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The Quality Improvement Collaborative Methodology To accelerate the pace of improvement and scale up best practices James Heiby GH/HIDN/HS MAQ Mini-University, May 10, 2004 Agenda How collaboratives are different from traditional QI methods Summarize the methodology Development in the US

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the quality improvement collaborative methodology

The Quality Improvement Collaborative Methodology

To accelerate the pace of improvement and scale up best practices

James Heiby


MAQ Mini-University, May 10, 2004

  • How collaboratives are different from traditional QI methods
  • Summarize the methodology
    • Development in the US
    • Fundamental elements
  • Experience in low and middle income countries
  • Discussion
the basic principles of the improvement movement
The Basic Principles of the Improvement Movement
  • The delivery of modern health services is complex and dynamic
  • It is feasible to study the process of health care and find ways to improve it
  • Our hypotheses about how to improve health care should be tested before we accept them
basic principles continued
Basic Principles, continued
  • Improvement work consumes health resources, and should be accountable
    • Benefits should exceed the costs
    • Current investments are
      • Extremely small
      • Primarily the time of health staff
  • The benefits of successful improvement work grow as it is:
    • Extended into the future
    • Spreads geographically
in practice quality improvement activities in ldcs are
In practice, quality improvement activities in LDCs are:
  • Carried out by regular health workers, usually in teams
  • Use tools to study the process of health care, e.g., flow charts
  • Test potential improvements
  • Teams select the problem to work on
  • What other models for improvement do we use?
how important are issues of quality and efficiency in health care

How important are issues of quality and efficiency in health care?

Can resource-poor, highly stressed health systems afford to pay attention to such things?

impact of an ebg for diarrhea in malnourished children in dhaka ahmed et al lancet 1999
Following standardized clinical protocol:

Mortality 9%

Oral fluids only 60%

Antibiotics used 18%

Following usual practice at ICDDR,B Hospital:

Mortality 17%

Oral fluids only 29%

Antibiotics used 40%

Impact of an EBG for Diarrhea in malnourished children in Dhaka(Ahmed, et al, Lancet, 1999)
implications of these examples
Implications of these examples:
  • Deficiencies in quality and efficiency are widespread and serious
  • The impact of training and supervision strategies appears limited
  • AIDS will make things much worse
  • What does traditional CQI have to offer?
issues with traditional cqi in developing countries
Issues with traditional CQI in Developing Countries
  • Successes (and failures) not widely shared
  • Limited motivation for extra work
  • Poor documentation of QI process
  • Weaknesses in measurement
  • Often not focused on important problems, esp. clinical care
  • Spreading slowly
how collaboratives are different from traditional qi
How Collaboratives are Different from Traditional QI
  • Organized around a specific topic
  • Participants are motivated
    • Volunteers
    • Leadership support
  • A community of practice
    • 10-30 teams
    • Every team knows the work of the others
how collaboratives are different continued
How Collaboratives are Different, continued
  • Chief source of improvement is mutual learning by peers
    • Provides a mandate to test changes in the organization of care
    • Teams share data on selected indicators
      • Meetings
      • Monthly reporting
      • Visits
How the collaborative addresses issues with traditional CQI: Organize multiple teams to work on a single problem area:
  • More rapid progress
  • Each team learns from work of the others: don’t re-invent the wheel
  • Peer group provides motivation for QI work
  • facilitates spread of improvements--more efficient
multiple teams value added continued
Multiple Teams Value Added continued
  • Pressure to keep better records
  • Can be focused on priority health care issues
  • Basis for scaling up a successful package of changes
history of the collaborative methodology
History of the Collaborative Methodology
  • Developed chiefly by IHI in 1990s
  • Extensive applications in US, Europe
    • >50 collaboratives, dozens of topics
    • 12-160 teams, over 2000 total

Modified version in Russia:

    • pilot results in 3 clinical problems
    • sustained at oblast level
    • phase 3 expansion to 31 oblasts
percent of neonates arriving to the neonatal center with hypothermia
Percent of Neonates Arriving to the Neonatal Center with Hypothermia

Intervention Started,


basic questions behind the design
Basic questions behind the design
  • Who knows about clinical content issues, eg, case management of TB?
  • Who knows about the organization of health care, eg TB case finding?
  • Are current levels of quality and efficiency known?
  • Are improvement methodologies known?
  • How can facility teams communicate?

