Culture of Continuous Learning Project: A Literature Review of the Breakthrough Series Collaborative

ReportEarly ChildhoodJan 18 2018

Promoting the quality of early care and education (ECE) is a central goal of state and national initiatives aimed at supporting children’s early learning and healthy development. Given these investments, program administrators, policymakers and researchers alike are interested in understanding how quality improvement activities can best target changes in practice that will support children’s development and can be sustained over time across a wide range of programs.

Advances in the science of improvement offer ECE a new framework for thinking about approaches to quality improvement. While some of the specific methods derived from improvement science have generated dialogue and investments in pockets of the ECE field, these methods are not yet widespread in practice.

The Breakthrough Series Collaborative (BSC) is a structured improvement methodology developed originally for use in the health care field. The goal of the BSC is to build organizational capacity for quality improvement; support data-informed decision making; engage leadership from all levels of the organization in the change process; and, ultimately improve quality, outcomes, and efficiency (Mittman, 2004). The Culture of Continuous Learning (CCL) Project: A Breakthrough Series Collaborative for Improving Child Care & Head Start Quality will examine the potential of the BSC to support the organizational capacity of child care and Head Start settings to test and implement program improvements.


The purpose of this literature review is to examine the evidence base of the BSC to better understand the outputs and outcomes of the BSC and the contextual factors that may support success.

The findings from this literature review will be incorporated into the next phase of the CCL Project, which includes a Feasibility Study examining the implementation of the BSC in both Head Start and child care settings. The results of this study will help determine if the BSC holds promise as a structured approach to improvement in ECE settings and the feasibility of implementing the BSC in different types of ECE programs. Results will also be used to inform planning for future research related to quality improvement in ECE.

Key Findings and Highlights

Overall, the literature examining the implementation and outcomes of the BSC indicates that the methodology has consistent evidence of improving practices in healthcare, child welfare, and mental health service provision by facilitating the implementation of evidence based practices (EBP) and building the infrastructure to support quality improvement efforts. Though outcomes at the recipient level were either not reported or mixed, the overall findings from this review indicate that the BSC model holds promise for improving the quality of organizational processes and individual practice in the early care and education sector.

The lessons learned from the literature suggest that the CCL Project may need to:

  • Support buy-in and engagement in the BSC at multiple levels of the system
  • Ensure there are supports for implementation including training, supervision, and data systems
  • Develop strategies for building capacity to engage in the improvement process at all levels
  • Examine ongoing incentives for supporting participation in the initiative
  • Identify strategies for trouble-shooting common problems that arise


Literature included in this review was identified through Google Scholar and EBSCOhost, including the following databases: Academic Search Complete, Consumer Health Complete, Google Scholar, Education Research Complete, ERIC, Health Source, PsycINFO, and Psychology and Behavioral Sciences Collection. The following search terms were used: Continuous Quality Improvement (CQI), Breakthrough Series Collaborative (BSC), Plan-Do-Study-Act Cycles (PDSA), Learning Collaboratives, Improvement Science, and Implementation Science.

Literature included peer-reviewed research articles, policy briefs, research reports, and white papers. The literature cited in this review was published between 1998 and 2016 though research conducted within the last ten years was prioritized. Sections I through V of this report include a mix of literature related to the BSC and other quality improvement methods relevant for early childhood, while Section V includes literature specific to the outcomes related to BSC implementation.

The literature search specific to the BSC identified 49 articles, of which 34 included a focus on BSC outcomes. These articles largely focused on studies conducted in the health care field. Four members of the Child Trends team analyzed the articles using a summary table to compile findings related to BSC outcomes.