2010, the proportion of cases in RACHS-1 risk categories 4 through 6 has increased slightly over time, along with the proportion of cases with age at surgery <1 year.
  • Risk-adjusted in-hospital mortality and major infection rates were significantly lower in each of the five years 2011 through 2015 relative to 2010.
  • Risk-adjusted in-hospital mortality has decreased since 2012 and risk-adjusted major infection has decreased since 2013.

Improvements at Children’s HeartLink Partner Hospitals Enrolled in IQIC

  • In 2014, five of Children’s HeartLink’s partner hospitals were compared to their peers in the IQIC.
    • Surgical site infections at five partner hospitals working with Children’s HeartLink since 2010 decreased from 7.6% to 1.7% in 2014.
    • Bacterial sepsis decreased from 20.4% to 6.3% in the same period, and other major infections decreased from 22.5% to 7.7%.
  • From 2010 to 2014, surgical site infections in postoperative patients decreased from 18.3% to 2.9% at Hospital da Criança e Maternidade in São José do Rio Preto, Brazil.
  • In a region with extremely long waiting lists, our partner hospital Nhi Dong 1 in Ho Chi Minh City, Vietnam, increased patient volume five-fold in just 2 years: from 3,308 patients in 2013 to 15,345 in 2015. It  doubled the number of surgeries since the partnership began, from 162 surgeries in 2008 to 335 surgeries in 2015, while also increasing the number of complex surgical cases.
  • Institut Jantung Negara in Kuala Lumpur, Malaysia, more than doubled the volume of open heart surgical cases in infants under one year old, from 94 infants in 2007 to 278 infants in 2014.
  • West China Hospital in Chengdu reduced its postoperative mortality rates from 4% in 2008 to 1.2% in 2014, and during that time period the case mix became increasingly complex.