Report on the AHRQ 2010 Consensus Meeting on Practice Facilitation for Primary Care Improvement
Prepared in partial fulfillment of requirements of AHRQ Task Order 13: Implementing Practice Coaching and the Chronic Care Model into Practices Serving Vulnerable Populations Task Order Officer: Cindy Brach Contractor: ePCRN through subcontract with L.A. Net Project Period: 6/2009 – 12/2011 Prepared by: Project P.I.: Lyndee Knox, PhD L.A. Net, A Project of Community Partners Fall 2010
A Wiki version of this report is available on-line that allows readers to add comments and material to the report (Go Live date: March 28th, 2011). To access go to: http://www.lanetpbrn.net/w/index.php?title=Report_on_the_AHRQ_Practice_Facilitation_Consensus_Meeting
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ProjectSteeringCommitteeTomBodenheimer,MD UniversityofCaliforniaSanFranciscoGraceFloutsis,MD ClinicaMsr.OscarA.RomeroLyndeeKnox,PhD L.A.NetJamesMold,MD UniversityofOklahomaJuneLevine,RN,MSN L.A.NetRichardSeidman,MD L.A.Care
ConsensusMeetingParticipantsVeenuAulakh,MPH CaliforniaHealthCareFoundationMichaelBarr,MD AmericanCollegeofPhysiciansTomBodenheimer,MD UniversityofCaliforniaSanFranciscoAdrianneBowes,RN RedwoodCoalitionCindyBrach,MPP AgencyforHealthcareResearchandQuality(AHRQ)CathyCatrambone,PhD RushUniversitySophiaChang,MD CaliforniaHealthCareFoundationEllenChristiansen,FNP CoastalHealthAllianceKateColeman,MSPH MacCollInstituteDarrenDeWalt,MD UniversityofNorthCarolinaCindyDickinson,FNP SouthwestCommunityHealthCentersPerryDickinson,MD UniversityofColoradoDenverDouglasEby,MD SouthcentralHealthFoundationGraceFloutsis,MD ClinicaMsr.OscarA.RomeroBrendaFraser QualityImprovementandInnovation(QIIP)MikeHerndon,DO OklahomaHealthcareAuthorityCraigJones,MD VermontBlueprintforHealthCharlesM.Kilo,MD GreenFieldHealth,OHSULisaKodmur L.A.CareJohnKotick,JD FamilyHealthCareCentersofGreaterLosAngelesLisaMLetourneau,MD QualityCountsClareLiddy,MD UniversityofOttawaJamesMold,MD UniversityofOklahomaTrishO’Brien QualityImprovementandInnovation(QIIP)RolandPalencia L.A.CareKevinPeterson,MD UniversityofMinnesotaKellyPfeifer,MD SanFranciscoHealthPlanMaryRuhe,RN CaseWesternUniversityRichardSeidman,MD L.A.CareCoreySevin,RN InstituteforHealthcareImprovement(IHI)LeifSolberg,MD HealthPartnersNeilSoloman,MD HealthNetCarolynShepherd,MD ClinicaCampesinaKatyD.Smith,MS OklahomaPractice‐BasedResearchNetwork
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ElizabethStewart,PhD UniversityofTexasAdditionalcontributorsMargieGodfrey ClinicalMicrosystemsResourceGroupZsoltNagykaldi OklahomaPhysiciansResearch/ResourceNetworkKateColwell LyleJ.Fagnan OregonRuralPracticeBasedResearchNetwork
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TableofContents
1.BACKGROUNDANDGOALS ................................................................................................. 7
2.SUMMARYOFDISCUSSION .............................................................................................. 142.1 Whatshouldwecallthedisciplineanditsserviceproviders?................................................................142.2 Whataresomeofthekeylessonslearnedbyparticipantsfromtheirworkinpractice
facilitation? ....................................................................................................................................................................152.3 Whatimprovementgoalsareappropriatetopursueusingpracticefacilitation?..........................162.4 Shouldfacilitationbemadeavailabletoallpractices? ...............................................................................182.5Dopracticesneedtopossessadegreeoforganizational“readiness”toengageinimprovement
workbeforetheycanbenefitfromfacilitation? ............................................................................................202.6 Whatfunctionsdopracticefacilitatorsfillandwhicharemoreeffectiveinproducingdesired
changes? ..........................................................................................................................................................................212.7Whatarethedifferenttypesoffacilitatorsandisonemoreeffective?...............................................212.8 Areinternalorexternalfacilitatorsmoreeffective? ...................................................................................222.9Howmanyhoursoffacilitationareneededtoachieveimprovementinapractice?.....................232.10Arelong‐termorshort‐terminterventionmodelsmoreeffective?.......................................................232.11Isdistancefacilitation(providedthroughemail,telephone,webconferences)aseffectiveas
on‐sitefacilitation?Isthereanoptimalmixofdistanceandon‐sitedelivery?...............................242.12Canpracticesbecomedependentonfacilitatorsandhowshouldthisbemanaged?...................252.13Howmanypracticesshouldafacilitatorsupportatanyonetime?......................................................262.14Canfacilitationbeprovidedasastand‐aloneservice?...............................................................................262.15Whatistheusualcourseforaninterventionusingpracticefacilitation?..........................................272.16 Whattypeofpersonmakesthebestfacilitators? .........................................................................................292.17 Whatcorecompetenciesandskillsdofacilitatorsneedtohavetobeeffective? ...........................302.18 Whatisthebestwaytosupportandtrainfacilitators? .............................................................................322.19Howmuchdoesitcostperpracticetoprovidefacilitationsupport? ...................................................342.20Howshouldfacilitationprogramsbeevaluated? ..........................................................................................342.21 Dodifferencesinpracticesize,locationorstructureimpacttheeffectivenessoffacilitation? 352.22Whatresearchquestionsshouldbeansweredaboutfacilitationinorderincreaseits
effectiveness?................................................................................................................................................................352.23Suggestedresearchquestions.....................................................................................................................................363.REFERENCES...................................................................................................................... 38
4.APPENDICES...................................................................................................................... 40AppendixA.CrosswalkbetweenICICPilotStudyandConsensusMeeting..................................................41AppendixB.LessonsLearnedinPracticeFacilitationSharedbyParticipants ...........................................47AppendixC.InventoryofResourcesProvidedbyParticipants .........................................................................53AppendixDTableSummarizingProgramCharacteristics.................................................... (SeparateCover) ListofTablesTable1.ListofFacilitationPrograms ..............................................................................................................................9Table2.Namesusedtoidentifyfacilitators ................................................................................................................15Table3.Goalsandobjectivesforfacilitationinterventions ................................................................................16Table4.Resourcesforassessingreadiness................................................................................................................20
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Table5Apartiallistoftrainingcurriculaandresources.....................................................................................33ListofFiguresFigure1.PartialmapoffacilitationprogramsinU.S.andCanada ....................................................................11Figure2.Questionsaddressedduringmeeting .........................................................................................................14Figure3.Anexampleofachangemodelwith8keydrivers................................................................................18Figure4.Thepracticefacilitationecology ...................................................................................................................19Figure5.Typicalstagesofapracticefacilitationintervention ...........................................................................29Figure6.Corecompetenciesofageneralistpracticefacilitator .......................................................................30
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1.BACKGROUNDANDGOALS
Improvingqualityinprimarycarewillbeapriorityissueoverthenextdecade.PrimarycareiscurrentlyinastateofcrisisduetoanumberoffactorsincludingthediminishingnumbersofU.S.medicalstudentsenteringprimarycare,patientdissatisfactionwithcareandaccess,physiciandissatisfaction,insufficientfundingandgrowingdemandsbeingplacedonprimarycarepractices(Bodenheimer,2006).DevelopingeffectiveandefficientstrategiesforimprovingqualitywillbecriticaltothetransformationofprimarycareintheU.S.Currentapproachesbeingusedatthepracticelevelincludeacademicdetailing,auditandfeedback,benchmarking,physicianeducation,performance‐linkedpaymentreform,organizationalconsulting,andcollaborativelearning.Eachoftheseapproacheshassupportedimprovementsatpracticeandproviderlevels.However,nonehavebeensufficientinachievingthetypeofsustainedcomprehensiveimprovementinprimarycarethatisbeingpursuedinthecurrentcontextofhealthcarereform.Impactstudieshaveshownthatcollaborativescanbeeffectiveinincreasingmotivation,knowledgeanddrivingchangeinthepracticesetting(Goeschel&Pronovost,2008;InstituteforHealthcareImprovement,2003;U.S.AgencyforInternationalDevelopment,2008).However,despitethesesuccessestheirimpacthasbeenlimited.Manypracticescannotordonotparticipateinthesecollaboratives.Providersthatdoparticipateleavewithnewideasandtools,butreportdifficultyimplementingtheseintheirpracticesduetoalackoftime,humanresources,andknowledgeneededtotailorthestrategiestofittheuniqueneedsoftheirpractices.Practicefacilitation1isasupportiveserviceprovidedtoaprimarycarepracticebyatrainedindividualorteamofindividualswhousearangeoforganizationaldevelopment,projectmanagement,qualityimprovementandpracticeimprovementapproachesandmethodstobuildtheinternalcapacityofapracticetoengageinimprovementactivitiesovertime,andtosupportattainmentofbothincrementalandtransformativeimprovementgoals. Practicefacilitators(PF)arespeciallytrainedindividualswhoworkwithprimarycarepractices“tomakemeaningfulchangesdesignedtoimprovepatientsoutcomes.[They]helpphysiciansandimprovementteamsdeveloptheskillstheyneedtoadaptclinicalevidencetothespecificcircumstanceoftheirpracticeenvironment”(DeWaltetal,2010,p7).Facilitatorsmayalsoassistcliniciansinconductingresearchinandontheirpractices(Nagykaldietal,2006)andaredistinguishedfromconsultantsthroughtheirspecializedtraining,broadscopeofpractice,andlonger‐term,moreholisticrelationshipwithapracticeanditsprovidersandstaff(Knox,2010). 1 Based on input from meeting participants and for the purposes of clarity, the term practice facilitation (PF) and practice facilitators (PFs) will be used in this report in lieu of practice coaching.
