The case for collaborative improvement

Lani Marquez

Knowledge Management Director, USAID ASSIST Project/URC

Collaborative improvement – an improvement strategy that harnesses the efforts of many teams or sites to work together intensively for a defined period to achieve “breakthrough” improvements in a specific area of care – is getting increasing attention as an effective health care improvement methodology.

ICAP’s quality improvement training program recently featured a webinar by Dr. Lynne Miller Franco, our colleague at EnCompass LLC, presenting findings from an evaluation commissioned by the U.S. Agency for International Development (USAID) to examine the evidence from a large number of collaboratives carried out under USAID’s Quality Assurance and Health Care Improvement projects.

The Health Foundation (a marvelous source of learning and guidance for health care improvement) recently published a new “evidence scan” on improvement collaboratives in health care. Noting that collaboratives “have been implemented throughout North America and in some parts of Europe and Australia” but have been “less well used in the U.K.,” the paper sought to answer the question, Are collaboratives effective for improving the quality of health care?  The paper also tried to identify, from the published literature, what factors have been associated with success in collaboratives, to offer guidance to practitioners in the National Health System who see collaboratives as a vehicle for change.

This is good news to those who have seen the results of collaborative improvement interventions, not the least of which is the U.S. Agency for International Development, which has been supporting the widespread application of modern improvement methods like collaboratives in over 30 countries since 2003.

USAID-supported health care improvement collaboratives have mainly involved teams of public sector care providers and implementing partners working on topics that are often mandated by central authorities to reflect government priorities.  Collaboratives is low- and middle-income countries have also typically made a number of adaptations to the Breakthrough Series Improvement Collaborative model pioneered by the Institute for Healthcare Improvement (IHI) to introduce more content on improvement methods and measurement in learning sessions and to  emphasize the role of coaches in guiding and motivating site teams.

Like the collaboratives supported by IHI in the United States and other countries, USAID-supported collaboratives have achieved rapid and significant improvements in the quality of diverse health services and demonstrated that the gains made in quality of care through collaboratives could be maintained over time.

The Health Foundation evidence scan, which looked at the evidence which came largely from North America and Europe, came to a more mixed conclusion about the effectiveness of collaboratives, noting that the two of the three randomized controlled trials of collaboratives did not show improvements in processes of care delivery, although 72% of the other studies examined did find positive effects.

At the same time, the evidence scan also summarized what the literature suggests are factors that facilitate the success of collaborative improvement.  Some of these—good planning, engagement of passionate professionals and leadership, allowing enough time to show impact—are associated with success of many endeavors, not just collaborative improvement.  But other factors resonated with what we have seen in USAID-supported collaborative improvement interventions:

  1. Focus on topics where there is established good practice and a large gap between current and ideal performance,
  2. Involve multiple disciplines on improvement teams, including patients and caregivers,
  3. Build the work on a hypothesis or “theory of change” about how activities will lead to planned outcomes, and
  4. Supplement learning sessions with organizational coaching and other strategies to accelerate the adoption and spread of evidence-based approaches across sites.

For some, perhaps, the jury on collaboratives is still out. But the evidence is growing: collaborative improvement is now a mainstay of improvement methods in health care.

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