Collaborative Steps


Select Topic




Identify Change Concepts







Planning Group

LS 1

LS 2

LS 3


E-mail Visits

Phone Assessments

Senior Leader Reports *

© 2002 Institute for Healthcare Improvement

overview of the methodology
Overview of the Methodology
  • Adapt for developing country setting
  • Traditional QI teams and methods
  • Starts with a specific topic
  • Leaders and experts develop a “change package”:
    • systematically outlines all components of the service
    • describes feasible improvements
    • indicators to measure progress *
malaria collaborative overview
Malaria Collaborative Overview
  • Geographical Scope
    • 4 districts(Gisenyi, Kibungo, Muhima, Ruhengeri)
    • 61 teams and sites
      • 3 hospitals
      • 58 health centres
  • Progress
    • baseline study in 2 districts completed Nov 2002
    • quality improvement (QI) changes and indicators proposed by level of care
    • 70% of sites used flowcharts to analyse their problems
    • QI changes currently being implemented
exampless of findings from initial assessment
Exampless of Findings from Initial Assessment
  • no children were (case) managed according to norms
  • only 29% of children treated according to norms
  • mothers wait an average of 3 days before going to health centre
  • 31% of health centres have had stock-outs during the 30 days before assessment
key changes
Key Changes
  • For malaria in children 0-4 years
  • Decision to seek care within 24 hours
  • Diagnosis and treatment at health centers and hospital according to national standards
  • No stockouts of drugs or supplies at district
  • Appropriate and successful referral of serious cases
  • Numbers of children treated in health centers
  • Numbers of severe cases treated in district hospital
  • Number of deaths due to malaria in hospital
  • Hospital case fatality rate for child malaria cases
  • Percent of children treated according to national norms in HC and hospital
  • Error rate of lab tests on quality control exercises
  • Stockouts of drugs or supplies at HC/hosp
recruiting the teams
Recruiting the Teams
  • Rule of thumb: 10-30 teams
    • provides a critical mass for innovation
    • but is manageable
  • Voluntary participation
  • Can work with multiple organizations, e.g., NGOs
  • Multinational collaboratives *
rwanda collaborative partners


Family Health International (FHI)/Impact

Pangaea Institute


Central Hospital of Kigali (CHK)

Butare University Hospital

King Faisal Hospital

Kanombe Military Hospital


Medecins sans Frontieres (MSF)



Cooperation Francaise

Elizabeth Glazer Foundation

LUX Development (Luxemburg) – Main partner with CHK Hospital

Cooperation Belge- helps many districts in Rwanda

Rwanda Collaborative Partners
implementing structure
Implementing Structure
  • Planning/Organizing Committee
  • Experts Group
  • National Coordinating Committee
  • Provincial or District
  • Site Teams
how collaboratives usually work
How Collaboratives Usually Work
  • Local ownership from day 1
    • prominent leadership
    • do the work
  • Facilitators remain in background
  • Teams start by studying existing system
    • use the change package
    • creates a baseline
next steps
Next steps
  • Team representatives meet 3 or more times to:
    • learn about QI methods
    • learn about the change package
    • discuss team experiences, share learning
    • share results
  • Teams communicate ~monthly
    • indicators and QI activities
    • various means of communication--from visits to the web
next steps continued
Next steps, continued:
  • Leaders and facilitators support teams
    • emphasis on communications system
    • also use the meetings
    • low level of external T/A overall
  • Teams use rapid QI cycles
    • focus on immediate, small scale changes
    • evaluate, measure
    • expand scale or move on, based on results
continuous quality improvement teams at work
Continuous Quality Improvement teams at work







Monitoring Results, Muhima District, 2003% of children 0-5 years old with malaria who were treated according to national norms in selected health centers



Results collected from field visits December 2003% of children 0-5 years old with malaria who consulted within 24 hours of the first symptoms




kinds of aids care implementation problems solvable at local level
Kinds of AIDS care implementation problems solvable at local level
  • Demand creation
  • Testing logistics
  • Roles for staff and volunteers
  • Strategies to ensure adherence
  • Re-supply of patient medication
  • Patient follow-up
  • Patient self care strategies
  • Counseling and support
evolution of the collaborative
Evolution of the Collaborative
  • Expected duration of 9-18 months
  • Leaders schedule final meeting based on results: teams using a package of improvements
  • Expansion (or Spread) Collaborative:
    • high performers can each lead a new effort
    • change package requires minor adaptation
    • Rogers’ Diffusion of Innovations
factors influencing rate of adoption adopter categorization








Factors Influencing Rate of Adoption: Adopter Categorization

# Adopters


Time to Adopt

key elements in the design of the oblast level scale up i
Key Elements in the Design of the Oblast Level Scale-Up - I
  • Gaining leadership support
  • Clarity on purpose & methods
  • Health authority leadership/management
  • Champions from phase I teams
  • TOT for champions from phase I teams
  • Training of all team members in QI and clinical content
  • Team approach for re-invention & clinical guideline adaptation
current collaboratives in ldcs
Current Collaboratives in LDCs
  • Topics
    • Under way: EOC, pediatric hospital care, PMTCT, malaria, PIH, RDS, adult AH
    • Planned: TB, ART, RH-PMTCT, infection control
  • Countries: Russia, Ecuador, Honduras, Nicaragua, Eritrea, Niger, Rwanda, Tanzania, Cambodia