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Practicefacilitationisemergingasapromisingapproachforsupportingpracticeimprovementthatcanbeusedincombinationwithapproachessuchaslearningcollaboratives,orprovidedasastand‐aloneresourceforpractices;andpracticefacilitatorsareapotentialworkforcefortheproposedNationalPrimaryCareExtensionprogramandRegionalExtensionCenterssupportingimplementationofHealthInformationTechnology.Inoneofthefirstreviewsconductedofthefacilitationliterature,Nagykaldi,MoldandAspy(2005)examinedstudiesofitsimpactonqualityofcareandpatientoutcomes. Ofthe25studiesreviewed,theauthorsfoundevidenceoftheeffectivenessoffacilitationinimprovingqualityofcarefordiabeticpatients,improvingrateofpreventivecareservicesforchildrenandadults,andscreeningforhemoglobindisorders.Insomeinstances,facilitationalsoresultedincostsavingsforthepractice.Forsomepractices,theeffectsoffacilitationfadedaftertheinterventionended;andlargerpracticeswerelesslikelytobenefitbecauseofthescaleofoperationsneededforimprovement.Baskerville(2009)conductedameta‐analysisof38studiestoevaluatetheimpactoffacilitationoncarequalityandfoundmoderateeffects(0.54)forfacilitationonquality.Alargereffectsizeandlikelihoodofimpactwasassociatedwithinterventionsthat:a)werecustomizedtothepractice;b)involvedmultipleinterventioncomponents;c)tookplaceoverlongervs.shortertimeperiods;andd)involvedgreaternumberofservicehours.Higherpracticefacilitatortopracticeratiosandthepresenceofcliniciansdescribedaspessimistictowardstheprocesswereassociatedwithlessfavorableoutcomes.ArecentstudybyCrabtree,Nutting,Miller,Stange,andStewart(2010)ontheuseoffacilitatorstosupporttransformationtoPatientCenteredMedicalHomes(PCMHs)aspartoftheNationalDemonstrationProject(NDP)comparedlowtomoderateintensityprimarilydistancefacilitationtoself‐directedpracticeimprovementacross39qualitycomponentsthatincludedareassuchasaccesstocareandinformation,caremanagement,practiceservices,continuityofcare,practicemanagement,qualityandsafety,healthinformationtechnology,andpractice‐basedcareteams.Crabtreeetalfoundlargerincreasesinadaptivereserve(definedas“practice’sabilitytomakeandsustainchange”)andmoreNDPcomponentsimplementedinfacilitatedpracticescomparedtoself‐directedpractices.Atleast12Practice‐BasedResearchNetworks(PBRNs)intheU.S.arecurrentlyusingpracticefacilitatorsto supportresearchandqualityimprovementintheirprimarycarepractices.TheseincludetheOklahomaPhysiciansResearchNetwork(OKPRN),theOregonRuralPracticeBasedResearchNetwork(ORPRN),theWisconsinResearchandEducationNetwork(WREN),AdvancedPracticeNurse‐AmbulatoryResearchConsortium(ARC),IndianaUniversityPrimaryCarePractice‐BasedResearchNetwork(ResNet),ColoradoResearchNetwork(CaReNet),TheUniversityatBuffaloFamilyMedicineResearchInstituteandUpstateNewYorkPracticeBasedResearchNetwork(UNYNET),andL.A.Net.StatessuchasVermont,Maine,TexasandOklahomaareusingfacilitatorstopromoteimprovementinprimarycarepracticesservingpubliclyinsuredpatients.Healthplansand
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foundationsarealsoexploringthevalueoffacilitation.BlueCrossofMichiganisengagingqualityimprovementexpertsfromtheautomotiveindustrytosupportimprovementinhealthcaresettings.PublichealthplanssuchasL.A.Care,CareOregonandtheSanFranciscoHealthPlanareexploringpracticefacilitationasaresourceforsupportingPatientCenteredMedicalHome(PCMH)transformationinpracticesprovidingcaretotheirmembers.FoundationsliketheRobertWoodJohnsonFoundationandtheCaliforniaHealthCareFoundationhaveinvestedheavilyinimprovementinitiativessuchasImprovingPerformanceinPractice(IPIP)initiativeandtheMassachusettseHealthCollaborativethatmakeuseofpracticefacilitationusuallyaspartofamulti‐methodimprovementstrategy.Qualityimprovementandresearchorganizationsarealsoinvestinginfacilitation.DartmouthClinicalMicrosystemsandtheInstituteforHealthcareImprovement(IHI)offertrainingprogramsforfacilitators.FederallyfundedHealthInformationTechnologyRegionalExtensionCenters(HITECHRECs)areexpectedtoutilizepracticefacilitatorsintheirworkpreparingpracticestoimplementelectronichealthrecords(EHR).FederalagenciessuchastheAgencyforHealthcareResearchandQuality(AHRQ)aresupportingresearchandresourcedevelopmentinpracticefacilitation.Policymakersarelookingatavarietyofstrategiesforimprovingthenation’sprimaryhealthcaresystem,someofwhichmaybeinformedbycurrentworkinfacilitation.Recentlypassedreformlegislation(Section5405WofthePatientProtectionandAffordabilityAct)containslanguagecallingforthecreationofaNationalPrimaryCareExtensionProgramthatmightbestaffedbyanationalnetworkoffacilitators(Grumbach&Mold,2009).Internationally,Englandwasoneofthefirsttoimplementacomprehensivepracticefacilitationprogramtosupportitsprimarycaresystem.InCanada,provincessuchasOntarioandBritishColumbiaareinvestinginfacilitationprogramstosupportimprovementsinprimaryandspecialtycare.Table1ListofFacilitationProgramsName Location WebsiteCaliforniaHealthCareFoundation,SmallPracticeeDesignProgram
Oakland,CA http://www.chcf.org/projects/2009/small‐practice‐edesign
CaliforniaHealthCareFoundation,TeamupforHealthProgram
Oakland,CA http://www.chcf.org/projects/2009/team‐up‐for‐health‐supporting‐patients‐for‐better‐chronic‐care
CaseWesternReserveUniversity,DepartmentofFamilyMedicine
Cleveland,OH http://www.case.edu/med/pbrn
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Name Location WebsitePBRNClinicalMicrosystems NewHampshire http://www.clinicalmicrosystem.org/ColoradoResidencyFacilitationProject
Colorado Contact:[email protected]
HealthTeamWorks Colorado http://www.healthteamworks.orgImpactBC Vancouver,Canada http://www.impactbc.ca/ImprovedDeliveryofCardiovascularCare
Ottowa,Canada http://www.idocc.ca
ImprovingPerformanceinPractice(IPIP)
Colorado,Michigan,Minnesota,NorthCarolina,Washington,Wisconsin,Pennsylvania
http://www.ipipprogram.org/
L.A.Net LosAngeles,CA http://www.lanetpbrn.netOklahomaHealthcareAuthority,SoonerCare
Oklahoma http://www.okhca.org/
OklahomaPhysiciansResearchNetwork(OKPRN)
Oklahoma http://www.okprn.org
OklahomaUniversityHealthScienceCenter,DepartmentofFamilyandPreventativeMedicine
Oklahoma http://www.oumedicine.com
OregonRuralPracticeBasedResearchNetwork(ORPRN)
Oregon http://www.ohsu.edu/orprn/
PittsburghRegionalHealthcareInitiative
Pittsburgh,PA http://www.prhi.org/
QualityCounts Maine http://www.mainequalitycounts.org/QualityImprovement&InnovationPartnership(QIIP)
Ontario,Canada http://www.qiip.ca
TransforMED Leawood,KS http://www.transformed.comUniversityofColoradoDenver,DepartmentofFamilyMedicine
Colorado http://fammed.uchsc.edu/
VermontBlueprintforHealth
Vermont http://healthvermont.gov/blueprint.aspx
SafetyNetMedicalHomeInitiative
Multi‐state(5) http://www.qhmedicalhome.org/safety‐net/about.cfm
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Name Location Website
SanFranciscoDepartmentofPublicHealth
California Contact:[email protected]
ThemapbelowdisplayslocationsofsomeofthemajorfacilitationeffortscurrentlyunderwayintheU.S.andCanada.Figure1.PartialmapoffacilitationprogramsinU.S.andCanada
AboutThisProject In2006AHRQcontractedwiththeRANDCorporation,GroupHealth’sMacCollInstituteandtheCaliforniaHealthCareSafetyNetInstitutetodevelopatoolkittosupportimplementationoftheChronicCareModel(CCM)insafetynetpractices.TheresultingdocumentandtoolkittitledIntegratingChronicCareandBusinessStrategiesintheSafetyNetwaspublishedin2009andcontainsresourcestoguidepracticesthroughkeychangestoimplementtheCCM.Itisavailableonlineathttp://www.ahrq.gov/populations/businessstrategies/businessstrategies.pdf.
