Barriers and facilitators to the implementation of the collaborative method: Reflections from a single site

Abstract

A collaborative is an effective method of implementing evidence-based practice across multiple sites through the sharing of experience and knowledge of others in a similar setting, over a short period of time. Collaborative methods were first used in the USA but have been adopted internationally.
This paper sought to document the facilitators and barriers to the implementation of the collaborative method, based on a single site's experience of participating in a multisite, state-wide heart failure collaborative. Method: Qualitative data was collected using three complementary
participant observation, reflective journalling and key informant interviews. Quantitative monitoring of team performance occurred monthly according to prespecified performance indicators. Findings: Barriers and facilitators that were identified by this study included: organisational factors, team composition, dynamics and networking, changing doctor behaviour, clinical leadership and communication.
The findings from this study underscore the importance of leadership, communication and team cohesion for the successful implementation of the collaborative method at individual sites. In addition, the importance of a preparatory stage that deals with known barriers and facilitators to the collaborative method before the commencement of the official study period was highlighted. The potential for the collaborative approach to improve clinical outcomes warrants further systematic evaluation of process issues and consideration of the barriers and facilitators to implementation in various settings.

Full text

DEVELOPING RESEARCH AND PRACTICE
Barriers and facilitators to the implementation of the
collaborative method: reflections from a single site
P J Newton, P M Davidson, E J Halcomb, A R Denniss
...................................................................................................................................
See end of article for
authors’ affiliations
........................
Correspondence to:
P J Newton, School of
Nursing, University of
Western Sydney, Locked
Bag 1797, Penrith South DC,
New South Wales 1797,
Australia; phil_newton@
wsahs.nsw.gov.au
Accepted 27 May 2007
........................
Qual Saf Health Care 2007;16:409–414. doi: 10.1136/qshc.2006.019125
Background: A collaborative is an effective method of implementing evidence-based practice across multiple
sites through the sharing of experience and knowledge of others in a similar setting, over a short period of
time. Collaborative methods were first used in the USA but have been adopted internationally.
Aim: This paper sought to document the facilitators and barriers to the implementation of the collaborative
method, based on a single site’s experience of participating in a multisite, state-wide heart failure
collaborative.
Method: Qualitative data was collected using three complementary methods: participant observation,
reflective journalling and key informant interviews. Quantitative monitoring of team performance occurred
monthly according to prespecified performance indicators.
Findings: Barriers and facilitators that were identified by this study included: organisational factors, team
composition, dynamics and networking, changing doctor behaviour, clinical leadership and communication.
Conclusion: The findings from this study underscore the importance of leadership, communication and team
cohesion for the successful implementation of the collaborative method at individual sites. In addition, the
importance of a preparatory stage that deals with known barriers and facilitators to the collaborative method
before the commencement of the official study period was highlighted. The potential for the collaborative
approach to improve clinical outcomes warrants further systematic evaluation of process issues and
consideration of the barriers and facilitators to implementation in various settings.
A
collaborative is a quality improvement method that
seeks to implement evidence-based practice through the
sharing of experience and knowledge of others in a
similar setting, over a short period of time.
12
The collaborative
method was first used in the USA, but other models have since
been developed in Australia, France, Norway, Sweden and the
UK.
1
Many collaborative models exist, including the Institute
for Healthcare Improvement Breakthrough Series.
1
The Plan-Do-Study-Act (PDSA) cycles are integral to the
collaborative method. The PDSA cycles are conducted in
repetitive cycles to drive change.
34
Figure 1 illustrates how
continuous PDSA cycles are used to move from hunches and
theories to implementing changes that result in improvements
in either process or outcome measures. These cycles are not
designed to be a singular intervention, rather they should be
undertaken as a dynamic, cyclical process that is continually
refined until the desired outcome is achieved.
The key characteristics that differentiate the collaborative
method from other quality improvement strategies are
5
:
N
engagement of clinical leaders and executive support;
N
structured timelines and reporting mechanisms;
N
an emphasis on implementation of evidence-based strate-
gies;
N
importance placed on collaboration and sharing of knowl-
edge across institutions.
Much of the evidence for the collaborative method has come
from multisite collaboratives.
