Methods & Tools
The improvement collaborative is a major new approach for rapidly improving the quality and efficiency of healthcare. A collaborative focuses on a single technical area (for example, prevention of mother-to-child transmission of HIV) and seeks to rapidly spread existing knowledge or best practices related to that technical topic to multiple settings, through systematic improvement efforts of a large number of teams. A collaborative is a time-limited improvement strategy, usually lasting from 12 to 24 months.
Teams participating in a collaborative typically are located in healthcare facilities in different geographic areas and may even work for different organizations. The collaborative engages the teams in working out the operational details in implementing a set of identified best practices in the focus area of the collaborative in their respective settings. The collaborative facilitates active sharing of strategies and ideas for improvement among participating teams, so that teams learn from each other and can quickly benefit from successful changes implemented by other teams.
Collaboratives are designed to achieve dramatic improvements in the quality and outcomes of care in a short period of time by fostering active learning among improvement teams and by regularly tracking and communicating results of the improvement efforts. Teams within a collaborative use a common set of core measurement indicators—usually five to 10 key indicators—that relate to the desired outcomes of the collaborative. Each team collects data for its facility on the indicators and reports these data, usually on a monthly basis, to the other teams. Frequent monitoring and sharing of results helps to spur the pace of improvements, creating a sense of friendly competition among teams to see which team can achieve the best results. The network of shared learning results in rapid development and testing of innovations and solutions to problems, rapid dissemination of effective changes, and rapid development of effective models of care.
Another distinguishing feature of the improvement collaborative approach is that it seeks to spread improvements beyond the participating teams, to be applied throughout the organization(s) participating in the collaborative. Typically, a collaborative on a new topic area may conclude with the development of a package of interventions that have been field tested and proven to yield results in a particular setting. The initial collaborative—sometimes called a demonstration collaborative—may then be followed by a second phase, often known as an expansion collaborative, that provides a framework for spreading the improvements from the initial or demonstration sites to the rest of the parent health system. This emphasis on intentional spread of the improvements achieved distinguishes collaboratives from other quality improvement approaches and makes collaboratives an attractive scale-up strategy.
The Institute for Healthcare Improvement developed the improvement collaborative approach in the mid-1990s in the United States. Since then, IHI has supported over 1000 teams applying this methodology, addressing diverse healthcare processes and clinical content areas. Healthcare organizations in many other countries have since implemented improvement collaboratives in hospital and clinical practice settings, demonstrating excellent results.
The Quality Assurance Project began to work with the improvement collaborative approach as part of the project’s technical assistance in the Russian Federation. In 1998, QAP began work in two Russian oblasts to develop and pilot test improved models of care for the management of pregnancy-induced hypertension, adult arterial hypertension, and neonatal respiratory distress syndrome. QAP worked with teams in a small number of health facilities in Tver and Tula Oblasts to update local clinical guidelines based on international evidence and then introduce a series of changes in the organization of services to put those guidelines into practice. Teams systematically monitored their results, and after 24 months, had succeeded in putting in place new models of care that had demonstrated results in the Russian healthcare setting.
In 2000, QAP used the improvement collaborative methodology to spread the new models of care to all the other health facilities in the same oblast. Healthcare providers from the pilot facilities led orientation and coaching sessions with teams in the new facilities, and within 12 months, the new models of care had been incorporated in all facilities in each oblast. In 2003, QAP assisted the Ministry of Health of the Russian Federation to start five national improvement collaboratives involving 23 Russian territories in the spread of the improved systems of care that had been developed in Tula and Tver.
QAP also began to apply the improvement collaborative approach in other countries and to new clinical areas, such as essential obstetric care and HIV/AIDS. In 2003, QAP started improvement collaboratives in Rwanda (one on PMTCT-VCT and a second collaborative on child malaria), Ecuador (essential obstetric care), Nicaragua (one on essential obstetric care and a second collaborative on pediatric care in hospitals), Honduras (essential obstetric care), Eritrea (pediatric hospital care), Niger (pediatric hospital care), and Tanzania (infection prevention). In 2004, QAP launched new improvement collaboratives in Rwanda (antiretroviral therapy), Malawi (pediatric hospital care), the Russian Federation (HIV/AIDS), Tanzania (one on pediatric hospital care, with a focus on pediatric AIDS, and another collaborative on family planning), and Benin (essential obstetric care). In 2005, QAP plans to initiate one or more collaboratives on improving tuberculosis case management.