Collaboration, Context and Cost: A realist-informed process evaluation of a quality improvement collaborative to improve dementia care in Australia

Author: Lenore de la Perrelle

de la Perrelle, Lenore, 2021 Collaboration, Context and Cost: A realist-informed process evaluation of a quality improvement collaborative to improve dementia care in Australia, Flinders University, College of Medicine and Public Health

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With increasing numbers of people living with dementia worldwide, there is an urgent need to support people with dementia to live as well as possible. While evidence exists for treatments to improve the quality of life of people living with dementia and their caregivers, they are not routinely offered in clinical practice. This gap between research and practice means that poor quality or inconsistent treatment is offered in dementia care and results in the underutilisation of research effort.

The aim of this research is to examine the feasibility and acceptability of the trial of a quality improvement collaborative strategy to understand how, why, in what circumstances and at what cost it worked (or not) to improve adherence by clinicians to clinical guidelines for dementia. This evaluation of the implementation process examined three questions: how the implementation strategy works to build knowledge and skills in clinicians to improve dementia care, what value is added by the involvement of people with dementia and caregivers in the research and what costs and benefits that accrue from the strategy. By considering how context, collaboration efforts, and costs can influence outcomes, this research developed an understanding of the mechanisms of the quality improvement collaborative strategy in dementia care.


A realist-informed process evaluation, using mixed methods, examined the experience of clinicians and experts-by-experience of dementia involved in the trial, to identify mechanisms of the strategy. A cost-benefit analysis identified the resources required to improve practice and a business case for future use of the strategy.


The 28 clinicians involved in the evaluation of the trial found the quality improvement strategy enabled them to make changes in practice. By overcoming pessimism about the benefits for people with dementia and resistance to change by others, the quality improvement collaborative strategy gave clinicians confidence in a credible process. With expert advice and coaching most clinicians were able to implement change in their practice and involve others in changes. Experts-by-experience of dementia made contributions at all stages of the research trial. The evaluation found that their perspective improved the relevance of the research and their involvement convinced clinicians that the clinical guidelines would meet the needs of people living with dementia. The strategy was found to be cost-beneficial if 150 clinicians participated and this provided a business case for the reuse of the strategy in future.


The evaluation of the trial of the quality improvement collaborative to improve adherence to evidence-based guidelines in dementia care found it both acceptable and feasible to clinicians. A refined program theory showed that supportive reflective practice, a credible and flexible process empowered clinicians to overcome constraints and attitudes about routine practice in dementia care. The involvement of experts-by-experience of dementia added perspective and focus on priority needs which benefited the clinicians and the research. The resources required for the collaborative strategy were cost-beneficial when scaled up to include more clinicians. Lessons learnt from this research may be applied to up-scale the collaborative strategy to improve the quality of post-diagnostic dementia care.

Keywords: Dementia, Realist-informed, Process Evaluation, Economic evaluation, Public involvement, Healthcare quality improvement

Subject: Ageing Studies thesis

Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Medicine and Public Health
Supervisor: Associate Professor Kate Laver