Improvement Breakthrough Series Research Articles

Team-based care in specialist practice: a path to improved physician experience in British Columbia

BackgroundSpecialist physicians in the province of British Columbia commonly work on teams in acute care settings such as operating rooms or inpatient hospital units. However, while the implementation of team-based care (TBC) has been supported in primary care clinics, no formal mechanisms have supported specialist physicians in adopting TBC in their private outpatient offices. Adopting TBC models is associated with improving physician experience, efficiency, and patient experience.MethodsThe Institute for Healthcare Improvement Breakthrough Series guided a program to support 11 specialist physicians, representing nine different specialties, to develop and implement TBC in outpatient offices. Participants were supported through resources including funding, mentorship, and learning opportunities. To determine whether the program improved physician experience, quantitative data were collected using the validated Mini Z survey and qualitative data were collected through monthly reports, semi-structured interviews, and focus groups. Patient experience data were collected through surveys and follow-up calls.ResultsThe fifteen-month program was successful, with 10 of the 11 specialists implementing TBC in their offices. The Mini Z results demonstrated that physician experience improved over the course of the program, with scores on job satisfaction, work pace, and time spent on the electronic medical record improving the most. Interviews with specialists and focus groups with specialists’ team members support these findings, with participants stating that TBC modulates workloads, begins to affect burnout, improves work-life balance, and increases the efficiency of care. Patients reported positive experiences while receiving TBC. Patients were less likely to visit the emergency department after consultations with specialist teams, and providers agreed that their patients would be less likely to seek acute care because of the new practice models.ConclusionTBC is a viable model for specialist physicians and their health care teams practicing in British Columbia to foster well-being, job satisfaction, and efficiency, and to improve patient experience. These findings may be of interest to specialists, health care providers, policymakers, and administrators looking to better support and retain specialist practices that are integral to patient care.

Improving Safety through a Virtual Learning Collaborative.

Frontline healthcare safety leaders require expertise and confidence to manage local safety programs effectively yet are confronted with substantial challenges in identifying risk and reducing harm. We convened a multidisciplinary safety learning collaborative in a children's hospital pediatric department and used the Institute for Healthcare Improvement's Breakthrough Series model. Participants attended four virtual education sessions over 13 months (September 2020-September 2021) focused on identifying harm and using tools to improve safety. We analyzed departmental safety data monthly throughout the collaborative. The primary outcome was the development of improvement projects using direct application of the session content. The secondary outcome was participant confidence in improving safety via pre- and postsurveys. Seventy clinicians and quality consultants participated. Fifteen divisional safety improvement projects were initiated. The percentage of survey respondents who reported feeling "completely confident" in their ability to improve safety increased from 26% (n = 39) to 58% (n = 26) from September 2020 to September 2021 (P = 0.01) and maintained at 65% 1 year after the end of the collaborative. We observed a decrease in the mean rate of reported inpatient preventable and possibly preventable moderate/serious/catastrophic events per 1000 bedded days from 1.10 (baseline) to 0.71 (intervention period). Through a collaborative effort in a virtual learning environment, we facilitated the development of fifteen safety projects, increased leaders' confidence in improving safety, and saw improved inpatient safety. This approach, which involves healthcare professionals from various disciplines, may be effectively adapted to other settings.

The Irish national chronic obstructive pulmonary disease quality improvement collaborative: an adaptive learning collaborative

BackgroundChronic obstructive pulmonary disease (COPD) is the the most common disease-specific cause of adult emergency hospital admissions in Ireland. Preliminary groundwork indicated that treatment of acute exacerbations of COPD (AECOPD)...

Timely Recognition of Abusive Injuries (TRAIN): Results from a Statewide Quality Improvement Collaborative.