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Originallydevelopedforpracticestouseontheirown,theprojectteamandAHRQquicklyrecognizedmostpracticeswouldrequireoutsidesupportinordertoundertakethemodificationssuggestedinthechangepackage.ThustheprojectteamdevelopedaPracticeCoachingManualasacompaniontotheAHRQToolkittoguidepracticecoaches/facilitatorsinthebestapproachtousingtheToolkitwithpractices.IntegratingChronicCareandBusinessStrategiesintheSafetyNet:APracticeCoachingManualwaspublishedin2009(Coleman,Pearson,Wu,&Brach,2009).TheManualprovidesanoverviewofthefieldofpracticecoachingorfacilitation,suggestsactivitiesforthecoach/facilitatortouseinordertoguidepracticesthroughthemodificationsrecommendedbytheToolkit,andprovidessuggestionsfororganizationsinterestedinusingtheToolkittosupportqualityimprovementintheirpractices.TheprojectteamconductedanevaluationofafacilitationinterventionusingtheARHQToolkitin24primarycarepracticesfromtwosafety‐netorganizations.Therewere9interventionpracticesand15controlpractices.Individualsintheinterventionpracticesperceivedfacilitationasenablingthemtogainskills,knowledge,andtoolsneededtoimprovetheirclinicalcare.However,theywerelesspositiveabouttheirgainsinorganizationalcapabilities,progressimprovingprocessefficiency,andimpactonrevenuegeneration.Fewstatisticallysignificantdifferenceswerefoundbetweeninterventionandcontrolpracticesonkeyoutcomeindicatorswithonenotableexception.Asignificantdifference(p<.05)wasfoundbetweeninterventionandcontrolpractices’diabeticpatients’ratesofhospitalizationinfavoroftheinterventiongroup.Theprojectteamattributedthesedifferencestotheuseofregistriestoidentifyandintervenewithhigh‐riskpatients.Facilitationwasseenasbridgetothechangepackage/toolkitandnecessaryformotivatingandpromptingpeopletomakechangesrelatedtochroniccare.FacilitatorsworkingwiththepracticesmademodificationstotheToolkitinanefforttoincreasebuy‐intoitsuseamongthepractices.However,despitethis,thetoolkitwasnotextensivelyused.Theteamsummarizedtheirfindingsinfivekeylessonslearned:
1. practicecoachingisafeasiblemechanismforfacilitatingCCMqualityimprovementinsafety‐netclinicsettings
2. differentmodelsofpracticecoachingmayworkbetterindifferentsettingsandtiming3. thetoolkitneedsabridgeforitsadoption4. CCMimplementationmayreduceutilizationinsafety‐netclinicsettings,and5. evaluationusingrandomizationdesignpresentsbothchallengesandopportunities
L.A.Net,aprimarycarepracticebasedresearchnetworkcomprisedofFederallyQualifiedHealthCentersandCommunityHealthCentersinLosAngelesandamemberoftheElectronicPrimaryCareResearchNetworkContractconsortium,wascontractedtoconductthenextphaseoftheCCMandpracticecoachingproject.ImplementingPracticeCoachingandtheChronicCareModelinPracticesServingVulnerablePopulationsisacontinuationoftheprojectdescribedabove.Thecurrenteffortinvolvestwoparts:conveningofapanelofexpertstosummarizewhatiscurrentlyknownaboutthefieldofpracticefacilitationandidentifywhatquestionsstillneedtobeaddressed;andtoevaluatetheprocessandimpactofafacilitation
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interventionbasedonthecontentsoftheAHRQCCMToolkit.Thisreportsummarizesresultsofthemeetingoftheexpertpanelonpracticefacilitation.ConsensusmeetingdesignThePracticeFacilitationConsensusMeetingwasheldinLosAngeles,CaliforniaonJanuary28thand29th.Itspurposewastobringtogetherleadingpractitionersandresearchersinpracticecoachingandpracticeimprovementtosharelessonslearned,exchangeideasandprovidepragmaticinformationabouttheirexperiences.Thegoalsforthemeetingweretoadvanceknowledgeaboutpracticecoaching(alsoreferredtoaspracticefacilitation),toidentifyemergingbestpracticesinthefield,andtoidentifyareasinneedoffurtherstudy.Meetingstructure,goalsandparticipantsweredeterminedcollaborativelybetweentheL.A.NetPracticeFacilitationProjectSteeringCommitteeandleadershipatAHRQincludingCindyBrachandDavidMeyers,andwithinputfrompractitionersinthefield.Thirty‐sevenindividualsparticipatedinthemeetingfromboththeU.S.andCanada.Participantswereinvitedtothemeetingbasedontheirexpertiseinpracticefacilitation.Toensureacomprehensiveperspectiveonthepracticeofpracticefacilitation,individualswithdifferingtypesofinvolvementinfacilitationwereinvitedtoparticipateincluding:practicingfacilitators,directorsoffacilitationprograms,researchersinterestedinpracticeimprovementandfacilitation,cliniciansthathadparticipatedinfacilitationinterventions,andfunders/purchasersoffacilitationservices.Ininstanceswhereseveralindividualspossessedknowledgeofsimilarfacilitationmodelsorprograms,onlyoneindividualwasinvitedtoallowinclusionofrepresentativesfromasbroadarangeofprogrammodelsaspossible.QuestionsthatwereaddressedduringthemeetingareprovidedinFigure2andwerebasedonworkstartedundertheprecedingtaskorderthatledtodevelopmentoftheToolkit,areviewofthefacilitationliterature,informalinterviewswithexpertsinthefield,andinputfromthesteeringcommitteeandAHRQ.ParticipantsreceivedacopyofNagykaldi,Mold,andAspy’s2005reviewofpracticefacilitationtoreadpriortothesession.Themeetingtookplaceovertwodaysandwasmoderatedbyaprofessionalfacilitator.Largeandsmallgroupdiscussionswereaudiotaped,transcribedandanalyzedforcontentandtheme.
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Figure2.Questionsaddressedduringthemeeting Whatshouldwecallthedisciplineanditsserviceproviders?Whataresomeofthekeylessonslearnedbyparticipantsfromtheirworkinpracticefacilitation?Whatimprovementgoalsareappropriatetopursueusingpracticefacilitation?Shouldfacilitationbemadeavailabletoallpracticesoronlythosethatmeetcertaincriteria?Dopracticesneedtopossessadegreeoforganizational“readiness”toengageinimprovementworkbeforetheycanbenefitfromfacilitation?Whatfunctionsdopracticefacilitatorsfillandwhicharemoreeffectiveinproducingdesiredchanges?Whatarethedifferenttypesoffacilitatorsandisonemoreeffectiveorusefulthantheothers?Areinternalorexternalfacilitatorsmoreeffective?Howmanyhoursoffacilitationareneededtoachieveimprovementinapractice?Arelong‐termorshort‐terminterventionmodelsmoreeffective?Isdistancefacilitation(providedthroughemail,telephone,webconferences)aseffectiveason‐sitefacilitation?Isthereanoptimalmixofdistanceandon‐sitedelivery?Canpracticesbecomedependentonfacilitatorsandhowshouldthisbemanaged?Howmanypracticesshouldafacilitatorsupportatanyonetime?Canfacilitationbeprovidedasastand‐aloneserviceorshoulditoccurinthecontextofmorecomprehensiveimprovementefforts?Whatistheusualcourseforaninterventionusingpracticefacilitation?Whomakethebestfacilitators?Whatcorecompetenciesandskillsdofacilitatorsneedtohavetobeeffective?Whatisthebestwaytosupportandtrainfacilitators?Howmuchdoesitcostperpracticetoprovidefacilitationsupport?Dodifferencesinpracticesize,locationorstructureimpacteffectivenessoffacilitation?Whatresearchquestionsshouldbeansweredaboutpracticefacilitationinordertoincreaseitseffectiveness?
2.SUMMARYOFDISCUSSION
2.1 Whatshouldwecallthedisciplineanditsserviceproviders? Namingtheactivityoffacilitationorcoachingandtheindividualswhodeliverthisserviceemergedasanimportantthemeduringthemeeting.Theareaisrapidlygaininginpopularityandmomentum,andthereisaneedtothoughtfullydefinetermsofartfordescribingthefieldanditsprofessionalsbeforetheterminologyissetbycommonusageregardlessofitsappropriateness.Establishingacommonvocabularyforthefieldisalsoimportantforsupportingcontinueddevelopmentofasharedresearchandknowledgebaseonthetopic.Atpresent,avarietyofdifferenttermsareusedtorefertoactivitiesconsistentwiththedefinitionoffacilitationprovidedinthebackgroundsectionofthisreport.Theseinclude:consulting,coaching,facilitating,qualityimprovementcoordination,qualityimprovementcoaching,andqualitynavigation(seeTable2).
