Breakthrough Series Collaborative


Background

The Breakthrough Series Collaborative is an evidence-based quality improvement methodology that has been used extensively around the world in both primary and secondary healthcare settings. It was developed by Dr Don Berwick and colleagues from the Institute of Healthcare Improvement and incorporates fundamental principles of quality improvement and system redesign common to all sectors, be it engineering, aviation, business or health. There was growing interest to see if this approach was as effective in New Zealand as it has been in Australia, Canada, UK and the USA so four projects from around the country were partially sponsored by the Ministry of Health.

What is a collaborative?

“The improvement collaborative is a structured improvement approach that organizes a large number of teams or sites to work together for a 12- to 24-month period to achieve significant improvements in a specific area of care. The collaborative approach combines traditional QI methods of team work, process analysis, introduction of standards, measurement of quality indicators, training, job aids, and coaching with techniques based on social learning and diffusion of innovation.

In a collaborative, teams of health care providers work independently to test out changes in how they deliver care that seek to implement best practices and accepted standards for the collaborative’s topic area. Teams use a common set of indicators to measure the quality of the care processes the collaborative is trying to improve and, where possible, the desired health outcomes. The collaborative organizes regular sharing of results among teams through learning sessions in which teams learn from each other about which changes have been successful and which were not. This results in a dynamic improvement strategy in which many teams working on related problem areas can learn from each other in a way that facilitates rapid dissemination of successful practices. In its emphasis on spread and scale-up of improvements, the improvement collaborative model offers a powerful new tool in the arsenal of proven QI methods.”

(Improvement Collaboratives, USAID Healthcare Improvement Project)


What are the benefits of using the collaborative methodology?

  • The collaborative methodology uses knowledge about what already works rather than continually trying out new ideas through research or pilot studies.
  • It uses a change management method designed to identify where a change actually leads to an improvement
  • Changes are tested in small cycles so they are manageable

  • Changes are measured so that the improvement can be demonstrated


An Overview of the Collaborative Programme

Participants at a Learning Workshop

The term ‘collaborative” has multiple meanings, however, in the context of the Breakthrough Series Collaborative, it generally consists of:

  • an Orientation Session and
  • Three Learning Workshops over a 9 month period, with
  • Activity Periods in between for teams to test and implement change in their organisations.


The Collaborative approach involves:

  • An overall aim
  • Three defined topic areas eg system redesign, improving access, diabetes management, or infection rates
  • A set of change principles, reviewed by a local expert advisory panel, which underpin best practice in set topic areas
  • Practical examples of change ideas teams can implement to achieve change
  • Shared learning with peers through various events, email groups, online websites
  • Applying learning to your own workplace through rapid testing of small, incremental changes
  • Using specific improvement measures to monitor the impact of the change and ensure that the change is an improvement.


Key Paper outlining the Breakthrough Series Collaborative Methodology Breakthrough-Series---White

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper. Boston: Institute for Healthcare Improvement; 2003.

 

(Free registration and download)








What are the benefits of participating?

Feedback from previous primary care collaboratives throughout Australia, UK, Canada and the USA has been overwhelmingly positive. Typical comments include:

“I wish we had done this years ago. The practice is running so much better now. The staff are happier and patients are happier. I can strongly recommend it.”

“Working in the same practice, year after year, can be a bit isolating and we kept doing things the way we always had. Participating in the collaborative has given us a new lease of life and helped us identify and implement some really practical and useful changes to improve not only our clinical work, but also our financial and administrative processes.”

“It was great meeting others, hearing their stories and taking back so many excellent ideas and tools for our practice to start using straight away.”


Topic areas covered in previous primary care collaboratives

  • Access & Care Redesign
  • Optimising cardiovascular disease management
  • Diabetes
  • Self management support
  • COPD
  • System redesign


Topics covered in secondary care or hospital services



Outcomes

LW 2 - Dr Sue WellsFor other collaboratives, evaluation reports typically show:

  • improved patient outcomes through better management of long-term conditions such as diabetes and coronary heart disease
  • improve efficiency, effectiveness and revenue for practices
  • increased best practice care through better use of information systems (both medical and business systems)
  • a shift from reactive individual patient care to proactive population based care
  • improved staff morale and patient satisfaction scores


Examples of BTS Collaboratives

New Zealand

Four BTS Collaboratives have been trialled in NZ over the last couple of years. Some are still in

EQUIPPED---LTC-website

progress. Information to be added shortly outlining each project and any evaluation findings.


Australia

National Programme now known as the Australian Primary Care Collaboratives (APCC) has been extended over several waves to reach over 800 general practice teams since 2007.


England

Since 2000, the National Primary Care Collaborative (the first of UK Improvement Foundation programs) has included over 5,000 practices covering almost 32 million patients and is one of the largest healthcare improvement programmes in the world. It has produced “quick results, including dramatic reductions in waiting times and improvements in patient care.” For information about their various phases, visit the following webpages.


Scotland

The Scottish Primary Care Collaborative has seen over 500 general practice teams participate. Topics have included diabetes, cardiovascular disease, access, COPD and chronic renal disease. Visit their webpage and links to their results.