The TRAIN Collaborative adopted the Institute for Healthcare Improvement's Breakthrough Series Collaborative Model, where partnerships between organizations facilitate learning from each other and experts. Collaborative members identified opportunities to improve injury recognition, implemented changes, responded to data, and reconvened to share successes and obstacles. As a result, institutions implemented different interventions, including education for clinical staff, increased social work involvement, and scripting for providers. Data collected over 3 years were compared to a 12-month baseline. The number of injuries increased from 51 children with concerning injuries identified monthly to 76 children sustained throughout the collaborative. However, within 2 years, the 3- and 12-month reinjury rates ultimately significantly decreased from 5.7% to 2.1% and 6.5% to 3.7%, respectively. Our data suggest the Institute for Healthcare Improvement's Breakthrough Series model can be applied across large populations to improve secondary injury prevention in infants.

Improving Stroke Measure Compliance and Outcomes Through Hospital Collaboration.

Globally, national stroke registries have been shown to improve the quality of patient care and outcomes. However, registry utilization and implementation vary by country. In the United States, stroke-specific performance measures must be met to achieve and maintain stroke center certification awarded by the state or nationally accredited certifying bodies. The 2 stroke registries available in the United States are the American Heart Association Get With The Guidelines-Stroke registry, which is voluntary, and the Paul Coverdell National Acute Stroke Registry, funded competitively to states by the Centers for Disease Control and Prevention. Compliance with stroke processes of care is variable, and quality improvement initiatives among organizations have been shown to have an impact on improving stroke care delivery. However, the effectiveness of interorganizational continuous quality improvement approaches, especially among competing institutions, to improving stroke care is ambiguous, and no uniform governance for successful interhospital collaboration has been identified. The purpose of this article is to review national initiatives focused on interorganizational collaboration to improve stroke care delivery with a focus on interhospital collaboration in the United States to improve stroke performance measures specific to stroke center certification. The state of Kentucky's experience and utilization of the Institute for Healthcare Improvement Breakthrough Series model with key strategies for success will be discussed to serve as a foundation and empower novice stroke leaders in learning health systems. The models may be adapted internationally for application to stroke-specific care process improvement locally, regionally, and nationally; among organizations within the same health system or competing systems; and among organizations with funding or without funding to improve stroke performance measures.

Increasing access to single-visit contraception in urban health care settings: Findings from a multi-site learning collaborative

ObjectivesMultiple barriers limit access to the full range of contraceptive options. The purpose of this quality improvement initiative was to increase single-visit access to the full range of contraceptive methods in primary care, postabortion, and immediate postpartum settings in New York City (NYC). Study DesignFrom 2015 to 2018 we convened 2 learning collaboratives, named the Quality Improvement Network for Contraceptive Access, with 17 teams (representing 40 sites) from New York City-based hospitals and health centers using an adaptation of the Institute for Healthcare Improvement's Breakthrough Series Learning Collaborative model. Participating teams sought to implement evidence-informed recommendations to increase access. The goal was to increase the patient-centeredness of services by reducing barriers. In the absence of a way to directly measure access, we measured progress toward implementation of the 4 recommendations and contraceptive care utilization measures as proxies for access, and asked teams to describe facilitating factors. ResultsLearning collaborative teams successfully implemented all 4 of the recommendations in 95% of the participating sites. Patients who chose and received a most or moderately effective method increased from 22% to 38% in primary care, and from 0% to 17% in the immediate postpartum period. Patients who chose and received a long-acting-reversible contraceptive increased from 5% to 11% in primary care, and from 0% to 3% in immediate postpartum. Facilitating factors included the involvement of interdisciplinary teams, consideration of costs, utilization of peers to demonstrate change, and champions to drive change. ConclusionsThe application of evidence-informed recommendations using a structured quality improvement initiative increases contraceptive access. ImplicationsThis paper identifies key facilitators and factors that influenced the successful implementation of evidence-based recommendations for access to the full range of contraceptive methods in primary care, postabortion, and immediate postpartum settings. Findings can inform future initiatives that seek to increase contraceptive access at the service delivery level, as a component of reproductive autonomy, and contraceptive equity.