6–8
Therefore, there is a paucity of
evidence for smaller scale, single setting collaboratives and a
limited understanding of the experiences of individual teams in
the collaborative process.
New South Wales (NSW) is the largest state in Australia and
has a system of universal coverage where responsibility for
healthcare funding and monitoring lies in both the federal and
state jurisdiction. NSW Health oversees the public health
system across the state, whereas the federal government is
responsible for community-based healthcare services.
Following a restructure after the collaborative, NSW Health is
now divided into eight area health services, each of which
provides a range of acute and primary healthcare services.
9
The
NSW Chronic Care Collaborative (CCC) was a joint initiative of
the Institute for Clinical Excellence and NSW Health conducted
in 2004–2005.
10
Twenty-two teams representing 18 area health
services from across NSW, participated in the collaborative.
11
Teams comprised a range of clinical and management staff
from both acute hospital and community-based health services,
including a general practitioner representative, consumer and
carer representatives, and an executive sponsor.
11
AIM
This study aimed to integrate the findings of a literature
review
12
with the findings of a descriptive exploratory study to
identify and explore the barriers and facilitators to the
implementation of the collaborative method at a single site
participating in a state-wide collaborative.
METHOD
Study site
The site of the local collaborative team discussed in this paper is
a multisite area healthcare service within NSW catering for an
estimated resident population of 677 870.
13
Residents are highly
culturally diverse, with 34.5% of the population being born
overseas compared with the NSW average of 23.4%.
13
In
addition to cultural diversity, the area contains pockets of
considerable socioeconomic disadvantage.
13
Abbreviations: CCC, Chronic Care Collaborative; NSW, New South
Wales
409
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At the commencement of the CCC, the area health service did
not have a dedicated heart failure disease management
programme. The introduction of a programme for this region
was being undertaken simultaneously with the implementation
of the CCC.
Data collection
A between-methods triangulated design allowed the researcher
to explore the single collaborative site within a multifaceted
and comprehensive framework. Ethical approval was gained
from the human research ethics committee of the area health
service and university before commencing data collection.
The impact of the collaborative changes was shown by the
quantitative audit data collected by the collaborative team
during the action cycle periods. Audits were undertaken on a
monthly basis and submitted to the coordinator as aggregated
data and used to track the progress of change. These data were
analysed using descriptive statistics.
Three complementary qualitative data collection methods,
participant observation,
14–16
reflective journalling,
17
and key
informant interviews,
18
were used to explore the attitudes of
team members to the collaborative process. With agreement of
the local collaborative team, the researcher became a partici-
pant in the process, attending all team meetings and assisting
with the data collection.
During the time as a participant observer, the researcher kept
detailed field notes and a reflective journal. The journalling
implied a reflective and critical analysis of individual and group
interactions, and was used by the researcher to reflect on their
own assumptions and practices.
19
The journal was a record of
thoughts and insights that emerged throughout the study and
assisted in providing context for the observations.
20
Key
informants were approached for individual interviews on the
basis of their role and function in the local team to achieve
representation across facilities and disciplines. These interviews
were audio-recorded and subsequently transcribed. Interview
transcripts and the researcher’s journal and field notes were all
analysed using the process of content analysis.
16
FINDINGS
Findings in key performance indicators
We have previously reported the findings of the potential of the
collaborative method to improve the outcomes of people with
heart failure.
12
Key barriers and facilitators that were identified
are summarised in box 1. Interventions for the collaborative
were placed into diagnostic and management bundles (box 2).
These data items were derived from the NSW Clinical Services
Framework for Heart Failure and were collected in three
discrete settings: (1) the emergency department; (2) on
discharge; and (3) in the community setting (general practice,
cardiac rehabilitation and community nursing).
10
A full report
of the NSW CCC has been published and is beyond the scope of
this paper.
21
Briefly, the report outlines the aggregated data
from all participating teams in the heart failure collaborative.
Some examples of improvements that occurred during the
collaborative period were increased reporting of diagnostic
bundle items for heart failure in the community (p,0.001) and
at discharge (p,0.001). These improvements were not seen in
the emergency department (p,0.10). However, the emergency
department showed significant improvements in the use of b
blockers (p,0.02) and dose titration schedules (p,0.001).
Referral to a rehabilitation programme and discussion of
advance care directives were not significant in any of the three
settings. Admissions to hospital with a diagnosis of heart
failure were significantly less during the study period than in
the corresponding 3 months in the preceding year. This is
indicative of the impact of the implemented strategies.
Figure 2 illustrates local team results in the prescription of
ACE inhibitors and b blockers and having a dose titration
schedule for these medications. This was a significant achieve-
ment for the local team as Intervention One of the CCC was to
have all patients with heart failure on a dose titration schedule
for ACE inhibitors and b blockers at discharge. Strategies
developed by the team to achieve this target included the
development of a dose titration proforma, educational and
Box 1: Key facilitators and barriers
Facilitators
N
Adequately resourced
N
Strong senior leadership support
N
Creating changes that are small scale and realistic within
methodological timeline
Barriers
N
Under resourced
N
Weak leadership
N
Attempting to create changes that are to large scale and
unrealistic
Box 2: Diagnostic and management bundles
Diagnostic bundle
N
Focused clinical history
N
Clinical examination
N
Echocardiography
Management bundle
N
Baseline investigations
N
ACE inhibitor
N
Approved b blocker
N
Dose titration schedule for ACE inhibitor and b blocker
N
Smoking cessation
N
Referral to cardiac rehabilitation
N
Completion of cardiac rehabilitation programme
N
Schedule of review with general practitioner
N
Current influenza immunisation
N
Current pneumococcal immunisation
N
After hours point of contact
N
Advanced care directives
Figure 1 The Plan-Do-Study-Act cycle.
10
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communication activities including a workshop for general
practitioners. The increase in use from 35% at baseline to 77%
probably reflects an improvement as a result of the targeted
interventions. However, evidence of gains in areas requiring
more complex cross-sector negotiation reveals achievements
were not as pronounced. For example, documentation of
referral to cardiac rehabilitation increased from 14% to 35%
and self-management support from 45% to 50%. Such
challenges are consistent with those reported in the litera-
ture.
822
These data must also be interpreted in the context of
small sample sizes and purposive sampling used in this
investigation. The more reliable and robust data derived from
the aggregated CCC data are described in table 1.
Evaluation of the collaborative process
The six key themes that emerged from the qualitative data
which explored the collaborative process were:
N
system inflexibility for rapid change—contextual and orga-
nisational factors;
N
need for clinical leadership;
N
cohesion to drive change;
N
conceptual challenges: ‘‘getting your head around the
method’’;
N
ensuring all voices are heard;
N
consciousness raising awareness and optimism.
These themes are discussed in turn below within the context of
the integrated literature review.
12
System inflexibility for rapid change—contextual and
organisational factors
The study site had recently implemented a clinical streaming
model, meaning that the organisational and management
processes for cardiac services had been integrated on an area-
wide basis, rather than being managed at individual facilities as
had been done previously. This meant that the team at the
beginning of the project were just getting to know each other
and as such was not a ‘‘natural team’’.
Each individual facility has its own culture, norm, values,
beliefs and behaviours.
23
The collaborative method had the
flexibility to allow these organisations to implement changes
that reflected the culture and behaviour of individual facilities.
An attempt to make a systemic change across all levels of the
organisation is an immense undertaking that requires a well-
developed understanding of the culture and how best to
implement and manage change. If teams believe in the change
process and can identify with the purpose of the change, they
are more likely to drive the change than if the relevance of the
change is not easily identified within the organisation.
24
Interview data revealed that participants considered that
current organisational systems in healthcare were ‘‘not geared
for rapid change’’. This is of particular concern given that rapid
change is an integral component of the collaborative method.
3
One participant commented that ‘‘the current system is already
stretched’’ making it difficult to accommodate additional data
collection tasks and meetings within the working schedule.
During the study period, a state-wide restructure of area health
services contributed to insecurities and anxieties related to
clinical systems and process issues.
System inflexibility is a characteristic of the bureaucracy of
acute hospital environments.