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Table2.Namesusedtoidentifycoaches/facilitators Names PracticeConsultantPracticeEnhancementCoordinatorQICoachPracticeImprovementCoachPracticeTherapistPracticeEnhancementAssistantPracticeFacilitatorPracticeRedesignerPracticeQualityNavigatorPracticeEnhancementandResearchCoordinatorsQualityimprovementfacilitatororconsultantChangefacilitator Participantssuggesteddecisionrulesforselectingthename.Theterminologyshould:1)beacceptabletotheindividualsorgroupsreceivingtheservice(e.g.thecliniciansandstaff);2)clearlyconveythefunctionandroleoftheindividualandtheactivity;and3)conveysufficientgravitastostimulateandsupportresearchandscientificpublicationsontheactivity.Severalhealthcarepractitionersandcoaches/facilitatorsvoicedsupportforthetermfacilitationsuggestingthattheendusersoftheservice,clinicians,foundthetermcoachsomewhatoff‐puttingandpreferredthetermsfacilitatororenhancementassistantinlieuofcoach.Asoneexperiencedfacilitatorexplained:“Idonotthinkdoctorswillreadilyacceptthattermbecausetheydonotfeeltheyneed'coaching'...whereasanenhancementassistantseemsmoreacceptable.”However,othersfeltthetermfacilitatordidnotadequatelycaptureeitherthelevelofexpertiseorthetypeofsupporttheimprovementprofessionalprovidedtoapractice.Thesedifferencesinpreferredterminologymayalsoreflectunderlyingdifferencesinopinionabouttheroleofafacilitator/coachinapractice.Participantsdidnotreachagreementonasharedvocabularyforthefieldduringthemeetinghowever,thetwotermsreceivingthemostsupportwerepracticefacilitator/tionandpracticecoach/ing.2.2 Whataresomeofthekeylessonslearnedbyparticipantsfromtheirworkinpracticefacilitation?Morethan764practiceshadreceivedfacilitationsupportfromtheprogramsrepresentedatthemeeting.Basedonthisextensiveexperience,meetingparticipantsprovidedalistof79
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lessonslearnedfromtheirworkfacilitatingimprovementinavarietyofpracticeenvironmentsandacrossavarietyoffacilitationmodels.Thelessonscoveredtopicsrangingfromdeterminingpracticereadinesstoproviders’responsetofacilitationandthecontentandprocessoffacilitationmodels.Theyalsoincludedaddressingissuessuchastrainingandsupportingfacilitators,managingfacilitationprograms,usingoffacilitatorstoimplementelectronichealthrecords,andthesufficiencyofcoaching/facilitationforsupportingpracticeimprovement.AcompletelistofthelessonslearnedsharedbyparticipantsisprovidedinAppendixB.2.3 Whatimprovementgoalsareappropriatetopursueusingpracticefacilitation?Goalsforfacilitationsupportedimprovementinterventionsaremostfrequentlysetbytheentityfundingthefacilitationservicesnotthepractice.However,theinvolvementofpracticesindefininggoalsforimprovementinterventionswasseenascriticaltopracticebuy‐inaswellasthesuccessoftheintervention.Thegoalsandobjectivesforafacilitationencountermaybedeterminedbythepractice,byanexternalagentoracombinationofboth.Someparticipantssuggestthatpracticebuy‐intotheimprovementprocess,andasaresultthesuccessofthepracticefacilitationintervention,wasgreaterwhenthegoalstobepursuedbythepracticefacilitationinterventionwereatleastpartlydefinedbythepractice.Improvementgoalspursuedusingfacilitationtypicallyinvolvedincrementalchangesratherthanpracticeorsystemwidetransformativechanges.However,smallerchangeswereoftenseenasapathwaytotransformativechangeovertime.Thegoalspursuedusingfacilitationcanbetransformative,meaningcomprehensivechangesthatimpactmultiplesystemswithinapractice,orincrementalinvolvingafocusonsmaller,moreconfinedchangesthatimpactalimitednumberofsystemswithinapractice.Mostfrequently,facilitationwasdescribedassupportingincrementalchanges.However,thelong‐termgoalevenforfacilitationinterventionspursuingincrementalchangewasoftentransformativechange,butachievedthroughrepeatedsmall‐scaleimprovementactivitiesratherthanthroughcomprehensive,practice‐wideredesign.Specificobjectivesforfacilitationinterventionsvarywidely.Participantsoutlinedawidevarietyofimprovementgoalsandobjectivesthatareappropriatetopursueusingfacilitation(seeTable3).Theserangedfromveryconcrete,definedprocessrelatedgoalsandobjectivessuchasempanelmentorimplementinggroupvisits,tomoresubjective,organizationallyfocusedoutcomessuchascreatinghope.Table3.Goalsandobjectivesforfacilitationinterventions GoalsandobjectivesthatmightbepursuedusingfacilitationProgressionfromreactivetopurposeful,principlebasedcareBuildingcapacitytodopopulationmanagement
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ImplementingcomponentsofthePCMHImplementingtheCCMIncreasingviability/capacityoftheorganizationanditssystems(clinical,administrative,financial,communitylinkages)Implementingstandardizedcare/guidelinesInstillinghopePanelmanagementKeepingchangespatientcenteredEngagingpatientsaspartnersinchangeprocessTranslatingnewevidenceintopracticeHelpingtoIdentifyandspread“bestpractices”CreatingaqualityimprovementsystemforpracticeThepossiblegoalsforfacilitationarepotentiallyinfinite.Becauseofthis,someprogramsfocusfacilitationinterventionsonstrengtheningspecificelementswithinthepractice.Theseelementsareoftenselectedbasedonresearchevidencesupportingtheirrelationshiptoimprovedoutcomes,patientexperienceand/orcosts,orbasedonaparticulartheoryofpracticechangeorimprovement.TwoofthelargestfacilitationeffortsintheU.S.,theImprovingPerformanceinPractice(IPIP)andtheSafetyNetMedicalHomeInitiative(SNI)focusfacilitatorsupportonalimitedsetof“key‐drivers”ofimprovement.InIPIP,facilitatorscalledQualityImprovementCoachesfocustheirworkonhelpingpracticesimplementfourspecificprocesses:usingregistriestosupportpopulationmanagement,deliveringplannedcare,usingstandardizedcareprocessesorguidelines,andprovidingself‐managementsupport.FacilitatorsworkingintheSafetyNetMedicalHomeInitiativefocustheireffortsoneightkeydriversofimprovement.Theseinclude:empanelment,continuousandteam‐basedhealingrelationships,patient‐centeredinteractions,engagedleadership,qualityimprovementstrategy,enhancedaccess,carecoordination,andorganizedevidence‐basedcare.ModelsofchangeusedtoguidefacilitationworkcanincludedriversrelatedtobuildingorganizationalcapabilitiestosupportimprovementsuchasformingaQIteam,prioritizationofimprovementwork,creatingarobustdatainfrastructureandacquisitionofrequisiteknowledgeandskillsinqualityimprovement(QI)methods(Solberg,2006);andspecificchangesmadetoclinicalcareprocessessuchastheuseofregistriesforpopulationmanagement,useofstandardizedcareguidelines,andtheintegrationofself‐managementsupportservices(DeWalt,2010).
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Figure3.Anexampleofachangemodelwith8keydrivers
2.4 Shouldfacilitationbemadeavailabletoallpracticesoronlythosethatmeetcertaincriteria?Participantsviewedfacilitationasascarceresourceandmostsuggestedthatpracticeswillvaryinthedegreetowhichtheycanbenefitfrompracticefacilitation.Themajoritybelievedastrategyisneededforselectingpracticesthatshouldreceivefacilitationservicesinordertoensurethattheresourceisdirectedtopracticesmostlikelytobenefit.Asorganizations,practicescanbeseenasfunctioningatdifferentlevelsofeffectiveness–exemplar,functional,low‐functional,andsurvival.Inaddition,theymayvaryinlevelofeffectivenessacrosstheirinternalsystems‐administrative,clinical,qualityimprovement,andconnectionstothecommunity.ApracticemaybefunctionalinadministrativeandQIsystems,exemplaryincommunityconnectionsandlow‐functionalinclinicalsystems.Figure4defines
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fourlevelsoffunctioningwithinapracticeacrossfiveinternalsystemsthatareaddressedduringfacilitation.Figure4.Thepracticefacilitationecology
Participantssuggestedthatpracticesthathavealreadyachievedhighlevelsofqualityontheirownarenotlikelytoreceivesignificantadditionalbenefitfromfacilitationandsoarenotlikelyrecipients.However,thesepracticesshouldbeactivelyengagedaspartnersinfacilitationinterventionstoserveas“exemplars”andapotentialsourcefor“bestpractices”thatmightbespreadtopracticesthathavenotyetachievedsimilarlevelsofeffectivenessintheirownsystemsandwork.Attheotherendofthespectrum,practicesthatareexperiencinghighlevelsofdisorganizationororganizationalstressarenotlikelytobenefitorbeabletotakefulladvantageofafacilitationinterventionandsoarealsonotlikelycandidates.Differentprogramsusedifferentcriteriafordeterminingeligibilityforfacilitationservices.TheOklahomaHealthcareAuthorityfocusesitsfacilitationresourcesonpracticesthatserveahighvolumeofpriorityorhighneedpatients.Otherstargetsmallerpracticesandpracticesnotengagedinotherformsofimprovementsupportsuchascollaboratives.Stillotherstakeatheorybasedapproach,focusingfacilitationresourcesonearlyadoptersandopinionleaderswithintheclinicalcommunityaspartofadeliberatestrategytosupportspreadofinnovationandmaximizedisseminationofthefocusedimprovements.
