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Improving quality step by step

September 1, 2007
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The conclusion to a two-part series about improving the quality of behavioral health services

Editor's note: In part one of this series in the August issue, Dr. Dougherty outlined the problems facing behavioral healthcare as it attempts to improve service quality. In the conclusion to this series, Dr. Dougherty outlines an approach that holds significant promise—learning collaboratives.

Learning collaboratives have been used extensively to promote quality improvement in healthcare, particularly over the past five years. There are several types of collaboratives, but generally they involve the use of: (1) cross-discipline and interorganizational teams; (2) work on a specific problem; (3) leadership by evidence; (4) faculty experts; and (5) project management coaches to modify and/or improve specific practices.


Collaboratives have been formed in large multidivisional organizations, among different providers, across purchaser or health plans, and at the community level. They provide a richer experience than traditional quality improvement approaches, in which the focus often is limited to a unit or organizational division. Collaboratives have aimed to improve chronic illness care, the treatment of depression, general community health, asthma care, and a number of other health concerns.2-4 The Institute for Healthcare Improvement is one of the leading proponents of this approach.5 Examples of mental health and substance abuse-related collaboratives include the:

  • Robert Wood Johnson Foundation Depression and Primary Care Initiative;

  • National Initiative for Children's Healthcare Quality ADHD and primary care effort;

  • Center for Health Care Strategies' Best Clinical and Administrative Practices Program for Health Plans Service to Children with Serious Emotional Disturbance;

  • California Institute for Mental Health's California Learning Collaborative; and

  • Massachusetts Department of Mental Health's Readmission Collaborative

One of the earliest collaboratives in mental health was undertaken by the New York City Department of Health and Mental Hygiene, Mount Sinai School of Medicine, and the New York State Office of Mental Health.6 This collaborative sought to improve access to services (first intake appointments) for children seeking care for mental health conditions.


Image courtesy of DMA Health Strategies

Over the past three to four years, the Robert Wood Johnson Foundation initiated a large national effort to improve access to and retention in addiction treatment. This work, led by the Network for the Improvement of Addiction Treatment (NIATx) at the University of Wisconsin, has been extensively supported by the federal Center for Substance Abuse Treatment. In behavioral health, NIATx is without peer in advancing quality improvement practices among providers.

Collaboratives start where your organization is now. No major change is first required. They seek to improve performance through a series of focused short-term interventions and improvement methods nested within a long-term goal. Groups of staff members work together to define specific project aims, measures, and interventions. Efforts are action-oriented. Barriers are identified quickly, and data become available to support larger systemic changes. Shewhart's “rapid cycle” use of the Plan-Do-Study-Act (PDSA) method has shown extensive promise and evidence of improvement in addiction treatment through the work of NIATx,7-9 and has resulted in documented improvements in other healthcare settings as well.

Quality improvement collaboratives are data-based change processes. With training, improvement tools, and a new language of change, they can encourage the growth of a true culture of quality, in which continuous efforts to improve practice and outcomes are the norm. Through small initial projects and measurement of their results, managers and staff learn the techniques, test the concepts, modify them as needed, and ultimately take the project to scale. They also can use the tools for change in other areas and on other projects.

Fundamental to most quality improvement approaches is sequential use of evidence-based and generalizable PDSA cycles to improve organizational processes. This approach has been tested in a variety of settings during the past five decades.10-13 PDSA cycles also have advantages when it comes to translating research to practice because the incremental nature of PDSA efforts allows for the systematic implementation of research findings and adaptation to local conditions.14 The PDSA method's efficacy may be due to imbuing systematic improvement with the scientific method (data and evidence) and sequentially implementing cycles of applied change and learning.15-18 The PDSA cycle also is fundamentally consistent with behavioral learning and general systems theory. In fact, one of the most important cultural changes is that by using the PDSA method, managers and organizations develop a new way to talk about group learning and systems change.