Canada

The Improvement Foundation has been supporting the Saskatchewan Health Quality Council (HQC) to run their first Primary Care Collaborative which started in 2005. Visit their website and search for Saskatchewan Chronic Disease Management Collaborative.


Developing Countries

The Breakthrough Series collaborative method has also been trialled and adapted for use in developing countries. Since 2003, the USAid Healthcare Improvement Project has funded over 75 improvement collaboratives in 16 developing and middle-income countries,Some impressive improvements have been achieved such as reducing post-partum haemorrahge, infant mortality and improving TB, malaria and HIV treatment.

For further information about the following topics, visit the USAID Healthcare Portal.

  • HIV/AIDS
  • Malaria
  • Maternal, Newborn and Child Health
  • Orphans and Vulnerable Children
  • Patient Safety
  • Reproductive Health
  • Tuberculosis


Additional Information

There are a number of key websites and organisations focusing on quality improvement collaboratives.

The MacColl Institute for Healthcare Innovation – Improving Chronic Illness Care is a national programme of The Robert Wood Johnson Foundation, with special interest in guidelines, specialty expertise and information systems for chronic care. Their website contains numerous resources relating to chronic care collaboratives from Learning Workshop agendas through to assessment tools and workshop presentations.


The Improvement Foundation (Australia) Ltd (IFA) is a not-for-profit organisation linked to the Improvement Foundation (from the UK) focused on providing expertise in the development and delivery of quality improvement programs to bring about systems change. They provide a range of workshops and quality improvement programmes including the Australian Primary Care Collaboratives, that has now reached over 800 general practice teams throughout Australia.

 

  • Health Disparities Collaboratives

Since the late 1990s, the Health Research and Services Association (HRSA) in the USA has worked with the Institute for Healthcare Improvement and other national organisations to roll out numerous BTS collaboratives. The HRSA Health Disparities Collaboratives (HDC) were developed “to transform primary healthcare practices in order to improve the healthcare provided to everyone and to eliminate health disparities.”

The HRSA Knowledge Gateway has an extensive array of articles, tools, resources and examples of quality improvement and collaborative work. – Knowledge Gateway Library


References for Breakthrough Series Collaboratives

The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series White Paper. Boston: Institute for Healthcare Improvement; 2003. (Free registration and download)

Knight, A. (200)9 Learning from four years of collaborative access work in Australia. Quality in Primary Care 2009;17:71–4 [Full article, pdf]

Miller OA. Ward KJ. (2008) Emerging strategies for reducing racial disproportionality and disparate outcomes in child welfare: the results of a national breakthrough series collaborative. Child Welfare. 87(2):211-40, 2008. [Abstract]

Shafer TJ. Wagner D. Chessare J. Schall MW. McBride V. Zampiello FA. Perdue J. O’Connor K. Lin MJ. Burdick J. (2008) US organ donation breakthrough collaborative increases organ donation. Critical Care Nursing Quarterly. 31(3):190-210, 2008 Jul-Sep.

Larsen K. Hvass KE. Hansen TB. Thomsen PB. Soballe K. (2008) Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskeletal Disorders. 9:59, 2008. [Abstract] [full text pdf]

Moore DE Jr. Overstreet KM. Like RC. Kristofco RE. (2007) Improving depression care for ethnic and racial minorities: a concept for an intervention that integrates CME planning with improvement strategies. [Erratum appears in J Contin Educ Health Prof. 2008 Summer;28(3):195-6] Journal of Continuing Education in the Health Professions. 27 Suppl 1:S65-74, 2007. [Abstract]

Mercier CE. Barry SE. Paul K. Delaney TV. Horbar JD. Wasserman RC. Berry P. Shaw JS. (2007) Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project. Pediatrics. 120(3):481-8, 2007 Sep  [Abstract] [Full text pdf ]

Glassou EN. Tilsted D (2007) [Compulsive treatment in a psychiatry--an economic evaluation of participation in the Breakthrough model]. [Danish] Ugeskrift for Laeger. 169(22):2118-21, 2007 May 28.

MacIntosh-Murray A. (2007) Challenges of collaborative improvement in complex continuing care. Healthcare Quarterly. 10(2):49-57, 2007. [Abstract]

Boushon B. Provost L. Gagnon J. Carver P. (2006) Using a virtual breakthrough series collaborative to improve access in primary care. Joint Commission Journal on Quality & Patient Safety. 32(10):573-84, 2006 Oct [Abstract & full article]

Øvretveit J, P Bate, P Cleary. 2002.  Quality Collaboratives: lessons from research. Qual Saf Health Care;11:345-351 [Abstract]

Leape LL. Kabcenell AI. Gandhi TK. Carver P. Nolan TW. Berwick DM. (2000) Reducing adverse drug events: lessons from a breakthrough series collaborative. Joint Commission Journal on Quality Improvement. 26(6):321-31, 2000 Jun. [Abstract]

Kilo CM. 1999. Improving care through collaboration. Pediatrics. 103(1 Suppl E):384-93, 1999 Jan.