25
As can be seen from fig 2, the
local collaborative team achieved improvements in the number
of patients receiving documented levels of titrated ACE
inhibitors and b blockers. In an attempt to sustain these
improved prescription levels, the collaborative team introduced
a medication titration chart which every patient admitted to
each cardiology department within the area health service was
to receive as part of their discharge, as a guide to their general
practitioner to titrate their medications. However, the imple-
mentation of this form was delayed. The form required
consideration by the collaborative team and formal endorse-
ment by the hospital forms and drug committees before testing
or implementation. This bureaucratic process impeded the
ability of the local collaborative team to implement changes
that required wider consultation and approval. One respondent
indicated that they felt that there was a ‘‘fear of change’’. This
‘‘fear of change’’ was described by another participant as
indicative of the health system wanting to ‘‘dot the i’s and cross
the t’s’’ before making a change because there was a ‘‘fear of
failing’’. It is evident that achieving this within the tight time
frames of a PDSA cycle is difficult and contributed to the
perceived lack of progress in achieving quantifiable improve-
ments in some outcomes.
Need for clinical leadership
The need for strong clinical leadership to drive the changes
through an organisation has been widely shown.
23 26–29
This
study used a clinical champion at each clinical site to drive
change through promotion, education and measurement of
change. Without strong clinical leadership and commitment at
the facility level, it would be not be possible for any of the
changes implemented to be sustained within the clinical
setting.
28
Executive leadership is important in driving change
by ensuring there are adequate personnel and resources
available to the collaborative teams. On a state-wide level, the
strong leadership at management, clinical and policy levels
drove the substantial improvements achieved at the various
sites.
21
The collaborative method is about closing the gap between
best practice and usual care.
12
In spite of this, the implementa-
tion of the method is contextually bound and a change in
Table 1 The New South Wales Chronic Care
Collaborative aggregated data (adapted from
NSW Health
21
)
N* Change p`
b Blocker prescription 82 2.78 0.04
ACE inhibitor prescription 82 2.91 0.01
Participation in rehabilitation
programme
82 2.11 0.27
Self-management support
programme
83 3.39 0.07
*Number of audits.
Average per cent change per month (the slope coefficient for
the linear trend across the months April to November).
`Significance of change.
Figure 2 Results of monthly audits.
Barriers and facilitators of the collaborative approach 411
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clinician behaviour is required for this to occur. All clinicians
can find the need to change systems, processes and be-
haviours challenging. The use of the principles of behaviour
change within the collaborative method facilitates change in
both individual clinicians and then more broadly at an
organisational level. Of key importance is the use of
multifaceted approaches in the collaborative method, informa-
tion, networking and behavioural interventions to achieve
improvement in clinical management. These strategies are in
line with the best available evidence in changing clinician
behaviours.
30–32
Collaborative teams must be conscious of the potential
barrier by clinicians to change and implement strategies to
dealt with this issue. A clinical champion who advocates the
change among other clinicians is an important component of
the collaborative method.
29 33
Clinicians and the organisational
executive must respect this clinical champion as the champion
needs to form trusting relationships with both groups.
Cohesion to drive change
The collaborative approach offers benefits of sharing informa-
tion, resources and provision of support to participating teams.
As the conduct of the collaborative is dependent on consensus
and cohesion, the composition and harmony between team
members is critical. Teams that are fully formed and function-
ing prior to the commencement of the formal collaborative
period seem to be most effective.
34
It would seem critical that
considerable effort is applied to choosing team composition and
that sufficient time is allowed before the commencement of the
formal collaborative period to establish relationships and trust
within the group.
It also seems that local teams who are spread across
specialities, facilities and regions require particular energy to
focus on tasks at hand and not bigger picture factors. The
sufficient allocation of time to establish team dynamics,
resources and training to better equip clinical leaders in the
collaborative method and change management theory will
facilitate the development of cohesion within the team.
Exploration of constructs such as self-efficacy and capacity
for change may be of use, given some comments of
respondents, regarding inertia and avoidance of change.
35
This study observed the challenges organisations face when
trying to implement multiple, diverse changes in a short time. It
seems that smaller scale projects, minimising the need for
broader consultation and improvement are more appropriate to
the PDSA cycle. Having said this, these small scale gains are
often in the short term, and broader, more sustainable system
change requires engaging with decision makers and the wider
bureaucratic process. Without consultation with key stake-
holders at this level, the changes implemented cannot be
sustained in the long term if there is no change in the system.
33
The collaborative approach is well placed to achieve these gains.
The ability of teams to keep the same personnel during the
course of the collaborative is vital for maintaining the
cohesiveness and team dynamics.