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2.5Dopracticesneedtopossessadegreeoforganizational“readiness”toengageinimprovementworkbeforetheycanbenefitfromfacilitation?Almostallmeetingparticipantsagreedthatpracticesshouldmeetcertainreadinesscriteriatoensuretheyareabletobenefitfromapracticefacilitationintervention.Participantssuggestedthefollowingcriteriabasedontheirexperience:
• Supportandengagementofthepracticeleadership(bothclinicalandnon‐clinical)• Abilityofthepracticetodevoteaportionofemployeetimetothechangeenterprise• Change/improvementisapriorityforthepractice• Basicfunctionalityacrossmostorganizationalsystems• Sufficientadaptivereservetomakethechanges(e.g.thetime,money,people)• Demonstrationofwillingnessandabilitytoengageinachangeprocessdetermined
duringthefirst3monthsofafacilitationintervention
Inadditiontotheabove,practicesmayalsoneedadditionalcompetenciestobenefitfrominterventionstargetinghighlyspecializedoutcomes.Forexample,ashort‐termfacilitationinterventiontoimplementpanelmanagementmayrequirethatthepracticehavepriorexperienceusingregistries,accesstoinformationtechnology(IT)support,andgenerallyfunctionaladministrativesystemsinordertobenefit.Someparticipantsnotedthataphenomenondescribedas“changefatigue”isanotherfactorthatshouldbeconsideredwhendeterminingapractice’sreadinessforfacilitation.Becauseofthemanyparallelimprovementandreformactivitiescurrentlytakingplaceinhealthcaretoday,manypracticesaresimplyoverwhelmedbychangeandreluctanttoengageinadditionalworkinthisarea.Readinessassessmentsshouldbeconductedpriortobeginningapracticefacilitationintervention.Theassessmentscanoccurinformallythroughquestionsandanswerswithpracticeleadershipandstaff,formallythroughvalidatedsurveys,orthroughexperientialassessmentduringa“pilot”improvementactivity.Table4containsalistofreadinesssurveysthatparticipantssuggestedasresourcesinthisarea.EightoutofnineprogramsrepresentedatthemeetingroutinelyconductreadinessassessmentsbeforebeginningaPFintervention.Inthreeinstances,theprogramsacceptallpracticesforservices,andthereadinessassessmentfunctionsasapre‐assessmenttoguidethePFintervention.Table4.Resourcesforassessingreadiness ResourcesforassessingpracticereadinessforfacilitationBobiakSN,etal.MeasuringPracticeCapacityforChange:AToolforGuidingQualityImprovementinPrimaryCareSettings.QManageHealthCare(2009)18(4):278.284.
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ResourcesforassessingpracticereadinessforfacilitationGustafsonDH,SainfortF,EichlerM,NuttingPA,DickinsonWP,etal.Developingandtestingamodeltopredictoutcomesoforganizationalchange.HealthServicesResearch(2003)38(2):751‐776.Lehman,W.E.K,JMGreener,DDSimpson.(2002).AssessingOrganizationalReadinessforChange.JournalofSubstanceAbuseTreatment22:197‐209.Ohman‐Strickland,PAetal.(2006).MeasuringorganizationalattributesofPrimaryCarePractices:DevelopmentofaNewInstrument.HealthResearchandEducationalTrust42(3):1257‐1273.Ruhe,MC,CarterC,LitakerD,&StangeKC.(2009).ASystematicApproachtoPracticeAssessmentandQualityImprovementInterventionTailoring.QManageHealthCare18(4):268‐277.2.6 Whatfunctionsdopracticefacilitatorsfillandwhicharemoreeffectiveinproducingdesiredchanges?Accordingtoparticipants,facilitatorsfillthreebasicfunctions:
• todeveloptheorganization’sinternalcapacityforon‐goingimprovement• toguideandmanageimprovementeffortsinthepractice• toprovidetechnicalassistanceintargetedareassuchasimplementingplannedvisits,
optimizingregistryfunctionstosupportpopulationhealth,improvingbillingsystems,andimplementinghealthinformationtechnologywithmeaningfuluseamongothers
Organizationaldevelopmentfocusesprimarilyonenhancingthehumanresourcesandfeedbacksystemswithinapracticethatareneededtosupportqualityimprovement.Facilitationfocusedonprojectmanagementisusedwhenapracticepossessestheknowledgeandskillsneededtoproducethedesiredchangebutneedsassistanceutilizingthis.Technicalassistanceisusedwhenapracticelackstheknowledgeorskillstoachieveadesiredchange.Dependingonthenatureandscopeofanimprovementeffort,facilitationmayserveoneorallofthesefunctionsoverthecourseofanimprovementintervention.Noonefunctionwasperceivedasmoreimportantthantheothersinproducingoutcomes.Whatdoesappeartobeimportant,however,isthegoodnessoffitbetweenthefunctionsundertakenbythepracticefacilitatorandtheneedsofthepractice.Forexample,apracticethatisfocusedonimplementinganElectronicHealthRecordthatisseekingtechnicalassistancerelatedtothismaynotbenefitfromorbesatisfiedwithafacilitationinterventionfocusedondevelopingtheinternalresourcesoftheorganizationforQI,nomatterhowimportantthisactivityistothelong‐termsuccessofthepractice.2.7Whatarethedifferenttypesoffacilitatorsandisonemoreeffectiveorusefulthantheothers?Threecategoriesoffacilitatorswereidentifiedbyparticipants:generalists,specialists,andteams.Ageneralistfacilitatorpossessesexpertiseinprojectmanagement,QImethods,
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resourcebrokering,andorganizationaldevelopment.AspecialistfacilitatoralsoreferredtoasacontentexpertpossessesdeepknowledgeinspecializedareassuchasEHRimplementationandpracticeredesign.Afacilitationteamcombinestheknowledgeandskillsofthegeneralistfacilitatorwithateamofcontentexperts.Ideallytheteamalsoincludesrepresentativesfromthepatientcommunity.Itlookssimilartotheapproachusedintheagriculturalextensionprogramwherearegionalextensionagent(analogoustoageneralistfacilitator)isabletomobilizecontentexpertsfromareauniversitiesandthelargerextensionsystemastheneedarises.Participantsviewedteamapproachestofacilitationasoneofthemoredesirableapproachestodeliveringimprovementsupporttopracticessinceitisunlikelythatanyoneindividualwillpossessthebreadthanddepthofknowledgeandskillsrequiredtosupportallpossibleimprovementgoalsthatapracticemightwanttopursue.Mostprogramsrepresentedatthemeetingutilizegeneralistfacilitatorsorfacilitationteamsintheirwork.2.8 Areinternalorexternalfacilitatorsmoreeffective?Afacilitatorcanbeexternaltoapractice,internaltoapracticeorembeddedwithinthepractice.Aninternalfacilitatorissomeonethatisemployedbythepractice.Oftenthisindividualhasotherdutiesinadditiontosupportingimprovementwork.Anexternalfacilitatorissomeonewhoisemployedbyanoutsideorganization.Oftenthisindividualisfocusedonlyonimprovementwork.Anembeddedfacilitatorissomeonewhooccupiesapositioninthepracticeoveranextendedperiodoftimebutisnotdirectlyemployedbythatpractice.Externalandembeddedfacilitatorswereseenasmoreeffectivethaninternalonesduetothelackofcompetingdemandsfortheirtime,theirabilitytofocusexclusivelyonimprovementwork,andtheirrelativeemotionaldistance.Inaddition,externalandembeddedfacilitatorsoftenareabletosupportanumberofpracticesatthesametime,whichhastheaddedbenefitofallowingthemtodisseminatebestpracticesandlearningacrosstheirgroupofpractices.Incontrast,internalfacilitatorswereseenasvulnerabletocompetingdemandswithinthepracticeenvironmentandsounlikelytobeabletosupportimprovementworkasconsistentlyoverthelongterm.Staffturnoverandattritionwasseenasanotherthreattointernalfacilitationmodels.Theperceivedineffectivenessofinternalfacilitatorsdidnotextendtothedesignationofinternal“changechampions”whoworkinpartnershipwithexternalfacilitatorstosupportimprovement.Theseexternal‐internaldyadsweregenerallyseenaseffective.TheoneinstancewhereinternalfacilitatorswereseenasviablewaswhentheyweresituatedwithinlargeorganizationssuchasanIPAorlargeFederallyQualifiedHealthCenterwithmultiplepracticesites.Inthissituation,althoughthefacilitatormightbeinternalto(e.g.employedby)theparentorganization,heorshewasexternaltotheindividualpracticesites.However,thissituationcomeswithitsownuniquechallenges,andthefacilitator’sconnectiontothecorporateofficemayattimesbeinconflictwithaneedfocusonandadvocateforchangeattheindividualpracticelevel.
