Driving Systemic Change: A Team-Based Approach That Supports High Learner Enrollments

Author Information
John Sener
The Sloan Consortium
Institution(s) or Organization(s) Where EP Occurred: 
Institute for Healthcare Improvement
Effective Practice Abstract/Summary
Abstract/Summary of Effective Practice: 

The Institute for Healthcare Improvement (IHI) Breakthrough Series employs a sophisticated collaborative, team-based, blended learning approach to reach large numbers of learners. The model enables panels of five to eight experts to support dozens of learning teams simultaneously in one Collaborative project. Since 1995, the IHI Breakthrough Series Collaborative has enabled thousands of health care teams to achieve dramatic results in reducing costs and improving quality.

Description of the Effective Practice
Description of the Effective Practice: 

How this practice supports access:
The Institute for Healthcare Improvement (IHI) developed the Breakthrough Series Collaborative Model to help health care organizations make "breakthrough" improvements in quality while reducing or maintaining costs. The driving vision behind the Breakthrough Series is that there is much sound science about how to improve current health care practices, but much of this science is unused in daily work. The Breakthrough Series is designed to help organizations close the gap between what is known and what is done by creating a structure in which organizations can easily learn how to make improvements from each other and from recognized experts in topic areas of interest.

A Breakthrough Series Collaborative is a (learning system that brings together a large number of teams from hospitals or clinics to seek improvement in a focused topic area for a six to 15-month period. This approach is team-based in two ways:

  1. Interested organizations form learning teams, from which each team typically sends three members to attend three Learning Sessions (in-person meetings over the course of the Collaborative), with additional members working on improvements in the local organization.
  2. Learning teams interact with panels of five to eight experts in topically relevant disciplines, including international subject matter experts, application experts, and outstanding clinicians. One expert chairs the Collaborative and provides the vision for the Collaborative, while another panel member serves as an Improvement Advisor who teaches and coaches teams on how to apply improvement methods in local settings.

Between the Learning Sessions, teams test and implement changes in their local settings during Action Periods, supported by the Expert Panel and by other collaborative teams via e-mail, phone conferences, monthly team reports, on-site visits, and assessments. During these Action Periods, local teams use the Model for Improvement developed by Associates in Process Improvement, which includes the following elements:

  • Determine what the team is trying to accomplish (set an aim);
    Identify appropriate measures to determine how teams will know that a change is improvement; and
  • Identify key changes to test to see whether they result in improvment, using a PDSA (Plan-Do-Study-Act) cycle.
Supporting Information for this Effective Practice
Evidence of Effectiveness: 

Since 1995, IHI has sponsored over 39 such Collaborative projects in the U.S., and five outside the U.S., on several dozen topics involving over 1,000 teams. Collaboratives range in size from 12 to 160 teams. Teams in Breakthrough Series Collaboratives have achieved dramatic results, including reducing waiting times by 50 percent, reducing worker absenteeism by 25 percent, reducing ICU costs by 25 percent, and reducing hospitalizations for patients with congestive heart failure by 50 percent. Some specific examples:

  • In 2001, one healthcare system reduced adverse drug events (ADEs) from four ADEs per 1,000 doses to one.
  • From July 2002 to October 2003, the Veterans Health Administration (VHA) reduced the number of veterans on its waiting list from >300,000 to <50,000, while also reducing waiting times in primary care clinics from 60.4 days to 28.2 days (53%).

IHI has also trained over 650 people in the Breakthrough Series methodology, thus spawning hundreds of Collaborative initiatives throughout the health care world, sponsored by organizations other than IHI.

Estimate the probable costs associated with this practice: 

High -- significant expenditures are required to achieve this level of systemic change. Fees for joining a Collaborative are $15,000/team. Each enrolled team costs its sponsoring organization an additional $30,000 to $60,000, including tuition, travel, and accommodation for its year of work. These direct costs are prohibitive for many otherwise willing organizations and individuals.

References, supporting documents: 

See reference to Breakthrough Series paper below, which also contains references to numerous pertinent articles.

Other Comments: 

IHI is in the process of figuring out how to reduce the number of required in-person sessions from three to zero without compromising quality.

From a pedagogical point of view, compare this approach with Michigan State University's "event-centered, online-supported" approach.

For me, what makes this approach compelling is that it illustrates how to use team teaching to support high learner enrollments, collaborative learning, and process improvement. Thus, the approach illustrates a high degree of scalability as well as documentable results (all four Kirkpatrick levels, including behavior and ROI). [-- js, 1/29/04]

Contact(s) for this Effective Practice
Effective Practice Contact: 
Penny Carver, Vice President at the Institute for Healthcare Improvement
Email this contact: