Four lessons for running impactful collaboratives in health care

Human beings are social animals and, while most breakthrough ideas and insights come from individuals, execution of these ideas is largely done through collaboration. Whether feats of engineering, a successful Grand Départ or humanitarian relief efforts, all draw on the positive energy that comes from people working collectively on a shared ambition.

So it isn’t surprising that the collaborative model has become a common vehicle for supporting quality improvement efforts in health care. The first collaboratives in the UK started with applying what were largely techniques from queuing theory and supply chain management to reduce waiting times.

The collaborative model subsequently expanded its range to employ human factors and other behavioural approaches to improve reliability and safety of care. At the heart of any collaborative are the core components of: a shared problem, an agreed and proven solution, support from senior management, and multi-disciplinary teams coming together to share successes and challenges and support mutual learning.

Running collaboratives isn’t easy. They need to be well planned and designed, expertly executed and, even then, their success is likely to be heavily dependent on the context in which the participating teams are working.

From my own involvement in many collaboratives, I’ve seen the energy and passion that can be unleashed in teams working as part of a collective – having like-minded people to problem solve with, commiserate with and hopefully celebrate with. But in a resource-constrained NHS, can we still afford to use the collaborative model to improve care?

To try to answer this question, we commissioned a scan of readily available research evidence about the impact collaboratives have had on the quality of health care delivery. As one would expect, there is no single unequivocal answer, but by reviewing the existing literature it is possible to identify some factors that are common to those collaboratives that appear to have had the greatest impact. Four lessons emerge:

• Involve the right people. Collaboratives are turbo-charged by discretionary effort and social capital. They work best when they are voluntary, inclusive (of all disciplines and patients) and in an environment where teams have senior support to make change.
• Pick the right problem. Collaboratives work best on issues where there is consensus on the problem and solution, and where teams can get traction. They are most likely to show results when there is a large gap to be closed between actual and desired practice, and tight coupling between the defect and the solution.
• Organise, organise, and adapt. Good collaboratives embody discipline through: working to the same goals and timelines; using standardised, evidence-based interventions; and embedding the necessary change skills and maximising connectivity. But the role context plays in implementing a successful intervention cannot be ignored - teams need to be given freedom on the ‘how’ of what they implement.
• Recognise and provide the necessary resources. While the enthusiasm and passion generated through shared endeavour can take teams a long way, you need a realistic assessment of the time and resources needed to support effective measurement and time for reflective learning.

If these then are the conditions for a successful collaborative, what does it tell us about when a collaborative model isn’t likely to work and what other approaches exist? From my own experience I would offer the following observations:

• Don’t assume people know the basic quality improvement methods needed to measure, test and study changes. Do a skills audit and make sure you have the right expertise in teams before you start.
• Don’t be over-ambitious. The real legacy of collaboratives is the mindset they cultivate that change and improvement are possible. Set realistic goals to build a sense of success and confidence.
• Don’t expect collaboratives to address systemic problems. System-level issues will only be addressed with the necessary leadership from the top.
• Don’t expect it to work everywhere, every time. The context for health care delivery can vary considerably – the same solution won’t always get the same results. Rather than seeing this as failure, use it as an opportunity to learn.

Four years ago I visited a collaborative programme that we supported to reduce maternal mortality in Malawi. For the previous year I had already seen amazing run charts from the participating teams and I was curious to see the context in which the work was being carried out.

I couldn’t have been more humbled. In clinical environments where post-partum women sometimes had to sleep under the already occupied beds, where obstetricians lacked basic resources such as weighing scales, and data were recorded by hand on wall charts, teams were being fuelled by the joy that comes from the collective endeavour to improve care for women and babies.

While the gap between theory and practice was far larger in Malawi than we have probably seen in this country since the advent of the NHS, we know all too well that there still remain many areas of basic care where we fall short of delivering what we know works reliably. While this remains the case there will, in my view, continue to be a place for collaboratives.

Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF