This synthesis report examined published evidence about how effective collaborative improvement (QIC) may be for teaching and enabling health workers to use quality methods to make improvements to their health care services and to spread the use of these methods in lower- and middle-income countries (LMICs)

Drawing on these findings, the synthesis review discusses the practical implications and provides recommendations for improvement practitioners and improvement researchers.

This presentation was given by Dr. Donna Jacobs, HCI Country Director for South Africa, at the 28th International Conference of the International Society for Quality in Health Care, Ltd. (ISQua), which took place in Hong Kong, China from September 14-17, 2011. The conference theme was, “Patient Safety: Sustaining the Global Momentum."

The Tanzania National AIDS Control Program (NACP) and PEPFAR initiated the Partnership for Quality Improvement (PQI) in 2007 to develop and promote a harmonized quality improvement (QI) plan for antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) services countrywide. The partnership included PEPFAR’s HIV/AIDS care and treatment implementing partners, with technical leadership from the USAID Health Care Improvement Project (HCI), implemented by University Research Co., LLC (URC), and PharmAccess International (PAI).

The collaborative model of quality improvement aims at testing and implementing Quality Improvement (QI) interventions on a small scale, synthesizing the most robust and effective changes, and spreading them at scale. Collaborative improvement not only generates improvements in the quality of care delivered in these initial sites, but also develops organizational learning. However, there still exist knowledge gaps on how to successfully spread evidence practices and ensure up-take and continuous application of these practices in resource-limited settings.

The study examines the process of spread of improvements from the demonstration phase of the MNCH Facilities Collaborative in Balkh and Kunduz to three new provinces: Parwan, Herat, and Bamiyan.  In the demonstration phase, different change ideas are tested and an intervention package composing of these change ideas and interventions that yield high outcomes will be prepared and used for scale up to the three new provinces. The aim of the spread study is to evaluate the uptake and implementation of a package of changes—which originated in the demonstration phase—in Bamyan, Parwan and Herat.

• How sites in new provinces react to and take up improvements coming from the demonstration phase
• How the applicability and effectiveness of QI methodology in improving quality of health care differs in new settings

• Which ‘change ideas’ were adopted, modified or rejected by health facilities in the three new provinces
• How were the ‘change ideas’ communicated to the sites, and what were the reasons behind the uptake of each ‘change idea’?
• Were there specific reasons that facilitated or hindered the uptake of change ideas? What were they and what are QI participants perspectives on them?
• What were the most successful means of spreading of quality improvement changes?

This paper summarizes 10 years of evidence of the effectiveness of collaborative improvement in improving health outcomes and compliance with health care standards. The collaborative improvement approach was designed by the Institute for Healthcare Improvement (IHI) in the United States to produce rapid, significant improvements in a targeted area of health care. The paper was commissioned by USAID and analyzes the results achieved by over 1,300 teams of health care providers who participated in 27 improvement collaboratives supported by USAID during 1998-2008.   Data analyzed consisted of 135 time-series charts representing pooled data from groups of teams from 12 countries. All together, the data covered 81 distinct measures of compliance with standards and outcomes for maternal, newborn and child health, HIV/AIDS care, family planning, and malaria and tuberculosis diagnosis and treatment.

In 1999, the Institute for Healthcare Improvement (IHI) chartered a team to develop a "Framework for Spread." The stated aim of the team was to "…develop, test, and implement a system for accelerating improvement by spreading change ideas within and between organizations." The team conducted a review of organizational and health care literature on the diffusion of innovations, and interviewed organizations both within and outside of health care that had been successful in spreading new ideas and processes.  Since then, IHI's Framework for Spread has continued to evolve. This white paper provides a snapshot of IHI’s latest thinking and work on spread.

The paper is divided into two parts.  The first part of the white paper describes the major spread projects that IHI has supported through early 2006 and harvests the lessons IHI has learned about the most effective ways to prepare for spread, establish an aim for spread, and develop, execute, and refine a spread plan.  The second part of the white paper is a reprint of an article published in the June 2005 issue of the Joint Commission Journal on Quality and Patient Safety, describing how the Veterans Health Administration (VHA) used the Framework for Spread to spread improvements in access to care to more than 1,800 outpatient clinics.

This white paper may be downloaded without charge from the IHI web site. Users must first register with the IHI site; registration is free. Once logged on to the IHI web site, A Framework for Spread can be downloaded free of charge at http://www.ihi.org/IHI/Results/WhitePapers/AFrameworkforSpreadWhitePaper.htm.