Initiative to Advance Trauma‐Informed Practice to Support Policy and Systems‐Level Culture Change

Research ObjectivePennsylvania has announced an initiative to prioritize state‐level action to become trauma informed, affecting culture, policy, and practice. The present study investigates support for the implementation and sustainability of trauma‐informed organizational, clinical, and milieu practices among rural behavioral health care providers.Study DesignA trauma‐informed care learning collaborative (TLC) following the Institute for Healthcare Improvement's Breakthrough Series Model was developed and implemented by a behavioral health managed care organization as part of a larger initiation to change organizational culture to become trauma informed. Innovative strategies to support trauma‐informed practice adoption and sustainability include an organizational self‐assessment and rubric guiding designation of organizations as Trauma Informed Care Centers. Aims of this initiative include monitoring consumer screening rates for exposure to trauma and increase staff confidence over the 15‐month TLC, provide training in evidence based practices, and implement the organizational Trauma Informed Care Center designation strategy.Population StudiedTwenty‐two mental health and/or substance use disorder provider organizations of outpatient, ambulatory care in rural Pennsylvania to Medicaid‐enrolled adults and children; initiative participation requires the involvement of organizational leadership, clinical staff, non‐clinical staff, and consumers and family members.Principal FindingsBy the fifth quarter of the initiative, over two thirds (68%) of participating organizations self‐assessed as either showing sustainable improvement or demonstrating outstanding sustainable results. Consumer trauma screening rates improved markedly over time, from 39.2% in the first quarter to 76.5% of consumers screened by the fifth quarter. Over half of agencies (55%) report screening rates better than 90%. Staff training scaled up rapidly, with over 2900 staff educated in trauma informed care in the first 15 months of the initiative (e.g. Trauma Focused Cognitive Behavior Therapy, Cognitive Processing Therapy, Trauma 101, Seeking Safety). Supervisors monitored 3–77 staff members each month depending on provider organization; the percentage of staff reporting high confidence in delivering trauma informed care rose from 18.6% in the first quarter to 68.0% in the fifth. After 3 years, there are currently 17 provider organizations designated as trauma informed Care Centers, of which all 17 meet exemplary center standards.ConclusionsThe trauma informed initiative has yielded positive changes in both process and outcomes with sustained improvement indicating trauma informed culture change on a systems level. This initiative has improved quality of care and access to trauma informed care for consumers.Implications for Policy or PracticeA learning collaborative framework can support the practitioner‐level and organizational‐level changes necessary to disseminate and implement a set of aligned clinical and organizational practices such as trauma‐informed practices. A specialty center designation rubric can further bolster this adoption process by providing organizations with additional incentive and with a structure to advance practice implementation and sustainability.

Implementation of a Maternal Early Warning System Quality Improvement Initiative in Texas Hospitals [20N

INTRODUCTION: Delayed response to abnormal maternal vital signs is a leading cause of preventable maternal death. Maternal early warning systems (MEWS) that alert providers to impending critical illness can improve maternal outcomes. Texas Department of State Health Services partnered with the Alliance for Innovation on Maternal Health (AIM) to launch the TexasAIM maternal safety initiative. The Texas perinatal quality collaborative (PQC) is implementing a quality improvement (QI) initiative to augment TexasAIM with a goal of integrating MEWS in a subset of Texas birthing hospitals by December 2019. METHODS: Reinforcement cohort (RC) hospitals were identified in January 2019 based on self-reported stage of MEWS implementation (n=15). The implementation framework uses the Institute for Healthcare Improvement Breakthrough Series modified to include the mentor model, and the AIM MEWS toolkit was adapted. Monthly data collection including process, structure and outcome measures began in June 2019. RESULTS: Most RC hospitals were urban (80%) and non-academic (53%), with at least 1,000 annual deliveries (73%). In 2017, the mean severe maternal morbidity rate in the RC hospitals and Texas overall was 196 and 170 per 10,000 deliveries, respectively. By August 2019, most providers (82%) and nurses (94%) were educated on the MEWS protocol. Three RC hospitals have fully integrated MEWS, with two serving as peer mentors to remaining RC hospitals. CONCLUSION: Implementation of MEWS, in conjunction with AIM bundles, may augment improvements in maternal health. Future work of the Texas PQC includes scaling the MEWS initiative to additional hospitals to support ongoing TexasAIM efforts to reduce maternal morbidity and mortality.

