Performance Improvement What Do Collaborative · PDF fileWhat Do Collaborative Improvement...

Joint Commission on Quality and SafetyJournal

February 2003 Volume 29 Number 285

What Do CollaborativeImprovement Projects Do?Experience from Seven Countries

Performance Improvement

Tim Wilson, MDDonald M Berwick, MD, MPP

Paul D. Cleary, PhD

The chasm between what is possible and what isroutinely achieved in health care has neverappeared wider.1 In the search for a remedy,

health care organizations are increasingly using formalquality improvement methods2–4 that often involvegroups working together on specific pressing issues.5,6

Improvement collaboratives were first developed in theUnited States, but models have also been developed inAustralia, France, the Netherlands, Norway, Sweden,and the United Kingdom (UK). The reform plan for theNational Health Service (NHS) in the UK calls for theestablishment of collaboratives on a wide variety of top-ics nationally.7 Many of the large collaboratives in theworld, and all the ones studied in this article, are derivedfrom the Institute for Healthcare Improvement (IHI)Breakthrough Series (BTS) model of quality improve-ment collaboratives.8,9 In the IHI model (Table 1, p 86),organizations are invited to work collaboratively on spe-cific improvement topics.

To our knowledge, there have been no studies thathave described how variations in different aspects ofcollaboratives affect their effectiveness or even what themost salient dimensions of variation are. In essence, col-laboratives are “black boxes.” What makes evaluatingthese activities especially difficult is that what is insidethe box varies considerably.

In this study, we first developed a framework fordescribing collaboratives based on the IHI model. Wethen interviewed collaborative leaders to ask them whatthey think the critical components of collaboratives areand used that information to refine our framework. In this article, we examine the components identified in terms of theories of organizational change10,11 and

Background: Health care organizations are in-creas-ingly adopting multiorganizational collaborativeapproaches to quality improvement. Collaborativeshave been conducted in many countries. There are largevariations in the way collaboratives are structured andrun, but there is no widely accepted framework fordescribing the components of collaboratives. Thus, it isdifficult to study which approaches are most effective.

Method: The authors conducted semistructuredinterviews with 15 leaders of collaboratives to ascer-tain the common components of collaboratives andidentify variations in the ways these components areimplemented.

Results: The study identified seven features of collab-oratives that the leaders interviewed thought were criti-cal determinants of how effective the collaborativeswere: sponsorship, topic, ideas for improvements, partic-ipants, senior leadership support, preliminary work andlearning, and strategies for learning about and makingimprovements. For example, every interviewee mentionedthat having participants collect data, perform audit work,or analyze the system they were in before the collaborationstarted was important to understanding their organizationand the nature of the problems they had and to developingbaseline data for later comparison. The authors describevariations in how these features have been implementedand possible functions of these features.

Conclusion: Systematically studying the impact of vari-ations in the seven key features of collaboratives couldyield important information about their role and impact.

Article-at-a-Glance

86February 2003 Volume 29 Number 2

diffusion of innovation12 to identify the potential func-tions of these features.

Research MethodsSurveyTo develop an initial framework, we reviewed the availableliterature describing the IHI model of collaborativeimprovement and developed a preliminary list of compo-nents. We interviewed four colleagues at IHI responsiblefor developing and running collaboratives and asked themto comment on our list. We then developed a semistruc-tured interview (Table 2, p 87) that asked respondentsabout each component, whether they felt it was important,and how they had implemented it. The interview alsoasked whether there were other components of collabora-tives that had had an important impacts on their success.

SampleWe asked IHI staff to identify a convenience sample of

people in different countries who had experience leading

collaboratives based on the IHI model for at least a yearand who had tried significant variations of the model typi-cally used in the United States. We identified 15 potentialrespondents in seven countries: Australia, France, theNetherlands, Norway, Sweden, the United Kingdom, andthe United States. We selected many respondents fromoutside the United States because we thought there wouldbe more variability in how those collaboratives were run.

InterviewThe experts were contacted by the lead author [T.W.]

by telephone in September–October 2000. Every identi-fied respondent was interviewed.

AnalysisWe reviewed interviews as they were completed and

used an informal consensus process to determine thechanges to the framework that were needed. We collec-tively reviewed the explanations of the leaders aboutwhy different components were important to the suc-cess of their collaborative and used that information, aswell as published theory, to develop explanations of thepotential functions of each of the components identified.

