Getting Knowledge into Action:
Overview of Knowledge Management Activities and Tools
to Support the Breakthrough Series and Plan-Do-Study-Act
Models for Improvement
1 Purpose
This note outlines how the flow of knowledge into action underpins the Breakthrough Series and Plan-Do-Study Act models for improvement. It suggests examples of knowledge management activities and tools to support each stage of these improvement models. The paper aims to help knowledge managers, practitioners and improvement advisers to align knowledge management support with quality improvement processes.
2. The Breakthrough Series
The Institute for Healthcare Improvement describes the Breakthrough Series as an improvement model to help organizations to close the gap between knowledge and practice by creating a structure in which interested teams and organizations 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 to seek improvement in a focused topic area. Collaboratives range in size from 12 to 160 teams. Each team typically sends threeof its members to attend Learning Sessions (three face-to-face meetings over the course of the Collaborative), with additional members working on improvements in the local organization.
The key principles underpinning the Breakthrough Model are:
- bring together people with subject expertise in specific clinical areas with people who have delivered significant improvement in practice in this area (“application experts”), and improvement advisors who can help organizations select, test, and implement changes on the front lines of care.
- alternate between periods of action, when teams aim to implement change in practice, and periods of learning, when teams from participating organisations come together to share experience and ideas, and to use that knowledge to plan changes.
Figure 1 below outlines the stages in the Breakthrough Model. The model is inherently dependent on effective utilisation of knowledge - sourcing, combining, capturing and sharing knowledge from research and experience, and monitoring the application of knowledge to practice. The Breakthrough combination of situated learning and social learning (ie applying knowledge to practice, followed by sharing experience and gaining mutual support from a wider community) is the essence of the community of practice framework for using knowledge to deliver change in practice.
Figure 1: Breakthrough Series Model of Improvement (from
2.1 Links with knowledge management
Key elements of the Breakthrough Series, and relevant knowledge management activities and tools, are outlined below.
It should be noted that the community of practice model supports all stages of the Breakthrough Series – sourcing and synthesising evidence as a basis for planning improvements; learning as a community through sharing experience of applying knowledge to practice in the workplace; and monitoring the utilisation of knowledge to deliver improved outcomes.
Likewise, the core knowledge management capabilities of finding, evaluating, combining, sharing knowledge, and monitoring its use and impact in practice, underpin the whole improvement process.
Breakthrough Series element(as described by IHI) / Examples of knowledge management activities and tools
Topic Selection: Improvement leaders identify a particular area or issue in health care that is ready for improvement. These are issues where existing knowledge is sound but not widely applied in practice, better results have been demonstrated in real-world settings, and current variation in practice affects many patients somewhat, or at least a few patients profoundly. / Scoping and rapid evaluation of synthesised evidence (systematic reviews, guidelines, etc), policy, published statistics, economic evaluations.
Faculty Recruitment: Improvement leaders identify subject matter experts and application experts as “expert faculty”. The chair of the Collaborative is responsible for establishing the vision of anew system of care, providing leadership, and teaching and coaching the participating teams. The chair and the expert faculty define appropriate aims, measurement strategies, anda list of evidence-based changes. An Improvement Advisor /s on the Faculty is responsible for teaching and coaching teams on improvement methodsand how to apply them in local settings. / Question/problem definition based on scoping study.
Rapid evidence search and synthesis
Source evidence from:
• research
• statistics
• policy
• economics
• practice /performance
• experience
Evidence evaluation and selection
Capture of tacit knowledge -
practice, experience, ideas from
practitioners and service users.
Key informant interviews
Action learning sets
“Ideas banks”
Round table events
Enrolment of Participating Organizations and Teams: Organizations apply to join a Collaborative, appointing multidisciplinary teams within the organization charged to learn from the Collaborative process, conduct small-scale tests of change, and help successful changes become standard practices. To help teams prepare for the start of the Collaborative, prework conference calls clarify the Collaborative processes, roles, and expectations of organization leaders and team members. / Community website can signpostand organise evidence sources, learning resources, guidance, process and procedure documentation.
Social media and social networking tools (eg podcasts, blogs, wikis, web- and teleconferencing) support the initial learning process.
Learning Sessions:
Traditional Learning Sessions are face-to-face meetings, usually three conductedduring a typical Collaborative, bringing together multidisciplinary teams from each organization and the expert faculty to exchange ideas.
At the first Learning Session, expert faculty present a vision for ideal care in the topic areaand 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 enablesteams 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 more from one another as they report on successes, barriers, and lessons learned in general sessions, workshops, storyboard presentations, and informal dialogue and exchange. / Sharing of experience and learning through social media (eg podcasts), social networking, webconferencing and teleconferencing.
Capturing tacit knowledge from experience – narrative and storytelling.
Creation of case studies
After action, Peer Assist and Lessons Learned reviews
Storyboarding to define and share opportunities for improving use of knowledge.
Quality improvement portal for access to knowledge about topic area and about improvement methods.
LMS/Virtual Learning Environment to create and access learning opportunities about topic area and quality improvement.
Community website provides online infrastructure for Collaborative to create and share learning resources and tools they create during the process of improvement in their own organisations.
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 theentire 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 organizations. The aim is to
build collaboration and support the organizations as they try out new ideas, even at a distance. / Creation of “actionable knowledge” – i.e. products that combine knowledge with implementation support. They are designed to facilitate direct application of knowledge to practice. Examples:
- Evidence bundles
- Action sets
- Change packages
- Checklists
- Automated prompts/reminders in online or offline systems
- Clinical decision support
- Guideline recommendations and pathways
- Mobile apps
- Patient-mediated prompts
- Embedding knowledge in policy and procedure.
Capture and analysis of performance and outcomes data to monitor application of knowledge to practice.
Knowledge management tools for communication and collaboration as described above under “Learning Periods”.
3. The PDSA Model for Improvement
To apply changes in their local settings, Breakthrough Collaborative participants learn the Plan-Do-Study-Act Model for Improvement (Figure 2). This model identifies four key elements of successful process improvement: a) specific and measurable aims, b) measures of improvement that are tracked over time, c) key changes that will result in the desired improvement, and d) a series of testing “cycles” duringwhich teams learn how to apply key change ideas to their own organizations.
Teams and organisations may also apply the PDSA cycle to define and deliver improvement outside the context of the Breakthrough Series.
Figure 2: Plan-Do-Study-Act model for improvement
3.1 Knowledge management support for the PDSA improvement cycle
Examples of knowledge management activities and tools to support the PDSA process are summarised below.
PDSA stage / Examples of knowledge management activities and toolsPlan / Search and synthesis techniques as outlined above under “Topic selection” and “Faculty recruitment”. Organisations conducting PDSA cycles as part of the Breakthrough Series will use evidence identified, reviewed and selected via the Faculty. Teams and organisations conducting PDSA cycles outwith the Breakthrough Series will need to identify, evaluate and select evidence themselves.
Do / Actionable knowledge and knowledgeexchange and dissemination techniques as described above under “Action periods”.
Study / Knowledge capture, review, exchange, and dissemination techniques as described above under “Learning periods.”
Act / Planning based on knowledge captured and reviewed during “Study” stage.
Knowledge dissemination techniques as described above under “Learning periods” to support spread of knowledge once improvement solutions are ready for large scale implementation.
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