Scaling up Quality Improvement for Surgical Teams (QIST) \u2013 avoiding surgical site infection and anaemia at the time of surgery: protocol for a cluster randomised controlled trial

BackgroundMeasures shown to improve outcomes for patients often fail to be adopted into routine practice in the NHS. The Institute for Health Improvement Breakthrough Series Collaborative (BSC) model is designed to support implementation at scale. This trial aims to assess the effectiveness and cost-effectiveness of quality improvement collaboratives (QICs) based on the BSC method for introducing service improvements at scale in the NHS.MethodsForty Trusts will be randomised (1:1) to introduce one of two protocols already shown to improve outcomes in patients undergoing elective total hip and knee replacement surgery.The intervention is improvement collaboratives based on the BSC model, a learning system that brings together a large number of teams to seek improvement focussed on a proven intervention. Collaboratives aim to deliver at scale, maximise local engagement and leadership and are designed to build capacity, enable learning and prepare for sustainability. Collaboratives involve Learning Sessions, Action Periods, and a summative congress.Trusts will be supported to introduce either: decolonisation for Methicillin Sensitive Staphylococcus aureus (MSSA) to reduce post-operative infection (QIST: Infection), or an anaemia optimisation programme to reduce peri-operative blood transfusions (QIST: Anaemia). Trusts will continue with their usual practice for whichever protocol they are not introducing. Anonymised data related to both infection and anaemia outcomes for patients undergoing hip or knee arthroplasty at all sites will mean that the two groups act as controls for each other.The primary outcome for the QIST: Infection collaborative is deep MSSA surgical site infection within 90 days of surgery, and for the QIST: Anaemia collaborative is blood transfusion within 7 days of surgery. Patient-level secondary outcomes include length of hospital stay and readmission, which will also inform the economic costings. Qualitative interviews will evaluate the support provided to teams.DiscussionThe scale of this trial brings considerable challenges and potential barriers to delivery. Anticipated challenges relate to recruiting and sustaining up to 40 organisations, each with its own culture and context. This complex project with multiple stakeholders across a large geographical area will be managed by experienced senior-level project leaders with a proven track record in advanced project management. The team should ensure effective project governance and communications.Trial registrationISRCTN, ISRCTN11085475. Prospectively registered on 15 February 2018.

A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants

A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid. The program was anchored in four clinical organizations with distinct models of care: community behavioral health, residential behavioral health, hospital-based obstetrical practice, and co-located obstetrical and behavioral health. A modified version of the Institute for Healthcare Improvement Breakthrough Series Model for Improvement was implemented using monthly performance data feedback to conduct small tests of change and improve care. Administrative data from the state's Medicaid, vital statistics, and child welfare systems were linked to evaluate the impact of MOMS on 252 mother-infant dyads compared to a sample of 846 Medicaid beneficiaries with OUD in the third trimester of pregnancy. MOMS participation was associated with increased likelihood of MAT in trimesters one, two and three (AOR = 2.30, 4.40, 2.75, respectively), behavioral health counseling during trimesters two and three (AOR = 3.75 and 2.07, respectively), retention in MAT during postpartum months one through three and four through six (AOR = 2.86, 2.40, respectively), and marginally lower out-of-home placement of infants born to mothers with OUD (AOR = 0.66). Within the MOMS program, greater participation in behavioral health treatment and MAT (χ2(3) ≥ 12.09) was observed in the co-located behavioral health/obstetrical care practice site compared to behavioral health-led and obstetrical provider-led sites.

