When Dr. Ann Borders was tapped to help launch the Illinois Perinatal Quality Collaborative (ILPQC), her first move was to ask for help. Other states had successfully launched and developed PQCs. Illinois’ best bet for achieving its own success, she knew, was to learn from them.
“We asked them, ‘If you were starting a new PQC what would you do?’” said Borders, Executive Director and Obstetric Lead for the ILPQC. “Then we went home and tried to imitate that.”
They succeeded. In the five or so years since, Illinois has emerged as one of those states worth imitating in its own right, with over 100 birthing hospitals participating in its initiatives and an impressive record of improving outcomes for mothers and babies. Borders herself has emerged as a national expert on creating, growing, and sustaining a PQC, and now serves on the National Network of Perinatal Quality Collaboratives Executive Committee.
We spoke to Borders after her keynote speech at the 2019 Texas Collaborative for Healthy Mothers & Babies Summit.
TCHMB News: When you first were launching the Illinois Perinatal Quality Collaborative (ILPQC), what did you do to maximize the chances of success?
Dr. Ann Borders: We started with that premise that we needed to learn from successful collaboratives, in states like Ohio, California, Florida, and North Carolina. We very specifically sought their input.
I remember we got a team together from Illinois to attend the annual meeting of the Florida PQC. We flew down there, and set up meetings with the Florida leadership, which was led by Bill Sappenfield, as well as with Jay Iams from Ohio, Elliott Main and Jeff Gould from California, and Marty McCaffery from North Carolina.
We asked them: How did you put a structure together? How did you create a data system? How do you interact with your teams? What are pitfalls to avoid? What are the key steps to be successful with stakeholders? We went home and tried to imitate their recommendations.
Illinois is now seen as one of those PQCs that knows how to make it work. You’re brought in (to Texas, for example) to help newer PQC launch and grow. From your perspective, what’s the secret?
From our experience, the collaboratives that make it work provide value to the hospital teams. I’d break that down into three strategies that are key to this work:
Provide opportunities for collaborative learning, getting teams together to share and learn from each other, whether that’s in person or through calls and webinars.
Have a rapid response data system that hospitals can really utilize to compare data across time and across participating hospitals to effectively drive QI.
Provide quality improvement support, primarily with QI coaching calls and follow up. Teams may also need site visits with key player meeting when appropriate or small group discussion calls to link up higher performing hospitals with hospital teams still struggling with a particular QI topic. The goal is to help every hospital succeed.
What about the ones that aren’t as effective? What are they doing wrong, or failing to do?
Every state is different in terms of the stakeholders, the funding, and the available infrastructure, so it is never one size fits all. We do think, however, that there are some strategies that may help teams achieve success more efficiently and hopefully more effectively. We also believe that every PQC has something to learn from every other PQC, no matter how long they have been at this work. Collaborative learning across PQCs is just as important as collaborative learning across hospitals in order to achieve success.
In our experience, we have found it important to use a quality improvement model, have access to rapid response data, and have an infrastructure that provides regular communication with hospital teams and opportunities for collaborative learning. Collaboratives seem to be more successful when they focus on quality improvement strategies to help their hospital teams be successful. Also successful collaborative teams focus on one or maybe two initiatives at a time. They don’t try to take on too much. They have clear aims and only collect data that helps hospitals drive change and show progress towards improvement. They stay focused on helping teams implement clear, measurable system changes and culture changes at primarily the hospital level (some collaboratives have successfully added outpatient settings, though it can be more of a challenge).
I think some collaboratives may fall into the trap of taking on too much when getting started, and this can be a hard way to start. It can be hard not to do this when stakeholders are pushing collaboratives to be responsive across a number of areas, but teams can feel overwhelmed when asked to do too much and it is hard to show effective improvement. This can be frustrating for everyone. It should be clear what the strategies are for improvement and what the aims are for demonstrating success. In our experience, staying focused is important for PQCs to be successful and for helping hospitals succeed.
As the PQC movement has developed, there have been some collaboratives that started with more of a public health model: needs assessment, project implementation with education and resources, and then evaluation with vital record data or other population health data. That is a model that can work well in many public health settings, but it does not seem to support rapid-cycle quality improvement through implementation of systems and culture change in the same way as the strategies that we now see most PQCs embracing.
From our experience in Illinois, and in collaborating with other state PQCs, it is hard for hospitals to wait six months or a year for data on efficacy. It is hard to be able to successfully use that data to drive quality improvement. Teams that have access to rapid response data with easy to use reports can most easily use that data for quality improvement. Also many hospital teams need QI support, because hospital teams don’t all have the same experience and infrastructure to support quality improvement. Also we have found that hospital teams benefit if they are able to learn in real time from other hospitals.
Tell me more about what you mean by rapid response data. How do you set up the kind of system that works?
A challenge for every developing PQC is how to manage data. Figuring out a data system that can help hospital teams drive QI is one of the early key steps in PQC development. From our experience, ideally PQC’s have a system that can provide rapid feedback and that is managed outside of the vital records or state data system. In that scenario participating hospitals feel that the QI data they are collecting is their data for their data reports, and it reduces concerns regarding data being used in more of a regulatory fashion. PQCs use all different sorts of data systems and data sources depending on resources available and on how best to balance data burden for each initiative. Some vital records data, particularly when it can be accessed with rapid turn-around, can be really helpful to PQCs for specific initiatives. From our perspective, having a PQC-managed data system has been helpful in developing hospital team buy-in with participation and data tracking. Providing rapid response data reports provides significant value for hospital teams and certainly helps teams use their data to drive rapid cycle quality improvement.
This goes back to what I was saying about the goal of providing value to the hospital teams. When the hospital teams meet every month, it helps to have simple data reports to review that track progress across time and provide comparisons to other participating hospitals. Ideally they can put the data reports up on the wall and say, ‘This is how we are doing.’ That is real value provided to teams, and it empowers them to make changes within their hospital.
Regardless of the system a PQC is using, we always try to remember that we are not collecting the data for a specific initiative with any reason other than to track the progress of the initiative and give data reports back to the hospitals to drive quality improvement. The best situation is when the hospitals in the collaborative feel ownership of the collaborative and the data system. That makes the teams feel safe being transparent. It also really enables collaboration and sharing between hospitals within the collaborative.
To give that kind of rapid response, do you need someone on staff creating a host of reports every month, or is it automated?
It is automated. That requires a lot of work and thought on the front end, working with a programmer to code a system where hospitals can input key data, through REDCap, and then instantaneously get back the report through a web-based portal.
To achieve that, we decide what reports we want, test them, get feedback, and iterate. That all happens during wave one, where we ask 25-30 hospitals to test the data form and test collecting the data. They give us a lot of feedback on what they think is the best data strategy before they start any QI activity. Is it readable? Is it easy to use? Are we collecting the right data and producing reports that are useful
The data has to be specific to each initiative. You are using the data to drive action for a specific initiative, which means collecting data only for the initiative in front of you, and feeding it back only on that front. If you’re collecting too much data, it ceases to be quality improvement. It becomes a burden, and if hospitals can’t see the benefit they won’t want to participate.
For hypertension, for instance, we tracked four key issues: time to treatment, percent of women who had preeclampsia education at discharge, percent of women who had early follow-up, and percent of cases with a nurse / provider debrief on time to treatment. Just those four things. We tried to make the reports very specific to drive the work.
The data system can be hard for folks, particularly because states have already put a lot of time and resources into systems for collecting vital records, and that typically is a very different system than what seems to be most helpful to support QI. There is a natural tendency to want to make use of the data collection system you already have, rather than invest more time and resources into developing a new system. That is completely understandable, particularly given constraints of budgets and staff resources. But from our experience, our rapid response data system has been really important to our teams and the collaboratives success.
“Collaborative learning” is something that is easy to say, but maybe not so easy to achieve. What does it look like to you, in the context of creating a successful PQC?
In the PQC context we try to be very pragmatic and genuinely collaborative. When we are meeting, whether in person or on calls and webinars, we are focused on what’s in front of us that month, and in the coming months, and on really learning from each other. What are the key strategies this month? How are we doing so far? Can we hear from another state, or from other teams within the state, on what is working and what isn’t? It is very different from having a webinar on how to treat pre-eclampsia, or listening to grand rounds, someone dispensing clinical wisdom. We talk a lot about QI strategies, think about data utilization, work on understanding what the task is in really specific ways and learning from others. It is also really helpful to hear about another team's successful strategies because it makes the challenge feel achievable.
That makes sense when you’re talking about people who are already on board, but how do you drive broader culture and system change? Hospitals are not always eager to change.
Absolutely. If you just put those other things in place, but you don’t convince nurses and providers and hospital administrators why, and how, they need to change their practice, then you are not going to get meaningful changes.
We work on a lot of fronts to support the hospital teams in effecting change within their organizations. The data is a part of that. Rapid response data is great for the teams implementing the initiatives, but it can also be really useful in helping them get buy-in from their hospital. It allows them to demonstrate improvements on the ground as well as the continuing gaps.
The QI support is essential. Some hospitals have a lot of experience implementing QI initiatives, but many don’t. For those hospitals we can help fill in the gaps.
We can also help by providing education and resources to the hospitals. In Illinois we have created a kind of speaker’s bureau, where we have volunteer clinicians who offer to give grand rounds at hospitals. They can come in and say, this is what everyone else is doing. These are the best practices. You should do this too.
We provide toolkits and resources, including some we’ve developed and others from other collaboratives and groups like ACOG and AIM. We’ll print them out and give them to teams. We’ll give them documents they can modify and add their own branding to, make it their own. We provide online training modules for nurses and physicians. Whatever they need to move the ball down the court, whether it is something we have developed, or something another team has done.
Ultimately, though, it can’t rest on us. You need nurse and physician champions to be the charismatic leaders, to convey the urgent sense that implementing this work will lead us to improved care which will lead to better outcomes. You need folks who can step up in the leadership roles and be the people who tell the story, who can conceptualize what we are trying to accomplish.