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Appendices
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The Breakthrough Series Method
Key Elements
of the
Breakthrough
Series
Appendix 1
The following information has been gathered directly from the IHI web
site www.ihi.com
The Breakthrough Series is designed to help organisations close that gap
by creating a structure in which interested organisations can easily learn
from each other and from recognized experts in topic areas where they
want to make improvements.
A Breakthrough Series Collaborative is a short-term (6 - to 15-month)
learning system that brings together a large number of teams from
hospitals or other health and disability services to seek improvement in a
focused topic area.
Collaboratives range in size from 12 to 160 teams. This Collaborative
would have 21 teams; one from each of the DHBs. Each team typically
sends five of its members to attend Learning Sessions (three face-to-face
meetings over the course of the Collaborative identified as LS on diagram
3.1), with additional members working on improvements in the local
organisation. Some collaborative processes have found that an orientation
session for teams before the Learning Sessions start is of great value.
Teams in such 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 hospitalisations
for patients with congestive heart failure by 50 percent. In addition, IHI
has trained over 650 people in the Breakthrough Series methodology, thus
spawning hundreds of Collaborative initiatives throughout the health care
world.1 A final, follow-up Conference to better ensure sustainability of the
improvement results achieved, is held approximately 7 months after the
completion of the last learning session.
After testing the Breakthrough Series model (Figure 1) in the first three
Collaboratives, IHI had the key elements in place. These elements have
remained fundamentally unchanged, even as the model has been
continuously refined as hundreds of organisations around the world have
participated in Collaboratives.
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1
www.ihi.com
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Figure 1. Breakthrough Series Model
Topic Selection
IHI leaders identify a particular area or issue in health care that is ripe for
improvement: existing knowledge is sound but not widely used, better results
have been demonstrated in real-world settings, and current defect rates affect
many patients somewhat, or at least a few patients profoundly.
Faculty
Recruitment:
IHI identifies 5 to 15 experts in the relevant disciplines, including
international subject matter experts as well as application experts, individual
clinicians who have demonstrated breakthrough performance in their own
practice. One expert is asked to chair the Collaborative and is responsible for
establishing the vision of a new system of care, providing faculty leadership,
and teaching and coaching the participating teams. Typically, chairs devote
one or two days per week for the duration of the Collaborative. The chair and
the expert faculty assist IHI in creating the specific content for the
Collaborative, including appropriate aims, measurement strategies, and a list
of evidence-based changes. An Improvement Advisor teaches and coaches
teams on improvement methods and how to apply them in local settings.
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Enrolment of
Participating
Organisations
and Teams
Organisations elect to join a Collaborative through an application process,
appointing multidisciplinary teams within the organisation charged to learn
from the Collaborative process, conduct small-scale tests of change, and help
successful changes become standard practices. Senior leaders from
participating organisations are expected to guide, support, and encourage the
improvement teams, and to bear responsibility for the sustainability of the
teams’ effective changes. To help teams prepare for the start of the
Collaborative, IHI conducts pre-work conference calls to clarify the
Collaborative processes, roles, and expectations of organisation leaders and
team members. IHI traditionally accepts all applicants who agree to commit
to these expectations.
Learning
Sessions
Traditional Learning Sessions are face-to-face meetings, usually three of
which are conducted during a typical Collaborative, bringing together
multidisciplinary teams from each organisation and the expert faculty to
exchange ideas. At the first Learning Session, expert faculty present a vision
for ideal care in the topic area and specific changes, called a Change Package,
that when applied locally will improve significantly the system’s
performance. Teams learn from an Improvement Advisor the Model for
Improvement (described below) that enables teams to test these powerful
change ideas locally, and then reflect, learn, and refine these tests. At the
second and third Learning Sessions, team members learn even more from one
another as they report on successes, barriers, and lessons learned in general
sessions, workshops, storyboard presentations, and informal dialogue and
exchange. Formal academic knowledge is bolstered by the practical voices of
peers who can say, “I had the same problem; let me tell you how I solved it.”
Action Periods
During Action Periods between the Learning Sessions, teams test and
implement changes in their local settings—and collect data to measure the
impact of the changes. They submit monthly progress reports for the entire
Collaborative to review, and are supported by conference calls, peer site
visits, and Web-based discussions that enable them to share information and
learn from national experts and other health care organisations. The aim is to
build collaboration and support the organisations as they try out new ideas,
even at a distance.
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The Model for
Improvement
To apply changes in their local settings, Collaborative participants learn an
approach for organizing and carrying out their improvement work, called the
Model for Improvement (Figure 3). This model, developed by Associates in
Process Improvement (The Improvement Guide, Jossey-Bass, 1996),
identifies four key elements of successful process improvement: specific and
measurable aims, measures of improvement that are tracked over time, key
changes that will result in the desired improvement, and a series of testing
“cycles” during which teams learn how to apply key change ideas to their
own organisations.
Figure 3. Model
for
Improvement
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The Model for
Improvement
The Model for Improvement requires Collaborative teams to ask three
questions:
What are we trying to accomplish? (Aim) Here, participants determine which
specific outcomes they are trying to change through their work.
How will we know that a change is an improvement? (Measures) Here, team
members identify appropriate measures to track their success.
What changes can we make that will result in improvement? (Changes) Here,
teams identify key changes that they will actually test.
Key changes are then implemented in a cyclical fashion: teams thoroughly
plan to test the change, taking into account cultural and organisational
characteristics; they do the work to make the change in their standard
procedures, tracking their progress using quantitative measures; they closely
study the results of their work for insight on how to do better; and they act to
make the successful changes permanent or to adjust the changes that need
more work. This process continues serially over time and refinement is added
with each cycle; these are known as “Plan-Do-Study-Act” (PDSA) cycles of
learning (Figure 4).
Figure 4.
Multiple PDSA
Cycles
Summative
Congresses and
Publications:
Once the Collaborative is complete, the work is documented and teams
present their results and lessons learned to individuals from non-participating
organisations at national and international conferences and meetings.
Measurement
and Evaluation
Collaboratives involve regular measurement and assessment. All teams are
required to maintain run charts tracking their system measures over time and
key faculty members review each team’s monthly report to assess the overall
progress of the Collaborative.
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Appendix 2
International Infection control programmes
CANADA
Programme:
Hand Washing
Public Service
Campaign
Programme Description:
The College of Registered Nurses of Manitoba’s hand washing campaign,
“Frequent hand washing is your best defense against illness and disease”.
http://www.crnm.mb.ca/handwashing.php
CANADA
Programme:
Handwashing:
Public
Education
Campaign
Programme Description:
Objectives of the program are:
• Educate the general population on proper hand hygiene
• Support stakeholder and healthcare provider patient-education efforts
• Educate the public on their role in helping to control infectious disease
• Create a framework of accepted infectious disease control through
healthcare promotion and support beneficial behaviour change
http://www.health.gov.on.ca/english/public/program/pubhealth/handwashing/
handwashing_mn.html
CANADA
Programme:
Clean Hands
for Life
Programme Description:
The Clean Hands for Life campaign is an ongoing effort to improve
awareness about the importance of hand hygiene in protecting patients,
residents, visitors and staff from nosocomial infection.
www.vch.ca/news/docs/2005_10_13_infection_prevention_campaign.pdf
AUSTRALIA
Programme Description:
A standardized tool for measuring hand hygiene compliance was developed
as part of the Debug Infection Prevention Program at Austin Health in
Melbourne, Australia. This standardized Hand Hygiene Compliance Tool
(HHCT) was an integral part of the culture change program that encouraged
the increased use of bedside alcohol-chlorhexidine hand rubs. This program
was associated with a sustained improvement in hand hygiene among Health
Care Workers and a reduction in the rate of Methicillin Resistant
Staphylococcus Aureus (MRSA) infections. The DeBug Infection Prevention
Program is based on the Hand Hygiene model implemented at the University
of Geneva Hospital.
http://www.debug.net.au/index.html
Programme:
DeBug
Infection
Prevention
Program
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SWITZERLAND
Programme:
Programme Description:
Cross-transmission of microorganisms by healthcare workers' hands is the
Hopisafe.ch – a main route of the spread of nosocomial infections. Hand hygiene can prevent
New Program to
cross infection in hospitals but compliance with recommended instructions is
Prevent
poor, usually below 50%.
Infection in
We promoted hand hygiene by implementing a hospital-wide program with
Hospitals
special emphasis on bedside alcohol-based hand disinfection. The campaign
produced a sustained improvement in compliance with a reduction of
nosocomial infections and MRSA transmission.
http://www.hopisafe.ch/next.html
UNITED
KINGDOM
Programme:
Clean Your
Hands
Campaign
UNITED
KINGDOM
Programme:
Wipe it out
Programme Description:
The “cleanyourhands” campaign aims to minimize the risk to patient safety
of low compliance with hand hygiene by National Health Service (NHS) staff
through a national strategy of improvement. The NPSA has developed and
produced the “cleanyourhands” campaign toolkit in light of pilot evaluation
findings and is currently implementing the campaign across the NHS acute
sector.
The campaign involves the following:
• Placing disinfectant hand rubs near to where staff have patient contact
• Displaying posters and promotional materials where they will influence staff
and patients
• Involving patients in improving hand hygiene
http://www.npsa.nhs.uk/cleanyourhands
Programme Description:
The Royal College of Nursing, with support from its partners, Nursing
Standard, Kimberly Clark and the Infection Control Nurses' Association, has
mounted the Wipe it out campaign.
The campaign aims to provide healthcare staff, employers, patients and
visitors with resources to promote better and safer practice around MRSA and
healthcare-associated infections (HCAIs).
http://www.rcn.org.uk/resources/mrsa/
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UNITED
STATES
Programme:
Clean Hands
Save Lives!
UNITED
STATES
Programme:
Infection: Don't
Pass It On
Programme Description:
The Clean Hands Coalition (CHC) is a unified alliance of public and private
partners working
together to create and support coordinated, sustained initiatives to
significantly improve health and save lives through clean hands. The CHC is
facilitated by the Centers for Disease Control and Prevention (CDC).
According to the Centers for Disease Control and Prevention, handwashing is
the single most important action that one can take to prevent the onset of
illness. The need for all individuals, as a public health imperative to routinely
wash their hands everyday, transcends all ages and demographic categories.
The Clean Hands Coalition has initiated grassroots education efforts to
improve food safety and public health by making hand washing an integral
part of the day.
http://www.cdc.gov/cleanhands/ or http://www.cleanhandscoalition.org/
Programme Description:
Infection: Don’t Pass It On is a VA public health campaign established
through collaboration between the Office of Public Health and Environmental
Hazards, National Center for Patient Safety, Employee Education System,
Infectious Diseases Program Office, and VA experts in infection control. The
goal of the campaign is to involve staff, patients and visitors in taking basic
steps to preventing infection, whether occurring daily, seasonally, or during
infectious disease emergencies (natural or man-made).
http://www.publichealth.va.gov/InfectionDontPassItOn/Default.htm
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INTERNATIONAL
Programme
Provider:
World Health
Organization
Program:
Clean Care is
Safer Care
Programme Description:
The World Alliance for Patient Safety was launched in October, 2004, the
result of approval by the Fifty-seventh World Health Assembly (May, 2004)
to create an international alliance to improve patient safety as a global
initiative.
The Global Patient Safety Challenge, a core element of the Alliance, creates
an environment where safety of care brings together the expertise of leading
specialists in the fields of hand hygiene and the safety of injections, surgical
procedures, blood use and the care environment.
The topic chosen for the first Global Patient Safety Challenge is healthcareassociated infection (HCAI), and a key action within the challenge is to
promote hand hygiene in healthcare globally as well as at the country level
through the campaign ‘Clean Care is Safer Care”. Hand hygiene, a very
simple action, reduces infections and enhances patient safety across all
settings, from advanced healthcare systems in industrialized countries to local
dispensaries in developing countries. In order to provide healthcare workers,
hospital administrators and health authorities with the best scientific evidence
and recommendations to improve practices and reduce HCAIs, WHO has
developed Guidelines on Hand Hygiene in Health Care (Advanced Draft), to
be issued as a final version in 2007.
http://www.who.int/patientsafety/events/06/newdelhi_inauguration/en/index
INTERNATIONAL
Programme Description:
Growing interest and concern about control of infectious disease in the
domestic setting has led an international group of experts to form the
International
International Scientific Forum on Home Hygiene (IFH). Through its
Scientific
Forum on Hand international initiatives the IFH is working to raise awareness of the
fundamental role that home hygiene plays in preventing infectious disease,
Hygiene (IFH)
and to promote understanding of good hygiene practice in situations where
infection risk exists including food hygiene, general hygiene, personal
hygiene and the care of the sick and other «at risk» groups.
The IFH is also seeking to promote research into areas of home hygiene
which are currently not well understood and facilitate debate and consensus
on issues relating to home hygiene.
http://www.ifh-homehygiene.org/2003/2mission/2ifh00.asp
Programme
Provider:
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Appendix 3
International Healthcare-Associated Infection
Surveillance
Year
Name
Country
Mandatory
/Voluntary
/State
No of
hospitals
(if
known)
Type of Infection Data Collected
Ventilatorassoc
pneumonia
(VAP)
USA
1970
NNIS
Voluntary
Belgium
1991
National
Programme for the
Surveillance
of
Hospital Infections
Voluntary
UK
1996
Nosocomial
Infection National
Surveillance
Scheme
Voluntary
Finland
1997
Finnish Hospital
Infection Program
Germany
1997
Holland
BSI
SSI
ICUspecific
MROs
UTI
Other

VAP
BSI
315
SSI



100+



Voluntary
4


Krankenhaus
Infektions
Surveillance
System
Voluntary
100+
1996
Preventie
van
Ziekenhuisinfecties
door Surveillance
Voluntary
93


Australia
2003
Hospital Infection
Standardised
Surveillance
Voluntary
as part of
pilot
10


Canada
1995
Canadian
Nosocomial
Infection
Surveillance
Program
Unknown
34
(MRSA)
110
(VRE)
NSW
2003
Mandatory
37
Illinois
2003
Mandatory

Florida
2004
Mandatory
Not
yet
specified
Missouri
2004
Mandatory
Pennsylvania
2004
Mandatory
from 1/7/04
California
2004
Mandatory
from a date
yet to be
determined


MRSA

VAP
BSI
Neonatal
Bonemarrow
transplant
patients
UTI
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
RSV,
Rotavirus

MRSA
VRE















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
Critical
incidents
related
to
reprocessing
Occupational
body fluid
exposures

Appendices