Improving Door-to-needle Times in the Treatment of Acute Ischemic Stroke Across a Canadian Province: Methodology.

Alteplase is a proven medical treatment for acute ischemic stroke; however, the effectiveness of this treatment is highly time dependent. Therefore, it is imperative that hospitals treat acute ischemic stroke patients as quickly as possible. The measure, door-to-needle time, is the time from hospital arrival to when alteplase administration begins. The goal in the Canadian province of Alberta was to reduce the door-to-needle time to a median of 30 minutes and to increase the percent of patients treated within 60 minutes to 90%. A modified version of Institute for Healthcare Improvement Breakthrough Series Collaborative was used. All stroke centers self-enrolled into the collaborative after initial contact, and sites created interdisciplinary teams to participate in the Collaborative. Leadership and faculty were highly experienced in quality improvement and acute stroke. There were 3 daylong face-to-face learning sessions that were attended by enrolled teams, which included presentation about the evidence, site presentations to promote cross-site learning, and time to plan changes with their teams. The sites were also supported by site visits, webinars, and data feedback.

Preschool Vision Screening Collaborative: Successful Uptake of Guidelines in Primary Care.

Introduction:Preschool vision screening rates in primary care are suboptimal and poorly standardized. The purpose of this project was to evaluate pediatric primary care adherence to and improvement in preschool vision screening guidelines through a learning collaborative environment.Methods:Thirty-nine Ohio primary care providers interested in preschool vision screening self-selected to participate in an Institute for Healthcare Improvement Breakthrough Series learning collaborative that spanned 18 months. Charts of patients attending 3-, 4-, and 5-year well-child visits were randomly selected and reviewed for documentation of vision screening attempts, referrals, and need for rescreening.Results:Practitioners improved evidenced-based screening attempts for distance visual acuity and stereopsis of 3–5-year-old patients from 18% at baseline to 87% (P < 0.001) at 6 months; improved screening rates were sustained through completion of the collaborative. Baseline referral rates (26%) of abnormal vision screens improved by 59% (P < 0.001) during the first 6 months and were maintained through month 18. Rates for children with incomplete screens that were scheduled for a repeated screening increased during the first 6 months. However, changes in this metric did not reach statistical significance (P = 0.265), nor did it change during the remainder of the collaborative.Conclusions:Rapid integration and maintenance of preschool vision screening guidelines are feasible across primary care settings utilizing a structured learning collaborative. Challenges with the rescreening processes for children with incomplete vision screens remain, with the 3-year age group having the greatest room for improvement.

Triple Aim Is Triply Tough: Can You Focus on Three Things at Once?

The I3 POP Collaborative sought to improve health of patients attending North Carolina, South Carolina, and Virginia primary care teaching practices using the triple aim framework of better quality, appropriate utilization, and enhanced patient experience. We examined change in triple aim measures over 3 years, and identified correlates of improvement. Twenty-nine teaching practices representing 23 residency programs participated. The Institute for Health Care Improvement Breakthrough Series Collaborative model was tailored to focus on at least one triple aim goal and programs submitted data annually on all collaborative measures. Outcome measures included quality (chronic illness, prevention); utilization (hospitalization, emergency department visits, referrals) and patient experience (access, continuity). Participant interviews explored supports and barriers to improvement. Six of 29 practices (21%) were unable to extract measures from their electronic health records (EHR). All of the remaining 23 practices reported improvement in at least one measure, with 11 seeing at least 10% improvement; seven (24%) improved measures in all three triple aim areas, with two experiencing at least 10% improvement. Practices with a greater number of patient visits were more likely to show improved measures (odds ratio [OR] 10.8, 95% confidence interval [CI]: .68-172.2, P=0.03). Practice interviews revealed that engaged leadership and systems supports were more common in higher performing practices. Simultaneous attainment of improvement in all three triple aim goals by teaching practices is difficult. I3 POP practices that were able to pull and report data improved on at least one measure. Future work needs to focus on cultivating leadership and systems supporting large scale improvement.

Effect of a thermal care bundle on the prevention, detection and treatment of perioperative inadvertent hypothermia.

To improve the prevention, detection and treatment of perioperative inadvertent hypothermia in adult surgical patients by implementing a Thermal Care Bundle. Keeping patients normothermic perioperatively prevents adverse surgical outcomes. Hypothermia leads to serious complications including increased risk of surgical bleeding, surgical site infections and morbid cardiac events. The Thermal Care Bundle consists of three elements: (i) assess risk; (ii) record temperature; and (iii) actively warm. A pre- and postimplementation study was conducted to determine the impact of the Thermal Care Bundle on the prevention, detection and treatment of perioperative inadvertent hypothermia. The Thermal Care Bundle was implemented using an adapted version of the Institute of Healthcare Improvement's Breakthrough Series Collaborative Model. Data were collected from auditing medical records. Data from 729 patients (pre-implementation: n=351; postimplementation: n=378) at four sites were collected between December 2014-January 2016. Improvements were recorded in the percentage of patients with a risk assessment; at least one documented temperature recording per perioperative stage; and appropriate active warming. Despite this, the overall incidence of perioperative inadvertent hypothermia increased postimplementation. The Thermal Care Bundle facilitated improved management of perioperative inadvertent hypothermia through increased risk assessment, temperature recording and active warming but did not impact on perioperative inadvertent hypothermia incidence. Increased temperature recording may have more accurately revealed the true extent of perioperative inadvertent hypothermia in this population. This study showed that a collaborative, context specific implementation method, such as the IHI Breakthrough Series Model, is effective at improving practices, which can improve thermal care.

Application of process mapping to understand integration of high risk medicine care bundles within community pharmacy practice.

The Scottish Patient Safety Programme - Pharmacy in Primary Care collaborative is a quality improvement initiative adopting the Institute of Healthcare Improvement Breakthrough Series collaborative approach. The programme developed and piloted High Risk Medicine (HRM) Care Bundles (CB), focused on warfarin and non-steroidal anti-inflammatories (NSAIDs), within 27 community pharmacies over 4 NHS Regions. Each CB involves clinical assessment and patient education, although the CB content varies between regions. To support national implementation, this study aims to understand how the pilot pharmacies integrated the HRM CBs into routine practice to inform the development of a generic HRM CB process map. Regional process maps were developed in 4 pharmacies through simulation of the CB process, staff interviews and documentation of resources. Commonalities were collated to develop a process map for each HRM, which were used to explore variation at a national event. A single, generic process map was developed which underwent validation by case study testing. The findings allowed development of a generic process map applicable to warfarin and NSAID CB implementation. Five steps were identified as required for successful CB delivery: patient identification; clinical assessment; pharmacy CB prompt; CB delivery; and documentation. The generic HRM CB process map encompasses the staff and patients' journey and the CB's integration into routine community pharmacy practice. Pharmacist involvement was required only for clinical assessment, indicating suitability for whole-team involvement. Understanding CB integration into routine practice has positive implications for successful implementation. The generic process map can be used to develop targeted resources, and/or be disseminated to facilitate CB delivery and foster whole team involvement. Similar methods could be utilised within other settings, to allow those developing novel services to distil the key processes and consider their integration within routine workflows to effect maximal, efficient implementation and benefit to patient care.

Collaborative Learning in the Texas Medicaid 1115 Waiver Program.