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Mostoftheprogramsrepresentedatthemeetinguseexternalorembeddedfacilitators.Twouseanexternalfacilitator‐internalchampiondyad.2.9Howmanyhoursoffacilitationareneededtoachieveimprovementinapracticeandhowfrequentaretheencounters?Amongtheprogramsrepresentedatthemeeting,theamountoftimefacilitatorsspentwiththeirpracticesrangedfromalowof60hourstoahighof200,withanaverageof114hoursacrosstheprograms.Thetotalhoursspentvariedbythespecificimprovementgoalsandunderlyingmodelofchange.Therewasnoclearagreementamongparticipantsastotheminimalnumberofhoursneededtoeffectimprovementinapractice.ParticipantsagreedthatcomprehensivechangessuchasPCMHtransformationscanrequireupto5yearstoachieveandasubstantialnumberoffacilitationhours.Participantssuggestedthatasaruleofthumb,mostimprovementprojectstakeuptothreetimeslongerthanoriginallyestimatedanditcanbeusefultoapplythismultiplierwhenplanningpracticeimprovementinterventions.Mostprogramsprovidedservicesweekly;threeusedamonthlyschedule.Allprogramsallowedforadhocsupporttooccurbetweenscheduledsessions.Programsprovidedtheseservicesthroughacombinationofin‐personvisits,email,andtelephonesupport.2.10Arelong‐termorshort‐terminterventionmodelsmoreeffective?Facilitationschedulesgenerallyfallintooneoftwocategories:short‐termandintensiveorlonger‐termandlessintensive.Short‐terminterventionstypicallytakeplaceover30daysorless,andinvolvedailyall‐daypresenceofthefacilitator.Longer‐terminterventionstypicallytakeplaceover6to12months,butcanlastaslongas24months.Thesetypicallyinvolveshortervisitsrangingfromafulldayeveryotherweektoa½dayaweek.Someparticipantssuggestedthatintensiveschedulescanoverwhelmpractices,especiallysmalleronesthatlacksufficientstaff,andsocanbelesseffectiveintheseinstances.Similarlytheysuggestedthatlonger,lessintensiveinterventionperiodsmayalsoallowpracticesthetimeneededto“metabolize”changesanddevelopcapacityandnewadministrativeandclinical“habits”thataremorelikelytobesustainedoverthelongterm.Rapidintensiveinterventionsmayrunagreaterriskofbeingshortlived.Regardlessofdeliveryschedule,boostersessionsprovided8monthsormoreafterthefacilitatedimprovementinterventionwereseenasimportanttoreinforcechangesandensuresustainabilityoftheimprovements.Amongtheprogramsrepresentedatthemeeting,facilitationinterventionsrangedinlengthfrom24to96weeks,withanaveragelengthof51weeks.Amongtheprogramsrepresented,8
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out9providedboostersessionstopracticestohelpcementchangesimplementedduringthemainpartofthefacilitationintervention.2.11Isdistancefacilitation(providedthroughemail,telephone,webconferences)aseffectiveason‐sitefacilitation?Isthereanoptimalmixofdistanceandon‐sitedelivery?Facilitationsupportcanbeprovidedatadistanceusingtechnology(telephone,email,videoconferencing,webinars)orin‐personatthepracticesite.In‐personfacilitationhasanumberofdistinctadvantagesoverdistancefacilitation.Itcanincreasetheecologicalvalidityofthefacilitationsupport,supportdevelopmentoftrustingrelationshipswithkeyindividualsinthepracticethatareconsideredbymanyasacriticalaspectofanyeffectivefacilitationeffort,allowformoreintensiveassessmentanddiscovery,andenablethefacilitatortoprovidemuchneededhands‐onassistancetothepracticeinstrategicareas;however,itisalsomorecostly,andcanbeintrusiveinthatitrequiresindividualstoleavetheirdailytaskstomeetwiththefacilitator.Distancefacilitationprovidedthroughtelephone,emailsupportandweb‐basedsolutionssuchasvideoconferencingandwebinarsislesscostly,eliminatesdrivetimewhichcanbeacriticalfactorinsprawlingurbanandruralcommunities,andisbelievedbysometoreduceover‐dependencybythepractice.Howeveritisalsolesspersonal,canbelessmotivatingforpracticepartnersandeasiertopushaside,andimpedesdeliveryofhands‐onsupport.Inreality,mostprogramsmixdistanceandon‐siteapproaches,emphasizingonemorethantheother.Programsthatuseprimarilydistancemethodsmaystarttheprogramwithaninitialsitevisit.Programsthatconsistmainlyofon‐sitesupportmayprovidesupportusingdistancetechnologiesbetweensitevisits.In‐personsupportwasbyfarthemostfrequentlyusedmodalityamongprogramsrepresentedatthemeeting.Thepercentofsupportprovidedin‐personrangedfromanestimatedlowof45%toahighof95%acrosstheprograms,withanaverageof65%facilitatorsupportprovidedin‐person.Emailsupportwasthesecondmostusedmodality,withpercentofcontactsconductedthroughemailrangingfrom2%to30%acrosstheprogramswithanaverageof15%.Percentofsupportdeliveredtelephonicallyrangedfrom0%to15%withanaverageof12%.Internetconferencingwastheleastfrequentlyusedmodality,rangingfrom0to10%amongtheprogramsrepresentedatthemeetingforanaverageof3%.Thereislittletonorigorousresearchavailableyettosuggestaclearadvantageofonemodalityoveranother;andmostdecisionsabouttheuseofdistancevs.in‐personsupportarebasedoncostandstaffingconsiderationsratherthananunderlyingtheoryofchangeorthefindingsfromeffectivenessresearch.Amongmeetingparticipants,interventionsdeliveredusingmainlydistancetechnologiessuchasthephoneandwebconferencingwereseenaslesseffectivethanon‐siteprograms.Distance
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approacheswereseenasthemethodofchoiceonlywithasmallgroupofpracticesthatwerealreadyhighlymotivatedtochange,andalreadypossessedtheadaptivereservesneededtoeffectthechangethemselves.Intheseinstances,facilitatorsservedtoprovideexternalaccountabilityandtomotivatethepracticestokeepmovingforwardontheirimprovementprojects,butprovidedlittledirectintervention.Afinalnoteontheuseoftechnologyinfacilitation.Currently,distancetechnologyisusedinfacilitationinterventionstolowercostsandincreasethenumberofpracticesafacilitatorcansupport.Limitedconsiderationhasbeengiventonewertechnologiessuchassocialnetworking,siteslikeFacebook,orserviceslikeSkypeordisseminationinfrastructuressuchasthatofProjectECHOmightbeharnessedtoincreasetheactualeffectivenessoffacilitatedimprovementinterventions.2.12Canpracticesbecomedependentonfacilitatorsandhowshouldthisbemanaged?Dependencybetweenpracticesandfacilitatorsfollowsapredictabledevelopmentalcourse.Greaterlevelsofdependencyareexpectedandconsiderednormalatthestartofanintervention.Asthepracticebuildsitsowninternalcapacitytosupportimprovementwork,thisdependencyisexpectedtolessen.Onepractitionerprovidedanexcellentanalogyofpracticefacilitation,describingitasatypeofself‐managementsupportforpractices.“Whatpracticesreallyneedistheirownformofself‐managementsupportthatisfocusedonhelpingusdeveloptheknowledgeandskillsandhabitsneededtomanageourownadministrativeandclinicalfunctioningmoreeffectively.Thegoalofself‐managementsupportistoempowerapatienttobebettermanagersoftheirownillnessandlives.Apatientstillneedstoseetheirdoctorperiodicallytohelpthemstayontrack,butbetweentimestheydoalmostallofthemanagementthemselves.Thesamecouldbesaidoffacilitation.”Continuingdependencypastacertainpointinaninterventionisviewedasproblematicandsuggestiveofalesseffectiveintervention.Concernsaboutdependencyinfluenceddecisionsaroundscheduling,intensityanddurationoffacilitationinterventions,andwereoftenaddressedbyprogramdesignsthattaperedsupportprovidedtopracticesovertimeasastrategyforweaningpracticesfromthefacilitator.Howeveritisnotclearthatpreventingdependencyactuallyimprovesoutcomes.Infact,thepresumedcorrelationbetweendependencyandpoorinterventionoutcomeshasnotbeenestablished,andthenatureandimpactofdependencyinthesecontextsisnotyetunderstood.Infact,dependencymaybeadaptiveinsomecontextsandmayactuallysupportbetterratherthanworseoutcomes.Facilitationmodelsthatprovideconsistentsupportandareaccessibleasneededoverextendedperiodsoftimemaybemoreeffectiveatsupportingtheorganizationaldevelopmentthatisrequiredtotransformcare.Anothercomplementaryandpotentiallymoreeffectiveapproachforaddressingdependencyistoincorporate“empowerment”approachesintothefacilitationmodel.Theseemphasize
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buildingtheknowledgeandskillsoftheparticipantover“doingforthem.”Theprocessisnuancedandrequirestheabilitytodeterminewhendirectintervention(doingfor)apracticeisneededandwhenthefocusshouldbeonbuildingthepractice’sownadaptivereserveforimprovement.2.13Howmanypracticesshouldafacilitatorsupportatanyonetime?Facilitationprogramsvariedwidelyinthenumberofpracticesafacilitatorsupportedatanyonetime.Programsrangedfroma1:1toa1:24facilitatortopracticeratio.Themajorityofparticipantsatthemeetingsuggesteda1:6to1:8ratioforearlystageinterventionsasoptimal.Asaninterventionprogressesandpracticesbuildtheirinternalcapacityforimprovementwork,afacilitatorcansupportalargernumberofpractices,uptoasmanyas30.Theoptimalratiooffacilitatorstopracticeswillvarybasedonthelengthoftheprogram,themodalityofservicedelivery,andtheparticularimprovementgoals.Short‐term,intensiveinterventionsdeliveredpredominatelyon‐siterequirelowfacilitatortopracticeratios.Facilitatorsdeliveringlonger‐term,lessintensiveinterventionsoronesutilizingdistancetechnologiesasopposedtoon‐sitedeliveryareabletosupportalargernumberofpractices.It’simportanttonotehowever,thatarecentmeta‐analysisoffacilitationstudiescarriedoutbyBakersfield(2009)foundthattheeffectivenessoffacilitationlessenedasthefacilitatortopracticeratioincreased.2.14Canfacilitationbeprovidedasastand‐aloneserviceorshoulditoccurinthecontextofmorecomprehensiveimprovementefforts?Mostparticipantssuggestthatfacilitationismosteffectivewhenitoccursinthecontextofcomprehensiveimprovementeffortsthatincludepaymentreformandotherstrategiessuchaslearningcollaboratives,benchmarkingandacademicdetailing.Anumberofprogramsacrossthecountryareoccurringinthecontextoflargerimprovementeffortsthatincludeallofthesecomponents.Forexample,theIPIPinitiativeinPennsylvaniaandeffortssuchasBlueprintVermontarecombiningfacilitation,collaborativesandstate‐levelpaymentreformwithverypromisingresults.Severalparticipantsexpressedconcernthatfacilitationnotbeviewedasapanaceaorassufficienttoproducechangealone.Anumberofmeetingparticipantsfeltstronglythatcomprehensive,scalableimprovementcanonlybeachievedinthecontextofpaymentreform.Othersfeltthatimprovementcanoccurwithoutthis,butthatitsscaleandsustainabilitywillbelimited.Manyoftheaspirationalmodelsofprimarycarehaveanegativeimpactonthefinancialviabilityofindividualprimarycarepractices.Toreallyachievesubstantialimprovementandchange,paymentmustbealignedsothatitsupportsandrewardsadoptionofdesiredtreatmentsandcareprocesses.Practicesthatviewimprovementactivitiesasimprovingtheirfinancialviabilitywillbemuchmorelikelytoengageindesiredimprovementworkandtosustainthechangesovertimethanthosethatdonot.LeifSolbergpointsoutthatadoptionofnewtreatmentsandproceduresinspecialtycaresettingsoccurmorerapidlyandwithlittleexternalpressurebecauseadoptionofthesenewtreatmentsandproceduresimprovenotonlyqualityandproviderreputation,butalsotheirbottomline.