33
If a change in personnel
is required, the leadership of the group must develop strategies
to maintain the group cohesiveness and team dynamics It is
also important when planning collaborative initiatives to take
into consideration the resources, time and burden on clinical
staff.
36–39
There is a natural resistance from clinicians to change
their current practice without justification to those trying to
implement the change. The current healthcare system is under
considerable strain, and changes that increase the workload of
clinicians are not likely to be sustainable in the long term.
Teams must be conscious of creating changes that increase the
workload of clinicians.
12
Conceptual challenges: ‘‘getting your head around the
method’’
Several participants described challenges in understanding the
conceptual elements of the collaborative process. One partici-
pant said: ‘‘concepts can be difficult getting your head around’’.
Another participant commented that they considered that the
group had not ‘‘understood the principles of small change’’ and
yet another participant perceived that the PDSA cycles ‘‘were
too big picture focused’’ and therefore not achievable in the
designated action periods.
The issue of overcoming barriers to the implementation of a
PDSA cycle were discussed throughout the process. For
example, the need to employ a cardiac rehabilitation nurse
before the implementation of the programme was a time
consuming exercise due to the bureaucratic process of human
resource management and the time spent developing and
implementing a rehabilitation model. This subsequently
affected the ability of the collaborative team to meet the
predetermined timelines. The researcher and other respondents
observed that the process of implementing a change was not
seen to have commenced until these issues had been addressed.
One participant stated that ‘‘sometimes this [the need to
employ someone] was used as an excuse’’ not to make a
change.
As part of the collaborative, four learning sessions were
conducted, which were an opportunity for all participating
teams in the state to come together and learn about the
collaborative method. These meetings also provided an oppor-
tunity for teams to disseminate results to the other teams since
the previous state meeting. One local team member said during
a meeting that the learning sessions ‘‘are more than a talkfest’’
when the question was asked about how useful they were.
Another local team member described them as ‘‘[being of] great
value because of sharing how programs are done’’. The
‘‘openness and honesty’’ of all the teams was seen as a positive
component of the learning sessions as they allowed discussion
of the barriers and facilitators experienced by each team and
identified measures that had been trialled to overcome these
issues. Another participant described the learning sessions as
useful because they allowed participants to ‘‘learn about the
collaborative’’ approach and benefit from the ‘‘team bonding’’
that occurred at these sessions. Although the solutions and
problems experienced by each team were unique to their local
situation, presentation of their experiences at the learning
sessions allowed other teams to apply that knowledge to their
local situation. This rapid spreading of knowledge through both
the experience of one team as it makes changes and the
learning from the experience of other teams participating in the
same process is a vital component of the collaborative process.
Ensuring all voices are heard
Throughout the meetings, the researcher observed tensions
between members of various facilities. These tensions largely
related to the reconciling of discrete systems and processes
across the area health service and mechanisms for implement-
ing change. Reflective journal notes also revealed differences in
opinions related to systems and process issues and also in
philosophical approaches to care. The researcher noted differ-
ences and tensions between the specialist heart failure and
more generalist, primary care approaches and philosophy of
chronic care. The latent political, social and cultural agendas
present in relation to amalgamation under a streaming model
were a constant undercurrent, which periodically limited the
ability of the group to achieve consensus and cohesion on
decisions impacting on improvement in the diagnostic and
management bundles.
40 41
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Some local team members felt that it was difficult to have
their opinions and voices heard within the collaborative
process. The area-wide approach to clinical care and governance
has led to a perception of the dominance of larger facilities.
Some local team members expressed feeling of disempower-
ment on both an individual and organisational level. One local
team member expressed that they were ‘‘very frustrated’’.
Further, the emphasis of the CCC on biomedical aspects of
heart failure management such as pharmacological interven-
tion and diagnostic testing tended to lose the consumer’s voice
in the process.
One of the core aims of the collaborative method is the
spread of knowledge across multiple sites.
4
To achieve this
effective communication between the participating teams is
necessary.
4
Sharing of experiences between participating teams
at the state-wide meetings allowed them to broaden their
concept of what is possible and was used to drive effective
changes across participating collaborative teams.
42
Communication between the collaborative team and the
executive sponsors is vital for the continuing support from
these managerial leaders.