The Texas Medicaid 1115 Transformation Waiver reforms the state's safety net systems by creating a Delivery System Reform Incentive Payment incentive pool for innovative healthcare delivery. The Waiver supports the design and implementation of transformative projects. As part of the Waiver requirements, regions created Learning Collaboratives to collaborate on project implementation and outcomes. This paper describes the experience of one region in adapting the Institute for Healthcare Improvement Breakthrough Series (IHI BTS) model, as a framework for their Learning Collaborative. Implementation of the Learning Collaborative was systematic, multidimensional, and regularly evaluated. Some features of the IHI model were adapted, specifically longer Plan-Do-Check-Act cycles and the lack of a single clinical focus. This experience demonstrates the ability of a region to improve health from a more diverse perspective than the traditional IHI BTS Collaboratives. Within the region, organizations are connecting, agencies are building continuums of care, and stakeholders are involved in healthcare delivery. The initial stages show a remarkable increase in communication and enhanced relationships between providers. At the end of the 5-year Waiver, evaluation of the impact of the regional and cohort Learning Collaboratives will determine how well the adapted IHI BTS model facilitated improvements in the community's health.

Statewide implementation &amp; sustainment of evidence-based treatment using learning collaboratives: A five-year mixed-methods study

Connecticut was among the first states to begin using learning collaboratives (LCs) for the statewide implementation of a behavioral health EBP in 2007. Based upon the Institute for Healthcare Improvement's Breakthrough Series Collaborative, LCs are an intensive quality improvement approach now being used to disseminate EBPs nationally. However, there has been little research on the LC model for EBP dissemination. This presentation summarizes mixed-methods data from a statewide dissemination of Trauma Focused Cognitive Behavioral Therapy (TF-CBT) to 16 community-based clinics using LCs. Pre-and post-implementation measures of staff attitudes towards EBPs and perceptions of organizational support were collected. Measures of acceptability of the LC model and satisfaction were collected post-implementation, and focus groups were held for clinicians, supervisors, and administrators. Monthly data on fidelity, penetration, and child level outcomes have been collected for 5 years post-implementation. Implementation outcome data from over 300 staff trained at the 16 agencies, who have served 2,300 children and families, will be presented. Results suggest that the LC is an effective, yet time intensive, implementation approach that resulted in sustained use of an EBP for several years despite significant challenges. Staff reported variability in the utility of various components of the model, but overall reported it to be an effective implementation approach. Staff reported significant improvements in attitudes about EBPs from pre-to post-implementation. Implementation costs, staff turnover, and sustainability were identified as significant challenges. Child outcome data indicate significant clinical improvements in PTSD and depression symptoms. This research provides support for the use of LCs as a dissemination model. The results suggest potential strategies for evaluating modifications to LCs to improve dissemination, and how to evaluate specific implementation strategies from LCs in other dissemination strategies. This study was funded through a contract with the Connecticut Department of Children and Families.

Improving and Sustaining Breastfeeding Practices through a Statewide Learning Collaborative

<h2>Poster Presentation</h2><h3>Objective</h3> The aim of the Texas Breastfeeding Learning Collaborative (TBLC) is to increase in‐hospital exclusive breastfeeding rates by 35% across three, sequential, regional, quality improvement, learning collaborative cohorts of as many as 81 birthing facilities. <h3>Design</h3> Use of the Institute for Healthcare Improvement's Breakthrough Series (BTS) and Model for Improvement (MFI) to facilitate uptake of the Ten Steps to Successful Breastfeeding (Ten Steps). <h3>Sample</h3> Cohorts A and B included 41 hospital improvement teams in two geographic regions cumulatively accounting for 99,000 births (26% of Texas births and 2.5% U.S. births) annually. Participating facilities included a diverse mix of urban/rural, large/midsized/small, and public, private, and academic center settings at varying stages of Ten Steps implementation. <h3>Methods</h3> The TBLC utilizes the BTS, MFI, and complementary support to facilitate implementation of the Ten Steps within participating facilities. <h3>Implementation Strategies</h3> Twenty hospital teams (Cohort A) were guided through a BTS Learning Collaborative with components including data collection, self‐assessment surveys, discussion forums, support calls, leadership events, face‐to‐face learning sessions (LS), and virtual action periods (AP) calls. Components work to accelerate plan‐do‐study‐act cycles for improvement and to facilitate sharing of best practices among teams. Learning sessions included didactic lectures to communicate the evidence base of the Ten Steps and interactive workshops focused on sharing strategies to overcome common and special cause barriers. Teams were linked to breastfeeding support resources of the Department of Health and Human Services. Cohort B built upon Cohort A successes, and collective learning was spread to hospital teams through cross‐cohort collaborative mentorship and continuous quality improvement within the project structure. <h3>Results</h3> Cohort A's quality data indicated aggregate improvements from February 2013 to April 2014 for multiple outcome and process measures. <h3>Conclusion/Implications for Nursing Practice</h3> Multidisciplinary teams engaged in a quality improvement learning collaborative to accelerate adaptation of recommended maternity practices across diverse hospital settings to achieve improved process‐ and outcome measures. Improvement strategies and lessons learned are transferable to other projects and settings.