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Collaborativesprovidesubstantivelydifferentbutcomplementaryformsofsupporttofacilitation.Wherefacilitationexcelsatdeliveringecologicallyvalidandtailoredorganizationalandtechnicalassistancetoapractice,collaborativesprovideopportunitiesforsharedlearning,ideaexchangeamongpeers,andstimulatepositivecompetitionamongacommunityofpeersthatcancreatemotivationandpriorityforchange.Amongtheprogramsrepresentedatthemeeting,themajority(80%)involvedtheuseofadditionalQIstrategies.Ofthese,halfcomplementedfacilitationwithtraditionallearningcollaboratives;andhalfaddedlocallearningcollaborativesinvolving3orfewerpractices.Otherstrategiesusedincludedpaymentreform,academicdetailing,benchmarking,expertconsultation,sitevisits,socialnetworkingatnationalmeetingsandprovisionofITsupport.2.15Whatistheusualcourseforaninterventionusingpracticefacilitation?Practicefacilitationinterventionstypicallyprogressthroughfivestages:readinessassessment,orientationandteamformation/engagement,practiceassessmentandgoalsetting,activeimprovementefforts,andcompletion.Withinthese,thespecificsofeachfacilitationinterventioncanvarywidelydependingontheneedsandgoalsofthepracticeandimprovementinitiative.Whilenotallfacilitationeffortsprogressthroughthesesamestages,manydo.Stage1.ReadinessAssessment.Thisinvolvestheinitialcontactwithapracticeandassessmentofboththepractice’sdesiretoworkwithafacilitatorandtheorganizational“readiness”toengageinafacilitatorsupportedimprovementeffort.Thisstagecanlastfrom1dayto3months.Stage2.Teamformation/engagementandorientation.ThisincludesgeneraladministrativeactivitiessuchascompletingMemorandaofUnderstandingandexecutingBusinessAgreements.Itmayalsoinvolvethefacilitatorleadinganorientationtrainingforthepracticeorfacilitatinganacademicdetailingsessionfeaturingpeertopeerlearning.Averyimportantactivityduringthisstageisorientingthepracticeonhowtouseafacilitator,clarifyingexpectationsofwhatcanandcannotbeaccomplishedusingfacilitation,andoutliningtheirresponsibilitiesandrolesintheprocess.Otheractivitiesincludeidentifyingdefactoleadersinthepracticethatcanhelpeffectuateimprovementefforts.Finally,duringthisphasethefacilitationworkswiththepracticetoidentifythePracticeImprovementTeamfortheintervention.Stage3.Practiceassessmentandgoalsetting.Duringthisstage,thefacilitatorconductsanassessmentofthepracticeappropriatetothegoalsoftheimprovementeffort.Avarietyoftoolsexistforassessingpractices.TheAHRQCCMTookitprovideslinkstoavarietyoftools.ClinicalMicrosystems,GroupHealthandIHIamongothersalsohaveexcellentresourcesforconductinginitialassessments.Findingsfromtheassessmentarepresentedasafirststeptowardssupporting“datadriven”change.Facilitatorswillneedtoworkwithpracticesto
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addressconcernsaboutthereliabilityandvalidityofdatacurrentlymaintainedbythepractice,andworkwithpracticememberstodevelopdatacollectionprocessesthatproducereliableandvaliddataforuseinimprovementwork.Thefacilitatorwillalsoneedtoworkwithpracticememberstotestcurrentassumptionsabouttheirfunctioningagainstthedataandagainstexternalbenchmarks.Duringthisstagethefacilitatormaycreateaninventoryofdatathepracticeiscurrentlycollecting,set‐upsystemsforregulardatacollectionthatcanbeusedtoguidechangeandtrackprogress,andpresentfindingstotheimprovementteaminordertodetermineimprovementgoalsfortheintervention.Stage4.Duringstage4,thefacilitatorassiststhepracticetobuildinternalcapacityforimprovementandtopursuespecificimprovementprojectsbasedonfindingsfromstage3.Duringthisstage,dependingontheneedsofthepracticeandtheparticularimprovementproject,thefacilitatormaytrainthepracticestaffandprovidersonQImethodsandstrategies,manageimprovementprojectsandworkwithmemberstobuildskillsinthisarea,providetechnicalassistanceinspecificareas,bringincontentexpertsasneeded,facilitatelocallearningcollaborativesandacademicdetailinginterventions,andincorporatemembersofthepatientcommunityinthechangeprocessasappropriate.Thefacilitatorwillprovidemonthlydatareportstrackingprogresstowardsstatedgoalsandworkwithmemberstobuildresourcesthatarekeydriversofpracticeimprovementthatcanbesustainedaftertheintervention.Stage5.Duringstage5,thefacilitatorbeginsaphasedwithdrawalfromthepracticeandtransfersmoreandmoreofthecoordinatingfunctionstopracticestaff.Thefacilitatorcontinuestobeavailabletoprovidesupportonanasneededbasis,provideboostersessions,andreengageonnewimprovementinitiatives.Aspartofthisprocess,facilitatorsmaydrawonparticularchangepackagessuchasAHRQ’sCCMToolkit,ImprovingPerformanceinPractice’schangemodel,TransforMed’sPCMHadvancementmaterials,theCaliforniaHealthCareFoundation’sHITimplementationprocess,orthoseavailablethroughIMACTBCtonameafew.ThefacilitatormayrelyonstructuredimprovementapproachessuchastheModelforImprovement,SixSigmaorLEAN;orguidetheirworkbasedonaparticulartheoryofchangeorpriorexperienceinworkingwithsimilarpractices.