Results: The Seven Key ComponentsInterviewees confirmed that collaboratives had sevencomponents that they thought were important determi-nants of success: sponsorship, topic, ideas for improve-ment, participants, senior leadership support, preliminarywork, and strategies for learning about and makingimprovements (Table 3, p 88). There were substantialvariations in how these components were implemented.

SponsorshipAll respondents thought that sponsorship is an impor-

tant determinant of the success of a collaborative. Therewas tremendous variability, however, in sponsors (Table3), including government and independent professional,membership, and independent quality and health careorganizations. Respondents suggested that in manycases sponsorship improved an effort’s credibility or per-ceived importance (for example, professional organiza-tions). Conversely, in one case of government sponsor-ship, the interviewee perceived that sponsorship gener-ated cynicism about the aims of the collaborative.


1. Sponsoring organization identifies topics where a sig-nificant gap exists between best and typical practice.

2. The Institute for Healthcare Improvement (IHI) thenassembles an expert panel.

3. Expert panel prepares a package of ideas for closingthe gap.

4. IHI recruits participating teams to be part of thecollaborative.

5. Participants engage in prework: forming localimprovement team, develop of goals and measure-ments, and characterizing current practice.

6. During a collaborative’s life, usually 6 to 12 months,teams from participating organizations attend threelearning sessions in which they learn about ideas forbetter practice and improvement methods that theyimplement between sessions.

7. Between learning sessions, teams share experiencesand maintain contact through such mechanisms asconference calls and Internet e-mail listservs whilesubmitting progress reports.

8. The lessons learned are spread through a nationalmeeting (congress) and reports.

Table 1. Steps in the Breakthrough SeriesCollaborative Model

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TopicAll leaders interviewed said that the choice of topic

was a critical determinant of how successful a collabo-rative would be, but opinions varied on the characteris-tics of an ideal topic. Broad topics were felt to be moreattractive to external funding sources (as was found inthe case of the French elderly care collaborative), andthree respondents claimed that broader topics led to themost innovation. Some thought that highly specific top-ics might be less relevant for local organizations with dif-ferent priorities (for example, a Norwegian intensivecare unit [ICU] collaborative had issues that were inap-propriate for some participating hospitals) but weremore conducive to rapid improvement.

Leaders thought that collaboratives that focused oncomplex or technically unfamiliar topics were less likelythan others to be successful or attractive to participants.For instance, in the UK, primary care collaborative par-ticipants were initially more attracted to work on thesimpler and more familiar topic of improving cardiovas-cular disease care than access or capacity demand man-agement until later in the collaborative process, whenthey began working on all the topics.

In some countries the topic became a national priority during the collaborative, which appeared tomotivate participants. For example, in the course of a UK primary care collaborative, national standards foraccess7 and coronary disease13 were introduced. In con-trast, Swedish leaders proposed but then deferred acesarean section collaborative because it was felt thatthe topic was not yet viewed by organizations as impor-tant enough.

Ideas for Improvement Most collaboratives used outside expert groups

(national or local, as appropriate) rather than partici-pants themselves to suggest improvements. Having anexpert panel to legitimize the knowledge was thought tobe most likely to lead to adoption, especially when theknowledge was not yet in mainstream practice (forexample, the use of clot busters for stroke). However,two interviewees mentioned that experts were occasion-ally too different from the participants for their advice toappear relevant.

Most, but not all, interviewees included experts inquality improvement and systems thinking in identifyingknowledge to provide general concepts that allowedlocal changes for implementation (reinvention).

A few collaboratives allowed teams to generate theirown knowledge. It was felt that this created commit-ment, although the interviewees thought that changeswere less rapid than when knowledge was generatedexternally. Most interviewees thought having an expertwith practical knowledge was crucial. One intervieweedescribed how assembled “experts” did not understandground-level issues, which stalled improvement.

Participants A few of the interviewees agreed that it was important

to select participants carefully, but there was great vari-ability in exactly how participants were selected. Somecollaboratives were voluntary, whereas others weremandatory. A few interviewees described how participa-tion criteria were used to select participants with previ-ous experience in quality improvement, commitment tothe collaborative and topic, and participation of a seniorexecutive. The majority of collaboratives relied on volunteers and had no selection.



1. Sponsoring organization (including the financingsystem)

2. Topic selection

3. Identifying knowledge for improvement

4. Participating organizations (including local teamformation)

5. Leadership

6. Mechanisms for learning and change

7. Mechanisms for sharing within the collaborative

8. Mechanisms for spread and dissemination

9. Sustainability

10. Judging the degree of success

11. National differences

12. Collaborative

13. General

14. Results

Table 2. Topics for Semistructured Interview for International Comparison of

Collaborative Improvement*

* A number of questions are asked under each topic.



