Collaboratives grow, even among traditional health care competitors

Rivals become allies in search for new ways to improve quality

Something’s happening in the world of quality improvement that might not have been thought possible 10 years ago. In ever-growing numbers, hospitals that once thought of each other only as competitors are joining forces to attack the major quality improvement challenges they all face.

For quite some time, facilities have recognized the value of one specific type of collaboration — benchmarking — but this is something else entirely. The collaborative model, which many credit the Cambridge, MA-based Institute for Healthcare Improvement (IHI) with creating, involves even greater interaction and sharing among facilities.

Number of advantages for using model

There are a number of advantages to the model, explains Jonathan Sugarman, MD, CEO of Qualis Health, the quality improvement organization (QIO) for Washington, Alaska, and Idaho.

"One of the benefits comes from the fact that when collaboratives are conducted using [IHI’s] breakthrough series model, it is based on the best evidence as it exists," he explains.

"It usually starts with an expert panel identifying a set of change concepts, which if implemented, will result in improved care. So just to get involved in a collaborative gives you access to experts on evidence of what works in real-world settings, as well as access to different kinds of knowledge than you could accumulate just through a literature search," Sugarman notes.

Qualis Health was one of the prime movers in a 56-hospital collaboration sponsored by the Centers for Medicare & Medicaid Services (CMS) to prevent surgical infections.

The second benefit of a collaborative is that it provides a QI team with all the tools it needs to improve, Sugarman adds.

"That includes not just the necessary cognitives on science, but the QI managerial — and sometimes even political — tools you need to engage practitioners around clinical problems," he says.

"These tools address, for example, how to implement change, the role of measurement, and the distinction of measures for improvement vs. research. It provides a sweep of tools," Sugarman points out.

Finally, the collaborative model is a multiorganizational, multi-institutional endeavor. "One of the most common responses from collaborators who are asked what they like most is the opportunity to interact with their peers and colleagues at institutions trying to deal with similar issues," he observes.

"They learn quite a bit from each other about effective activities. When they are struggling, it’s good to see that others are as well; also, when something works, they can see how someone else has used it as well," Sugarman adds.

"People from one institution, for example, get flow sheets from another institution, which they are then free to adapt or adopt." This, he explains, embodies one of the mottos of the collaborative model — "Sharing seamlessly and stealing shamelessly."

A surprising level of sharing

Regina Berman, director of process improvement at Hackensack (NJ) University Medical Center, a large teaching hospital, already is a believer; her facility is participating in the IHI’s "100,000 Lives Campaign" collaborative.

"Our medical staff have come to realize how the transparent sharing fosters learning," she notes. "They’ve actually been surprised at the level of sharing, because in the old days, it never existed. In the old days, it was very competitive. Not only that, you simply didn’t share your defects for fear of lawsuits or losing market share."

E. Patchen Dellinger, MD, professor and vice chairman of the department of surgery and chief of the division of general surgery at the University of Washington, Seattle, was a lead participant in the Qualis/CMS collaborative; and while he appreciates its initial success (the surgical infection rate was cut by 27%), he does have concerns about the ability of collaboratives to sustain improvement.

"I retain an underlying caution regarding the process, in that I think it’s very possible to participate in a collaborative, achieve a good portion of the changes desired, then see it slip away as the collaborative ends," Dellinger observes.

That does not, however, diminish his appreciation of the process itself. "Personally, as someone who led that particular collaborative and a regional that followed and traveled to 10 state collaborations around the country as an outside speaker, I can tell you the collaborative process is an energizing, generally upbeat, positive experience for those involved. It really helps an organization kick-start improvement," he adds.

Sugarman says he is aware of the potential problem noted by Dellinger. "Typically, collaboratives are time-limited," he concedes.

"However, in some cases, things continue on. We in Washington state started a statewide collaborative in 1999 on diabetes. We are now starting its fifth iteration and have expanded it to include adult preventive services and cardiovascular disease."

(Editor’s note: We hope the articles in the rest of this month’s Healthcare Benchmarks and Quality Improvements will give you a clearer understanding of exactly what collaboratives are and how they work, and the opportunities available for you to get your own facilities involved in such initiatives.)