So, you’ve decided to start collaborating in your healthcare setting in order to improve patient safety and drive transformational change. Maybe you are looking at setting up your own collaborative to support Quality Improvement (QI) or maybe you’re doing something different. You may find that your QI plans are progressing smoothly, which is fantastic - but – as with the best laid plans - you can sometimes come across barriers that might stall progress. However, if you are prepared for these potential barriers, you can work out ways of overcoming them by learning from other peoples’ experiences.
A number of potential barriers to collaboration in healthcare have been identified by writers in the BMJ article ‘Building motivation to participate in a quality improvement collaborative in NHS hospital trusts in Southeast England…' . Also, in the report ‘What’s getting in the Way, Barriers to Improvement in the NHS’,  the writers identify Initiative Barriers, Individual Barriers, Organisational Barriers and System Wide barriers. The researchers also identify 10 key challenges to improvement in the NHS, which can occur during the design, delivery or dissemination stages.
We have created a list of potential barriers – and ways to get around them - so that you can be prepared for any eventuality in your journey to quality improvement and transformational change!
Lack of engagement and clinical ownership
Although the outcome of collaboratives can be impressive, it can sometimes be difficult to get great team players involved, as they are already busy with their own projects and unable to take on additional workloads. A report by the National Institute for Health Research (NIHR ) found that ‘those [trusts] with high levels of engagement performed better on available measures of organisational performance than others.’ So, early engagement – and encouraging clinical ownership – could be a great way to motivate and excite people into wanting to get involved.
Lack of support or engagement with the board
In the BMJ article , the writers cite 'A key barrier was the lack of board engagement in the participating National Health Service organisations, which may have affected motivation among front-line staff.' The same article states: ‘.. inadequate board (medical director) engagement at trust level may affect motivation among team members.’ You really need engaged staff to participate in your successful QI collaborative, so make sure you get buy in from the board as soon as you can, as ‘individuals can act as change agents, driving the quality improvement agenda at a local level.’
Keeping the collaborative close to home
You might be encouraged to keep your quality collaboration efforts ‘in house’, however, there is evidence that external help may serve you better. The Health Foundation report cites: ‘External facilitation reportedly provided focus and helped to reduce inter-professional barriers.’
Culture and hierarchical structure
This includes the lack of support from an organisation or department, which could slow down the creation of QI collaboratives. The BMJ article states: ‘Sustaining engagement with the collaborative was viewed as a significant challenge and was thought to be because of intra-organisational issues such as staff turnover or dwindling resources.’ In addition, if participants feel like they are being ‘dictated’ too and not allowed to work on their own initiative, it can remove the very ethos of the quality improvement collaborative, i.e. the principal of ‘all learn, all share’. The Health Foundation report identifies problems arising when teams or organisations have a hierarchical structure, which can lead to lack of collaboration and teamwork. A flat structure works much better in a collaborative situation – so it might be better to communicate this element at the outset.
Lack of support and communication
The BMJ article cites lack of communication as a problem in forming good collaboratives, stating: ‘There were key barriers to motivation at trust level….The lack of support was compounded by mainly senior staff undertaking improvement work with junior nurses in particular, neither aware or involved. These issues were thought to reflect a broader challenge of embedding an improvement culture within organisations.’ Clear communication is a key area when working collaboratively. By keeping everyone informed of the work going on – and engaging across disciplines – you can get around this issue.
Conflicting department or organisational priorities
The BMJ report cites an example of trust boards who had initially shown interest in participating in the collaborative, had signed an agreement with the host organisation, but this did not develop into a sustained commitment, as other priorities intervened. The researchers concluded that using a bottom-up approach and getting frontline teams involved from the start might have led to continued involvement in the collaborative. You could therefore get round this barrier by using clear communications as to what is expected of participants.
Lack of good leadership
Good leadership – and a leadership which supports Quality Improvement - is acknowledged as crucial within successful healthcare systems. Leaders need to embrace QI for it to become embedded within a healthcare organisation, so it’s vital that you chose excellent leaders to help set up your collaborative. An article by NHS Scotland  talks about: “Enthusing, involving and engaging staff. Evidence about successful quality improvement indicates that it is not necessarily the method or approach used that predicts success, but rather it is the way in which the change is introduced. Factors that contribute to this include leadership, staff engagement (particularly of clinicians) and patient participation, as well as training and education.”
This barrier could include lack of resources or investment. Studies show, for example, that a lack of effective data collection system or investment in IT can act as a barrier to successful collaboratives. There are, however, solutions that could help you that won’t break the bank. Life QI is a solution which helps to run collaboratives for a wide range of organisations across multiple locations. For example, an international 18-month long collaborative covering 17 hospitals across 3 countries is using Life QI to facilitate its Joy in Work programme
Lack of time / motivation / engagement
In the BMJ article, sources were quoted as saying they didn’t find QI important and that it was ‘secondary to the need to deliver routine care….As the collaborative progressed, a few ‘champions’ identified by the team emerged. From learning sessions these champions were observed to be similar to change agents, driving the patient safety agenda in their teams and departments. Their motivation to shape the local level patient safety strategy and the sharing of this narrative with the collaborative led to the spread and adoption of a champion’s model in other teams. Some champions emerged in trusts where there were significant internal and external pressures.’ This is the time to seek out your champions!
Lack of structure
Not having a good structure in place can inhibit success in a quality collaborative. Once again, if you set off from the outset to structure your collaborative with the support of appropriate technical resources, training etc, this will help support communication between participants, and in turn, help you to overcome these particular challenges.
It may appear that there are quite a few potential barriers to overcome in your journey towards transformational change, however, if you are aware of them, you can work to avoid them! Take heart that healthcare organisations are sharing real success stories that demonstrate it is possible to overcome hurdles and move towards QI change and shared learning.
Dickinson H, Ham C, Snelling I, Spurgeon P.Are We There Yet? Models of Medical Leadership and their effectiveness: An Exploratory Study. Final report. NIHR Service Delivery and Organisation programme; 2013.