Table 3. Seven Components of Collaboratives, Common Variations, Critical Dimensions, and Functions*

* Italicized items indicate the dimensions that the authors suggest as priority issues for investigation.

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One interviewee highlighted the need for a certainnumber of teams to participate in a collaborative, sug-gesting that very small collaboratives had problems withidentifying best practice and engaging in constructivecriticism. Many interviewees described how they identi-fied good and poor performers and encouraged them towork together. Involvement of governmental organiza-tions occasionally led to some reluctance to discloseinformation.

In terms of funding strategies, in some collaborativesparticipants covered all costs and paid fees. Other collab-oratives required no fees and provided extra resources. Insome settings, such as the NHS, it was felt that it would becountercultural to ask participants to pay, whereas manyother interviewees, especially those in the United States,expressed the opinion that payment was more likely tolead to commitment. Interviewees who had experiencewith both systems discerned little difference.

Teams always included clinicians, and all but one col-laborative team included a physician. Two intervieweesemphasized how many changes involve physician behavior, and how spread was dependent on communi-cations from clinician to clinician, especially amongphysicians. Every collaborative had multidisciplinaryteams. Managers were less often included. The inclusionof a quality improvement officer or project manager varied. All interviewees felt that it was important toinclude personnel (clinical and nonclinical) who were tobe directly affected by the changes.

Teams attending learning sessions were usually com-posed of three or four people but ranged from two toeight. Many teams had additional members who partici-pated in the improvement process in their organizationbut did not attend the collaborative.

Senior Leadership SupportMost interviewees emphasized that support from

senior organizational leaders (for example, chief execu-tive officer of a hospital or health system, head of adepartment) was crucial. For example, in Sweden someteams withdrew from a collaborative because of weaksupport from senior leadership. Other teams that were thinking of dropping out stayed only after receivinghelp from their organizations’ leaders. One exception to this observation was when the teams worked

independently, (in relatively self-contained units such asa neonatal ICU, although in that case senior leaders werekept informed.

Doing Preliminary WorkEvery interviewee mentioned that having participants

collect data, perform audit work, or analyze the systemthey were in before the collaboration started was impor-tant to understanding their organization and the natureof the problems they had and to developing baseline datafor later comparison.

Some leaders added early sessions to teach partici-pants about setting aims and quality improvement tech-niques. This varied from residential courses for selectedmembers of the teams to video links. In the Netherlands,testing was covered in the preliminary work, whereasthe Vermont Oxford Network (U.S.) teaches improve-ment methods and encourages teams to complete someimprovement cycles before the first learning session.

Strategies for Learning About and MakingImprovements

All interviewees thought that teaching collaborativeparticipants about quality improvement theory and techniques was extremely important. Each used theimprovement model developed by Langley and colleagues. This model encourages teams to assess the aims, measurements, and changes needed forimprovement and then work on rapid cycles of changeand evaluation.14

Every interviewee thought that having participantsshare improvement strategies facilitated improvement.In only a few collaboratives was this a problem, with onecountry having cultural barriers to open exchange.Those interviewed thought that less sharing resulted inslower improvement. Although all respondents empha-sized the importance of having participants share expe-riences, showcasing high-achieving teams was not felt tobe appropriate in all countries (especially in the UK,where the term was altered from showcasing to how we

solved a problem). Many interviewees stated that theyfelt competition was important because the collabora-tive fulfilled three important characteristics for competi-tion: Everyone can win (or make an improvement), therules are fair (success is judged on the improvement




from where you started), and the teams themselves arethe major determinants of success.15

The meetings ranged in number from two to seven andin length from half a day to 3 days. Most collaborativeshad three meetings of 2 days each. Shorter sessions didnot seem any less successful than larger ones. Severalinterviewees mentioned that these meetings needed care-ful planning and clear agendas and objectives. There werelarge variations in the balance between plenary and work-shop sessions. Teams are likely to have different learningneeds and styles, so collaboratives need to understandthese to adapt the balance of the activities within themeetings to meet varying needs and preferences.16

All interviewees mentioned the element of socialexchange within and between teams as being veryimportant. It seemed to them that such exchange helpedteams establish peer support and feel that they were “notin this alone.” Some collaborative organizers stimulatesocial interaction through meals, parties, and time outand encourage mixing. Three interviewees describedhow participants themselves arranged extra meetings tocontinue social interaction.