34
The teams must keep the executive
informed of the exact requirements and expectations of the
group. This allows senior leadership to help in removing the
barriers to the implementation of the changes.
Consciousness raising awareness and optimism
Overwhelmingly local team members considered that the CCC
had been successful in ‘‘getting heart failure management on
the table’’ within the area health service. The CCC was
perceived, in its short existence, to have ‘‘highlighted issues
in cardiology that need to be worked on and improved’’. This
was a major achievement as several members of the team had
been trying, unsuccessfully, to engage ongoing funding and
executive support for many years. It was considered that the
publication of the state-wide standards for heart failure
management
40 41
and support of NSW Health had been
instrumental in driving this process. Several participants
viewed the increased emphasis on accountability and scrutiny
of care as a positive outcome. For example, one participant
commented the collaborative process ‘‘creates awareness and
desire to change and want to improve things’’. Described by
another participant as ‘‘talked about in that context formally
[creating awareness of issues] rather than in the corridors’’.
One local team member acknowledged that although they
perceived that only ‘‘small gains’’ had been made during the
period of intervention, the CCC has been good for publicising
the need for improved management of heart failure. Most local
team members viewed the future optimistically and considered
that the CCC had provided leverage for long term clinical
change.
Some local team members viewed the potential sustainability
of clinical improvements achieved within the CCC with some
scepticism. One local team member indicated that he ‘‘wants to
see them [the changes] sustained’’ but ‘‘not sure if changes will
be sustainable’’ because they are reliant on gaining ongoing
funding and the continuation of executive support. Another
participant commented that there was a clear ‘‘need [for]
endorsement from the organisation for the changes to be
sustainable’’.
LIMITATIONS OF THE STUDY
This project had several limitations. A purposive sample of key
stakeholders was identified from the team to participate in the
qualitative interviews. As is the case in all qualitative research,
such sampling limits the generalisability the study findings.
16
This study focused on a single heart failure team participat-
ing in a state-wide CCC. This team had its unique culture and
political environment that influenced its performance in the
CCC and may not necessarily be transferable to all future
collaboratives. However, the barriers and facilitators identified
in this study potentially provide useful information for teams
planning future collaborative interventions. The replication of
this study on a larger scale may provide greater understanding
of the processes of the collaborative approach within the
context of the individual collaborative team.
CONCLUSIONS
The need for health systems to embrace the collaborative
method as a tool for closing the treatment gap has been widely
shown.
1329
Common facilitators and barriers to the implemen-
tation of the collaborative method identified in this study and
the published literature include organisational factors such as
resources and leadership, time pressures and clinician work-
load. The composition of teams and their ability to harmonise
and maintain the same personnel throughout the process are
important factors for the successful implementation of the
collaborative method. The engagement of clinicians to modify
their practice is reported in the literature to be difficult,
29
and
the local collaborative team attempted to overcome this with a
clinical champion in each of the units and strong executive
support to ensure there were adequate resources and organisa-
tional support.
Despite the host organisation providing education sessions
both before and during the collaborative, interview data
revealed the local team felt there were challenges under-
standing the method during the early stages of the collaborative
and this greatly impeded their initial progress. A greater
preparatory stage before the commencement of the collabora-
tive to dealt with known barriers and facilitators to the
collaborative method may have helped overcome this barrier.
Consolidation of team dynamics and cohesion is reported in the
literature to be a critical factor in ensuring success of the
collaborative approach, and this was identified in the present
study to have been made difficult due to the uncertainty
regarding the state-wide organisational restructure that was
occurring simultaneously as the collaborative. Although imple-
mentation of these findings by future collaborative teams will
depend on local cultural and environmental issues, they
highlight potential facilitators and barriers to the successful
implementation of the collaborative method, which may assist
teams to identify and begin implementing strategies to over-
come these before the commencement of the quality improve-
ment initiative.
Authors’ affiliations
.......................
P J Newton, E J Halcomb, School of Nursing, College of Health and
Science, University of Western Sydney, New South Wales, Australia
P M Davidson, Centre for Cardiovascular and Chronic Care, School of
Nursing, Curtin University of Technology, Sydney, New South Wales,
Australia
A R Denniss, Sydney West Area Health Service, New South Wales,
Australia
Competing interests: None declared.
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