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ANNEX SEVEN: CASE STUDY 6: USING COLLABORATIVES TO BUILD CAPACITY TO USE INFORMATION FOR THE IMPROVEMENT OF PRACTICE
A Collaborative is a model of collaborative learning which was originally devised to achieve breakthrough improvements in quality whilst reducing costs in health care 36.
The approach is based on the premise that there is sound evidence that could support improvements in the costs and outcomes of health care practices, but that "much of this science lies fallow and unused in daily work". In other words, there is a gap between what we know and what we do.
Collaboratives are designed to help close that gap by creating a structure in which interested organisations can learn from each other and also from recognised subject matter experts in specific clinical areas with application experts who could help select, test and implement changes in front line settings. Teams alternate between learning sessions in which teams from all participating organisations come together to learn about an issue and plan changes and action periods in which the teams return to their organisations and test those changes in clinical settings.
The IHI Collaborative Model in outline
A IHI Breakthrough Series Collaborative is a short-term (6 - 15month) learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area.
Since 1995, IHI has sponsored over 50 such Collaborative projects on several dozen topics involving over 2,000 teams from 1,000 health care organizations.
Collaboratives range in size from 12 to 160 teams. Each team typically sends three of its members to attend Learning Sessions (three face-to-face meetings over the course of the Collaborative), with additional members working on improvements in the local organization.
Teams in such Collaboratives have achieved dramatic results, including reducing waiting times by 50 percent, reducing worker absenteeism by 25 percent, reducing ICU costs by 25 percent, and reducing hospitalizations for patients with congestive heart failure by 50 percent.
In addition, IHI has trained over 650 people in the Breakthrough Series methodology, thus spawning hundreds of Collaborative initiatives throughout the health care world, sponsored by organizations other than IHI.
The Scottish Primary Care Collaborative ( SPCC)
The SPCC is a form of capacity building and skills development which uses a variety of redesign tools and techniques to diagnose the causes of problems within the primary health care system and test potential solutions through small scale rapid cycles of change. It is based on the premises that:
- change will not be delivered by issuing guidance and directives
- solutions must be designed to fit local needs and circumstances
- staff must be actively engaged in the process if significant and sustainable change is to be achieved.
Phase 1 of the SPCC has addressed the two issues of improving access to general practice and tackling diabetes. The first wave began in September 2003 with over 100 participating GP Practices across 20 sites in nine Health Boards. Wave 2 began in May 2004 and has 80 participating GP Practices.
The SPCC has followed the collaborative process described in Figure A7.1.
Figure A7.1: the Collaborative Process
Source: www.npdt.org/healthiercommunities/Healthy%20Communities%20Inserts.pdf
The SPCC started with an orientation workshop attended by clinicians, managers, GP practice nurses and practice managers. This event was also attended by clinicians who had already made changes using the methodology. The practitioners leave this workshop and establish their baseline for the collaborative measures by which they will judge their own improvement progress.
The collaborative participants met subsequently at three workshops over the course of the following year. Each site has a project manager whose role is to facilitate the site at the workshops, provide support to participants in between workshops and report on progress. Between workshops, participants used the Plan/Do/Study/Act cycle ( PDSA) and other tools such as Process Mapping37 to apply their learning in real life situations in general practice settings.
Plan, Do, Study, Act - in outline
PDSA is a tool to try out changes on a small scale to begin with and to rely on using many consecutive cycles to build up information about how effective the change is. A cycle should take a week. This makes it easier to get started, gives results rapidly and reduces the risk of something going wrong and having a major impact. When there is enough information to feel confident about the change it can then be implemented as part of the system. In this way any member of a team can be involved and take ownership of the changes being implemented, so leading to more sustainable improvements. The model can be condensed to the cycle shown below:
Source: http://www.scotland.gov.uk/library5/health/cftb.pdf
The SPCC provided PDSA pro-formas to participants to develop their plan and record their actions. PDSA's are also recorded on line as part of the information gathering process. At workshops participants also met for 'team time' talks which provide the opportunity to discuss common issues across the different GP practices within a single site. In the second year of the collaborative, participants choose a topic of their own in addition to access and diabetes. Some have chosen clinical issues whilst others are interested in how they can gather and respond to service users' views.
In terms of the wider dissemination of the learning from the collaborative, practices are encouraged to spread the learning to other practices, so that the transfer of knowledge about 'what works' is active and localised. The programme has shown significant improvements through the use of these approaches, including improvements in waiting times and patient satisfaction and improved clinical outcomes for diabetic patients.
Phase 2 of the SPCC will start in June 2005 looking at access and the secondary prevention of Coronary Heart Disease. A second collaborative programme on Unscheduled Care is also due to commence in May 2005 38. These are two collaboratives and it is anticipated that this methodology will be used for other improvement programmes. Collaboratives have been more widely used in the UK to bring about systematic and sustainable change in a number of public service environments 39.
For further information: see http://cci.scot.nhs.uk
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