Shared learning among quality improvement teams in Nicaragua: Spread of better care practices in HIV/AIDS, family planning, obstetrics and pediatric care through collaborative learning

An improvement collaborative is a shared learning system that gathers many teams to work together, with the purpose of rapidly achieving significant improvements in quality and efficacy of a specific care area, with the intention of diffusing these methods to other sites. The improvement collaborative improvement approach often consists of an initial demonstration (pilot) phase in which improvement teams share their experiences. A subsequent expansion (spread) phase allows for the best innovations to be synthesized and communicated to a larger number of health facilities and enables rapid uptake of best practices across the system.

In 2003, the Ministry of Health of Nicaragua (MINSA), with the technical support of USAID through their Quality Assurance Project (QAP) and later through QAP’s follow-on, HCI, developed three parallel improvement collaboratives for to introduce continuous quality improvement methods for: Essential Obstetric Care(EOC), Pediatric Hospital Improvement (PHI) and HIV-Family Planning. All three collaboratives concluded their demonstration phase in the 2007.  
The effectiveness of the collaborative in achieving rapid improvement across the participating facilities is determined by the process of sharing of learning between teams. The objective of this study was to analyze how change ideas are communicated across teams, determine what information is useful for other teams to effectively implement the change ideas, and identify what factors enable or hinder teams from adopting effective change ideas. The study also explored whether certain changes are easier to diffuse than others and what is the speed at which teams adopt new change ideas. It was expected that the study findings would help HCI to improve the process of shared learning so that we can achieve faster and more effective spread. 
The study was performed in 9 hospitals and 8 health centers of the Ministry of Health. Data were obtained from 50 semi-structured interviews with key individuals and five focus groups.
From this qualitative study it was seen that respondents found learning sessions to be the preferred channel for shared learning. The collaborative environment led to a competitive spirit among teams which motivated them to perform better. Learning in the collaborative spread even to facilities not involved in the collaborative thus strengthening the referral system. 62% of respondents said that it is faster to implement change ideas generated within the team rather than those received from other teams. This was said to be due to the fact that, team members are not easily convinced about changes that are developed by other teams.
Conclusions and Recommendations
Respondents expressed that learning sessions should be an ongoing activity, performed at least three times a year and to this end, authorities should advocate for funding and technical assistance with cooperation agencies. They also gave some recommendations to improve quality of the learning sessions. Also, other channels for shared learning need to be developed further such as communication over the internet and using the telephone for communication between learning sessions.


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