Learning and improving in quality improvement collaboratives: which collaborative features do participants value most?

Quality improvement collaboratives are an increasingly common strategy for implementing evidence-based practices in health care. Most collaboratives are modeled after the Breakthrough Series (BTS) model, developed by the Institute for Healthcare Improvement (IHI). In the BTS collaborative model, IHI identifies a topic for which a large gap exists between actual and recommended care, assembles expert faculty to develop a “change package” of evidence-based practices to close the gap, and invites organizations to join the effort. Multidisciplinary teams from participating organizations then work together on the specified topic for approximately a year. Teams attend a series of multiday meetings, known as “Learning Sessions,” where they learn improvement techniques from experts and share their experiences implementing new practices with one another. Between Learning Sessions, teams implement changes in their own organizations using Plan-Do-Study-Act cycles in which they investigate quality problems, develop and implement small-scale changes, measure the effects, and make various changes for improvement. Teams learn from one another by participating in monthly conference calls, team-to-team telephone calls, listserv discussions, site visits to other organizations, monthly exchange of written reports detailing improvement activities, and monthly posting of performance data to the collaborative extranet. After the collaborative ends, teams summarize their results and lessons learned, and present them to nonparticipating organizations at conferences (Kilo 1998, 1999; IHI 2003). Previous studies of the impact of collaboratives on organizational performance have mixed results, with some demonstrating substantial impact on improvement (Horbar et al. 2001; Dellinger et al. 2005; Howard et al. 2007) and others finding no significant effect (Landon et al. 2004; Homer et al. 2005). The vast majority of these studies have examined collaboratives as a single intervention as opposed to the diverse set of features that comprise most collaborative models. A smaller group of studies has described the various features of collaboratives (e.g., Kilo 1998; Wilson, Berwick, and Cleary 2003; Ayers et al. 2005), but none has evaluated the influence of these various features on performance, particularly from the perspective of collaborative participants. Research by Fremont et al. (2006) and Leape et al. (2006) are notable exceptions. However, the former examined only three features of collaboratives, and the latter included a restricted sample of a single-state collaborative. Moreover, neither study empirically tested the relative helpfulness of various features of the collaboratives. Thus, we know little about which features are viewed as most helpful, why they are helpful, and which features are rated most highly by participants whose organizations are most successful in improving performance. This knowledge is central for researchers, practitioners, and policy makers seeking to use collaboratives effectively to improve quality of care. Therefore, we sought to examine Participants' views on the relative helpfulness of various features of collaboratives, why each feature was helpful, and which features the most successful participants viewed as most central to their success. We used quantitative and qualitative data from participants (53 teams) in four 2004–2005 BTS collaboratives. Findings from this study inform ongoing discussions about the most effective activities for promoting quality improvement. They also inform debates about whether the collaborative model can be modified to make it accessible to resource-constrained organizations without sacrificing the most valued features. For example, some have questioned whether multiday, face-to-face Learning Sessions, which require additional financial and nonfinancial investments are fundamental or can be replaced by 1-day or virtual sessions with equal success (Fremont et al. 2006). The findings from this study offer insight into which collaborative features should be maintained because of their value for participants.