Central support from the collaborative organizers varied considerably from one part-time person for theentire collaborative to one full-time project officer perteam; most collaboratives provided part-time support forevery three or four teams. A few interviewees stated that having strong central project management or quality improvement support drove projects more rapidly. A few felt, however, that this led to dependency.A minority of interviewees described a very tight level ofcentralized collaborative control, while others had amuch looser style. The leaders interviewed did not thinkthis had a discernible effect. Two interviewees said theythought that it was important to drive teams to makeimprovements while maintaining friendly support: “asmile with intent.”

All the collaborative improvement projects used for-mal reporting. Interviewees felt that reporting created adiscipline not otherwise present, allowed teams to judgetheir own progress, and helped the collaborative leadersassess progress and target extra support. Half of theinterviewees used validated self-administered ratingscales, generally Likert scales of 1 through 517 to assessprogress toward improvement.

DiscussionAlthough research has been reported on quality improve-ment in health care,18–20 to our knowledge there has beennothing published on how collaborative projects func-tion. Improvement collaboratives have evolved out ofseveral disciplines, and their structure and theoreticalfoundations have not always been explicit. Most makeuse of modern quality improvement theory, whichemphasizes that changes in performance requirechanges in systems.21

The framework that emerged from our interviewsshould allow researchers to more accurately describeand test variations in the way collaboratives are imple-mented. Both the comments of those interviewed andthe literature on organizational change provide insightsinto the possible functions and importance of these dif-ferent components. We now discuss which of the sevenfeatures of collaboratives might affect degree of involve-ment of participants, likelihood of participants makingsubstantial changes in their organizations, how wellteams work together, and rate of change.

What Features Affect Whether Participants BecomeInvolved?

Every leader interviewed agreed that sponsorshipwas a critical component of his or her collaborative,although there was great variation in the types of spon-sors selected. In Rogers’s framework,12 one coulddescribe the sponsor as the agency that wishes to bringabout change, or the “change agency,” and the collabora-tive itself as an agent that brings about change (“changeagent”). However, a change agent that is perceived asbeing oriented to the change agency’s—as opposed tothe participant’s—needs, can be ineffective. This mightexplain why government sponsorship might be counter-productive.

Thus, we suggest that one of the important character-istics of sponsorship that needs to be evaluated is theextent to which participants respect and agree with thepriorities of the sponsor.

According to diffusion theories, selecting a topic ofsufficient priority is important to generate motivation forchange. Theoretically, topics that are simple and com-patible with organizational needs and the priorities ofexternal funding sources should be the most successful.


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Leaders tended to think that broad topics were morelikely to engage a broader group of participants. Thus,the perceived salience and complexity of the collabora-tive topic should be important characteristics to be con-sidered when comparing collaboratives, but the bestapproach to topic selection is not apparent.

What Features of Collaboratives Might AffectWhether Participants Make Changes?

Experts, and in particular the collaborative chair, actas opinion leaders—people providing advice and infor-mation about change. Opinion leaders, who are usuallypart of the system in which the change is going to occur(for example, a practicing clinician in the same speciali-ty), should not be too innovative but should have a perceived high level of technical competence.

Ideas that are most likely to be adopted have a rela-tive advantage for participants and are compatible withlocal practices, and it is helpful if local reinvention ispermitted. Furthermore, if the changes are of practicalrelevance to daily work, learning research suggests thatadoption is more likely.12

It is generally accepted that both individuals andorganizations22–25 must be ready for change beforeattempts are made to help them change. Selection andrequiring payment are ways of assessing such readiness.Furthermore, many interviewees were looking for earlyadopters of innovation in the anticipation that diffusionwould occur naturally from that group to others.12

What Features of Collaboratives Might Affect HowWell Teams Perform?

Heterogeneous membership of improvement groupsis important,15 as is involving physicians,2 while learningin teams that work together is more likely to be effec-tive.26 Theories about effective teams suggest that five toseven members are most likely to bring about change.15

Although most collaborative teams had four membersattending events, more people participated in theimprovement projects at the home organizations.15

Quality problems often persist because no single person or group is clearly responsible for improving thesystem.27 Early improvement work showed that seniorleaders were necessary to provide a mission for a proj-ect.2 We suspect that senior-level leaders support teams

in two ways—first, by facilitating teams and overcomingbarriers to change (including suspending rules) and, sec-ond, by allowing and encouraging spread of the improve-ments through the whole organization. Adult learningtheories suggest that an issue with higher status is likelyto receive greater attention.16

What Features of Collaboratives Might Affect theSpeed of Improvement?

