Collaborative improvement is a variant of process improvement that organizes a large number of teams or sites to work together for a 12- to 24-month period to achieve significant improvements toward a set of common aims in a specific technical area (e.g., community case management of childhood illness.). The collaborative approach combines traditional quality improvement methods of team work, process analysis, compliance with standards, measurement of quality indicators, training, job aids, and coaching with techniques based on social learning and diffusion of innovation theories.
The Institute for Healthcare Improvement (IHI) pioneered the improvement collaborative approach in 1995 to address a common problem in the health care system in the United States: while evidence existed for a particular standard of care, it was not routinely practiced. IHI designed the Breakthrough Series or BTS Improvement Collaborative model to overcome obstacles to the consistent application of evidence-based practices and, at the same time, increase the pace and efficiency of improvement in health care (IHI 2003).
In collaborative improvement, teams in different sites (i.e., facilities or communities) work independently to test out changes in how to improve the delivery of care. 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 where teams learn from each other about which changes have been successful and which were not. These learning sessions result in a dynamic improvement strategy, and many teams working on related problem areas can learn from each other to facilitate rapid dissemination of successful practices. In its emphasis on spread and scale-up of improvements, the improvement collaborative model offers a powerful tool in the arsenal of proven improvement methods.
USAID has supported the widespread adaptation and application of the collaborative improvement approach in more than 20 countries since 2003. USAID-funded health care improvement collaboratives have involved mainly teams of public sector health care providers and implementing partners (Catsambas et al. 2008). These efforts, begun under the Quality Assurance Project and continued under the USAID Health Care Improvement (HCI) and USAID Applying Science to Strengthen and Improve Systems (ASSIST) projects, made a number of adaptations to the BTS Improvement Collaborative model to accommodate government health system structures, introduce more content on improvement methods and measurement in learning sessions, and emphasize the role of coaches in guiding and motivating site teams (HCI 2008b). Like the collaboratives supported by IHI in the United States and other countries, USAID-supported collaboratives have achieved rapid and significant improvements in the quality of diverse health services and demonstrated that the gains made in quality of care through collaboratives could be maintained over time (Franco & Marquez 2011).
USAID-supported collaborative improvement applications have found that shared learning among teams engaged in collaborative improvement accelerates the adoption and spread of evidence-based approaches across sites. While collaborative improvement has been extensively applied to clinical care processes (both preventive and curative), it has also been applied to non-clinical areas such as human resources management, information systems, supply management, health promotion, community-based care for vulnerable children, and social services (Crigler et al. 2011; Were et al. 2013).
Text box: CHW Improvement Collaborative in Ethiopia
Since its inception in 2003, Ethiopia’s Health Extension Program has deployed over 30,000 health extension workers (HEWs) to rural communities across the country. HEWs are paid government health workers who deliver some 17 different services covering disease prevention and control, hygiene and environmental health, family health, and health education and communication at the village level. A 2008 evaluation of the Health Extension Program found that while community demand for HEW services was high, HEWs had too great a workload and inadequate skills to address all the health issues they faced. To address these challenges, in 2011 the USAID Health Care Improvement (HCI) Project was invited to implement a CHW improvement collaborative to bolster linkages between the informal community system and the formal health system, improve the effectiveness of HEWs, and improve the capacity of community groups to take ownership of health programs.
Implemented in Illu and Tole districts (woredas) of Oromia Region, the improvement collaborative brought together key stakeholders to form improvement teams focused on strengthening the community health system, with particular attention to HIV/AIDS and hygiene services. These improvement teams, comprising key community stakeholders and representatives of key community groups, formed the foundation of a community health system to support HEWs in service delivery.
Before the community improvement teams were established, HEWs were going house to house to identify pregnant women and provide basic antenatal care (ANC) information and services. Since they were not able to go to every household, the number of pregnant women identified by HEWs was low. But after community groups started sensitizing their members’ families, the number of pregnant women identified by the community groups and the number of pregnant women who visited the health post for ANC increased. For example, nine health posts in Illu district identified 259 women in an eight-month period and registered 86% of them for ANC at the health post. The changes that led to improvement were house-to-house visits and mobilization of Idir (community funeral cooperative) and other community groups to support the identification of pregnant women. In a similar fashion, another health post community improvement team in Illu increased the number of households with latrines from 30% to 60% and the proper use of latrines from 36% to 76%. The change ideas that led to this increase involved community leaders, funeral cooperatives (Idir), savings and credit groups, and religious groups to reach out to the community. The nine health posts that participated in the improvement collaborative in Tole registered increases in the number of pregnant women tested for HIV from 36 in September 2011 to 191 in June 2012. The improvement teams also offered a venue for HEWs to raise concerns or challenges with service delivery and receive support and guidance.
Source: Shrestha 2014.