What is a Collaborative?
A Collaborative is a specific method of quality improvement used to distribute and adapt existing knowledge to multiple groups to achieve a common aim. The Collaborative methodology is user friendly and simple to apply. It promotes rapid change, allowing your team to create results and reap the rewards in short time frames. You are supported throughout the Collaborative and provided protected time to solve problems as a team.
The methodology is designed to implement change in small, manageable cycles, and identify where a change actually leads to an improvement.
How Does it Work?
The Collaborative methodology is underpinned by:
- The psychology of change, which suggests that knowing and learning from peers who have successfully made a change improves an individual’s own motivation to change. In this context, a culture of trust, peer learning and support, and the engagement of clinical leaders are important.
- Active clinical engagement in the Collaborative and support from the wider clinical community.
- The collection of data, in line with the following principles:
- Measurement and data collection for improvement, rather than judgement or research
- Use of data to inform activity and identify when a change leads to an improvement; and
- Primary care health service and hospital data sets are owned by the respective bodies and not released beyond participants. These data are used for supporting the Collaborative infrastructure.
Northern NSW Local Health District, North Coast Primary Health Network, local Aboriginal Medical Services and NSW Ambulance are partners in the Northern NSW Integrated Care Strategy, funded by NSW Health under the Planning and Innovation Fund. The partnership has been involved in conducting and Integrated Care Collaborative with the support of the Improvement Foundation. This quality improvement approach has been effective in engaging clinicians to test and adopt changes to provide better integrated care.
The implementation of an Integrated Care collaborative provided a mechanism to engage with clinicians from across the system and gave these clinicians with the license to test new ideas by implementing small changes and measuring the effects of these changes.
- Our aim was to build bottom up change that would work across a health system that has some long standing funding and structural barriers to change.
- Complexity Science suggests that in complex systems precedence cannot be relied upon. We needed to do things in new ways and foster innovation.
What is the Model For Improvement?
Change can often seem threatening and overwhelming. During the ICC participants used the Model For Improvement (MFI). The MFI breaks change down into small, less threatening steps, which are tested to ensure that things are improving and that no effort is being wasted. By making small, incremental changes, participants were able to test the changes on a small scale and learn about the risks and benefits before implementing them more widely.
The MFI is basically broken into two parts of equal importance. First is the thinking part which consists of three fundamental questions;
- What are we trying to accomplish?
- How will we know that a change is an improvement?
- what changes can we make that will result in improvement?
The second part, the doing part is made up of Plan, Do, Study, Act cycles (PDSA cycles).
A well-developed plan includes the what, who, when, where, outcome predictions, and the data to be collected. Consider the following questions:
Write down what happened when the plan was implemented. Document observations and record data.
Reflect upon what happened. Think about and summarise what has been learnt, analysing the data collected and comparing these data to your predictions. If there was a difference between the predictions and what happened, consider why this was the case.
In light of the results from the test, will you implement the tested change, amend it, or try something else? Write down the next idea the team will test. What will you do differently? Be sure to start planning the next cycle sooner rather than later to continue the improvement momentum.
*A well-developed plan includes the what, who, when, where, outcome predictions, and the data to be collected. Consider the following questions:
- What exactly will the team do? Remember to only test one small idea with each PDSA cycle.
- Who will carry out the plan?
- When will it take place? This should be in a short timeframe, generally no more than a week.
- Where will it take place?
- What do you predict will happen?
- What data/information will be collected to know whether there is an improvement? These data should be specific to the change being tested. It is likely that data required to test the change idea will differ from the data collected for the second Fundamental Question, which measures progress towards the overall goal.
- When you plan the PDSA cycle, it is important to be as clear and as detailed as possible. The results are dependent on how good the plan is.
When working with PDSA cycles remember:
- Anyone can use a PDSA cycle in any area
- No PDSA cycle is too small - in fact they are often too big!
- You should expect to complete a series of PDSA cycles to achieve your goal
- PDSA cycles can build upon one another to achieve rapid results
- PDSA cycles help the team learn from their work
- Documenting PDSA cycles is a great way of motivating the team and sharing information and learnings with other people; and
- You will learn as much from something that did not go well as you can from something that did!
Outcomes / Results
- More than 130 clinicians participated in the Integrated Care Collaborative
- More than 200 ideas for improvement were submitted and shared
- Nearly 200 patients with chronic conditions and complex care needs were enrolled and managed by integrated care teams with clinician judgement a key determinant of which patients would most likely benefit
- Integrated care teams comprised clinicians from across the system – primary care, general practice, Aboriginal Medical Services, LHD clinicians
- 35% increase in the number of patients with GP Management Plans (GPMPs) and/or Team Care Arrangements (TCAs)
- 15% increase in number of patients with Advance Care Directives (ACDs)
- Automatic electronic patient Admission & Discharge Notifications (ADNs) for enrolled patients
Take Home Message
It is possible to run a collaborative that spans the health system embracing clinician led change to improve integration of care for this cohort of patients.
The role of the participating organisations in the ICC was one of enablement – trusting and supporting clinicians to effect clinical level (microsystem) change for the benefit of patients.