Work before meetings probably increased tension ormotivation for change by reemphasizing the relativeadvantage of the proposed changes over current practice. The modification of the original breakthroughmodel to add extra learning sessions shows that some collaboratives have recognized that according to adult learning theories, matching the educationalneeds of the learner is more successful than using a setcurriculum.28

Alemi and colleagues29 studied improvement activitiesin several health care organizations and found thatresults were most quickly achieved when the focus wason testing changes rather than on detailed analysis of thecurrent practice. Thus the focus on rapid testing of smallchanges is probably a critical component of the modelsused to teach participants how to make and evaluatechanges.

Diffusion theory suggests that ideas are most likely tobe adopted from the same professional group. TheBreakthrough Series encourages peer-to-peer spreadfrom innovators to early adopters.12

Social support, often emphasized in the collabora-tives, is important for change, as is the development ofsocial networks for the diffusion of ideas.10

The central support and reporting acted as both feed-back mechanisms30 and mechanisms for maintaining the tension for change.10 It has been suggested that threefactors—which are apparently present in collabora-tives—need to be in place before successful change cantake place: curiosity, forgiveness (allowing for mistakesand encouraging teams to learn from them), and trust.15

LimitationsThis study was limited in several ways. First, because weused IHI personnel to help identify study sites, the col-laboratives we studied do not reflect the diversity of




approaches others have adopted. However, this model isthe most commonly used worldwide. Furthermore, wemay not have identified important variations in whicheven the IHI model has been implemented. Third, we hadno way of assessing the effectiveness of the collabora-tives studied. Thus, although we asked respondents toassess what components of their collaboratives con-tributed to their successes or lack or success, we coulduse these judgments as indicators of salience. Even if thecollaboratives were successful, it probably would beextremely difficult for leaders to know which compo-nents were important for success. Aspects other thanthose identified might have had an important influence.It is also possible that any achieved successes are due inpart to a Hawthorne effect.31

This article does not and could not attempt to demon-strate how successful the collaborative strategy is, eitherin itself or compared with other types of improvementactivities. A number of major evaluations of collaborativeimprovement projects are currently under way in theUnited States to do this. The interviewees were enthusias-tic about the benefits of collaboratives, but they are notunbiased observers. An increasing number of researcharticles have reported on the potential benefits of collabo-ratives,32–35 although it would be difficult to generalize theresults to collaboratives conducted in different ways.

ConclusionThe interviews suggest that there tend to be a set of well-defined features of collaboratives which are often imple-mented in different ways. Making explicit, for the firsttime, how these components are implemented in differ-ent collaborative will facilitate the testing of hypotheses

about specific features of collaboratives (Table 3). Weencourage other researchers and quality improvementexperts to join this continuing international dialogue36 toaccelerate development and investigation of collabora-tive improvement.

PostscriptImprovement collaboratives are being used worldwidewith considerable financial, political, and personalinvestment in the process. Since the interviews wereconducted, collaboratives have evolved; the latest variations include providing additional days at the startof a collaborative (“learning session zero”), increasingattention to teamwork, bringing together teams andorganizations from diverse agencies (for example,health, social, and voluntary sectors), including usersand carers in teams, and utilizing learning set techniquesfor participant development.

This work was supported by The Commonwealth Fund, New York. Theviews presented here are those of the authors and not necessarily thoseof The Commonwealth Fund or its directors, officers, or staff. Drs Wilson and Berwick have received funds from running and design-ing collaborative improvement projects. Dr Berwick is the CEO and President of the Institute for Healthcare Improvement, which developed the model evaluated. Dr Cleary has received separate funding for the evaluation of a collaborative improvement project. The authors acknowledge Paul Plsek, who helped with early versions ofthis article.

J


Tim Wilson, MD, is Director, RCGP Quality Unit, RoyalCollege of General Practitioners, London, United Kingdom.Donald M. Berwick, MD, MPP, is CEO and President,Institute for Healthcare Improvement, Boston. Paul D.Cleary, PhD, is Professor, Department of Healthcare Policy,Harvard Medical School, Boston. Please address correspon-dence to Tim Wilson, MD, [email protected].

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