Interdisciplinary teamwork and the power of a quality improvement collaborative in tertiary neonatal intensive care units.

Significant gaps in healthcare quality and outcomes can be reduced via quality improvement collaboratives (QICs), which improve care by leveraging data and experience from multiple organizations.The Children's Hospital Neonatal Consortium Collaborative Initiatives for Quality Improvement team developed an infrastructure for neonatal QICs. We describe the structure and components of an effective multi-institutional neonatal QIC that implemented the "SLUG Bug" project designed to reduce central line-associated bloodstream infections (CLABSIs).The operational infrastructure of SLUG Bug involved 17 tertiary care neonatal intensive care units with a goal to reduce CLABSI in high-risk neonates. Clinical Practice Recommendations were produced, and the Institute of Healthcare Improvement Breakthrough Series provided the framework for the collaborative. Process measures studied the effectiveness of the collaborative structure.CLABSI rates decreased by 20% during a 12-month study period. Compliance bundle reporting exceeded 80%. A QIC score of 2.5 or more ("improvement") was achieved by 94% of centers and a score 4 or more ("significant improvement") was achieved by 35%.Frequent interactive project meetings, well-defined project metrics, continual shared learning opportunities, and individual team coaching were key QIC success components. Through a coordinated approach and committed leadership, QICs can effectively implement change and improve the care of neonates with complex diagnoses and rare diseases.

Formation of an international quality improvement collaborative for palliative care: The Global Palliative Care Quality Alliance (GPCQA).

91 Background: Formal mechanisms to share data on quality remain immature in specialty palliative care. As the field grows, infrastructure that promotes collaboration among academic and community-based practice will be required to foster comparisons and benchmarking of data to inform areas for quality improvement. Further, such relationships will create a palliative care “quality improvement laboratory”, where proposed guidelines and best practices can be developed, implemented, and tested. Methods: We set out to bring together specialty palliative care practices with a shared vision for collaborative quality improvement. We modeled our approach after the Institute for Healthcare Improvement Breakthrough Series alongside our Rapid Learning Quality Improvement paradigm. We use a set of common data collection procedures, across an electronic point-of-care platform called Quality Data Collection Tool (QDACT), alongside a centralized data registry. Further, we meet and discuss challenges and issues, compare best practices, and brainstorm new projects through biweekly conference calls. Results: We have created a multi-institutional collaboration for quality assessment and improvement in specialty palliative care. Termed the Global Palliative Care Quality Alliance, we have brought together 11 academic and community organizations, both general and oncology-specific, across six states to study various areas of quality practice. Short-term, we will conduct rapid-cycling quality improvement projects addressing National Quality Forum domains for quality palliative care, including documentation of spiritual assessment and timely advance care planning. Long-term, we aim to study the link between quality measure adherence and outcomes and further align our initiatives with those of other large consortia, like the Palliative Care Research Cooperative and Palliative Care Quality Network. Conclusions: Collaborative quality improvement is needed in specialty palliative care across a national platform. Developing the infrastructure to perform standardized quality improvement is achievable across multiple palliative care settings.