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Figure5.Typicalstagesofapracticefacilitationintervention
2.16 Whatindividualsmakethebestfacilitators?Practicefacilitatorsneedexcellentinterpersonalandcommunicationskills.Inadditiontheyneedtheabilitytoapproachapracticeinacollaborativeandhumblemannerwithoutusingqualityimprovementjargon,andshouldbecomfortableandeffectiveworkingwithindividualswithvaryinglevelsofeducationfromhighschoolleveltomastersanddoctoraldegrees.Likelytheyalsoneedtounderstandempowermentconceptsatadeeplevel.Participantsweresplitonwhetherafacilitatorneedspriorexperienceworkinginaclinicalsettingoraclinicaldegreetobeeffective.Whilesomefeltthatthisexperiencewasessentialforthefacilitatortobeeffective,othersfeltthatthisknowledgeandexperiencecouldbeacquiredonthejobandthatextensiveclinicalexperienceinsomeinstancesmightimpedeeffectivefacilitation.IndividualswithbackgroundsinPublicHealth,SocialWork,Nursing,CounselingandPsychologywerethoughttobewellsuitedforfacilitationbecauseoftheirbasicskillsandknowledgein
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humanandgroupinteractions.Individualfromabusinessbackgroundororganizationalconsultingmayalsobewellappropriate.Inaddition,somefacilitationprogramshaveusedtrainedlaypersonswithsuccess.Participantsweresplitabouttheuseofphysiciansasfacilitators.Whiletheypossessfirsthandclinicalexperiencethatcanmakethemeffectivefacilitators,theirdeepinvolvementintheprofessionmayalsolimitthewaystheythinkaboutproblemsandtheirpotentialsolution.Inaddition,pullingaclinicianoutofpracticewhenthereisashortageofprimarycarephysiciansandnursesalsowarrantsthought.Physiciansandotherswithvitalclinicaltrainingmaybestbeusedtoprovidepeer‐to‐peersupportthroughacademicdetailingandcontentexpertiseinparticularareas,andashighlevelexpertsonafacilitationteam.Amongtheprogramsrepresentedatthemeeting,themajorityofprograms(66%)usedRNs/PAs/NPsasfacilitators.Fifty‐fivepercentofprogramsusedMPHs;44%usedMSWsasfacilitators.Only22%ofprogramsusedMBAsordoctoraldegreedindividuals(MDsandPhDs)asfacilitators.Oneprogramusedindustry‐basedspecialists(automotive)anotheralsousedOT/PTs,andathirdprogramengagedmedicalstudentsandpre‐medstudentsasfacilitators.2.17 Whatcorecompetenciesandskillsdofacilitatorsneedtohavetobeeffective?Facilitatorsneedtopossesscompetenciesinsevenareas:basicknowledgeofprimarycarepracticesandvarioustheoriesofpracticeandorganizationalchange,competenciesintheuseofvariousQImethodsandprojectmanagementskills,competenciesinprovidingtechnicalassistancetopracticesinkeyareasincludingtheuseofregistriesandHITtosupportpopulationmanagement,providingstandardizedcareforkeyhealthconditions,andself‐managementsupport,competenciesintheuseofdatatodrivechangeandtrackprogress,competenciesincommunicationandconflictmanagement,andcompetenciesinself‐managementandprofessionalism.Figure6outlinesthecompetenciessuggestedbyparticipantsatthemeeting:Figure6.Corecompetenciesofageneralistpracticefacilitator GeneralKnowledge
• Theoriesofchange,diffusionofinnovationandcomplexity• Empowermenttheoriesandstrengthbasedapproachestoassessmentandintervention• Adultlearningtheory• ChronicCareModel• ModelforImprovement• Currentaspirationalpracticemodels(Ex:PatientCenteredMedicalHome)• Knowledgeofdifferentpracticeenvironments,models,structures• Knowledgeofthelocalhealthcarecommunityandresourceenvironment• KnowledgeofvariouschangepackagessuchastheAHRQCCM,IPIP,etc.
Knowledgerelatedtothedesignanddeliveryoffacilitation
• Knowledgeoffacilitationapproaches,modelsandevidenceofbestpractices• Orientingandbuildingpracticecapacitytousefacilitators
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• Managingpracticeexpectationsofthefacilitator• Managinglong‐termrelationshipswithpractices• Determiningfacilitationschedule• Determiningmodalitymix• Problemsolvingandterminatingineffectivefacilitator‐practicepartnerships• Formingandmanagingapractice‐specificfacilitationteam• Managingabudgetforafacilitationintervention• Participatinginlearningcommunitiesoffacilitatorstospreadinnovationsandbest
practices
Knowledgeandskillsinqualityimprovementmethods• FormingandfacilitatingQIteams• DesigningchartersforQIteam• Conductingworkflowanalyses• Conductingchartauditsandbenchmarking• UsingPlanDoStudyAct(PDSAs)cycles• GeneralunderstandingofLEAN,SixSigmaandotherapproaches• Developingandimplementingimprovementworkplans• Facilitatinglocallearningcollaboratives• Supportingimplementationofstandardizedcare(guidelines)• Engagingpeertopeeracademicdetailingsupportasneeded• UsingtechnologyasaQItool• Skillsinbuildingcompetenciesinpracticestaffintheseareas
Projectandpeoplemanagementskills
• Generalprojectmanagementskills• Effectivecommunication• Skillsinconductingeffectivemeetingsandpresentations• Managingconflictandproblemsolving
Knowledgeandskillsinobtainingandusingdatatodriveimprovement
• Developingadatainventory• Accessingandusingpracticedatatoidentifyareasforimprovement• Accessingandusingpracticedatatotrackprogresstowardsimprovementgoals• Identifyingandremediatingthreatstothereliabilityandvalidityofpracticedata• Skillsinusingqualitativedatatosupportimprovementwork• Skillsindesigningandadministeringsurveys• Skillsinconductingkeyinformantinterviews• Skillsinmanagingdataandconductingbasicanalysissuchasfrequencies,main
tendencies,andcreatingtrendlinesandruncharts
Knowledgeandskillstoprovidetechnicalassistanceincriticalareas• UsingregistriesandHITtosupportpopulationmanagement
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• Supportingstandardizedcare• Self‐managementsupport• EvaluatingEHRs• Translatingcomparativeeffectivenessfindingstopractice• Additionalareasbasedonpolicy,payer,funder,project,practice,community
FacilitatorEvaluation,ProfessionalismandEthics
• KnowledgeofHIPPAandhumansubjectsandpracticeconsistentwiththis• Adherencetoprogramrequirementsandpoliciesandprocedures• Adherencetoclientpracticepoliciesandprocedures• Continuousself‐evaluationandprofessionaldevelopmentthroughsupervision,training
andexchangewithotherfacilitatorsandQIpersonnelinotherindustries• Self‐careincontextofahighstressworkenvironment• Documentingfacilitationencountersandprogress• Monitoringfidelityofthefacilitationintervention• Evaluatingprogressandeffectivenessofthefacilitationinterventionagainstpre‐defined
benchmarksBrendaFraseroneofthemeetingparticipantshasdevelopedasetofcompetenciesforfacilitatorsthatisavailableonlineat:http://www.qiip.ca/userfiles/QIIP%20‐%20QI%20Coach%20Competencies%20Launch%20Jan‐10.pdfAnalternativesetisoutlinedinImplementingPracticeCoachingandtheChronicCareModelinPracticesServingVulnerablePopulations(Colemanetal,2009).2.18 Whatisthebestwaytosupportandtrainfacilitators?Meetingparticipantsagreedthatfacilitatorsshouldcompletespecializedtrainingdesignedtoproducethecorecompetenciesrequiredtobeaneffectivefacilitator.Trainingprogramsvariedwidelyinlengthandscoperangingfrom2‐dayworkshopstomulti‐yearprofessionaldevelopmentcourses.Trainingshouldbedeliveredusingadulteducationmethods.Aonetotwoweekapprenticeshipwithanexperiencedfacilitatorwasseenasausefulbutnotessentialpartofthetraining.Trainingshouldbetailoredtothefacilitators’backgroundandpriorexperience.Facilitatorswithoutpriorclinicaltrainingorexperienceworkinginprimarycaresettingsshouldreceiveadditionalinstructionintheseareasandwhenpossible,gainexperienceinthesesettingsthroughaninternship,orfieldexperiencethattakesplaceconcurrentwiththeirinitialworkwiththeirpractices.Anumberoftrainingprogramsareavailableforfacilitators.ApartiallistingoftheseprogramsisprovidedinTable5.
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Table5.ApartiallistofPFtrainingcurriculaandresources
Source Title Year WebsiteOklahoma
Practice‐BasedResearchNetwork
(PEA)PracticeEnhancementAssistantManual
2009‐2011
www.okprn.org
DartmouthCoach‐The‐
Coach
DartmouthClinicalMicrosystemImprovementCurriculum 2006
www.clinicalmicrosystem.org
HealthcareResearchand
Quality
IntegratingChronicCareandBusinessStrategiesintheSafetyNet:ApracticeCoachingManual
2009www.AHRQ.gov
IMPACTBCPracticeSupportProgramFacilitatorHandbook 2007
www.impactbc.ca InstituteforHealthcare
ImprovementPrimaryCarePracticeCoach
2010
www.ihi.org/IHI/Programs/ProfessionalDevelopment/PrimaryCarePr
acticeCoach.htm L.A.Net PracticeFacilitatorPresentation
2010http://www.lanetpbrn.net/resourc
es/practice‐facilitation (PCMH)MainePatientCenteredMedicalHome
QualityImprovementCoachDescription 2009
www.vpqhc.org
VIPStudy(RushUniversity)
VIPStudyNurseCoachMaterials2007
http://www.rush.edu/professionals/vip/
QualityImprovement&
InnovationPartnership
(QIIP)
QualityImprovementCoachCompetencies:
BuildingQualityImprovementCapacity&CapabilityinPrimary
Healthcare
2009www.qiip.ca
OklahomaSoonerCare
PracticeFacilitationTrainingGuide 2008
www.commonwealthfund.org/.../Oklahomas‐SoonerCare‐Health‐Management‐Program.aspx
L.A.Net SafetyNetFacilitatorTraining2010
www.lanetpbrn.net
Inadditiontostandardintroductorytraining,facilitatorsneedregularsupervisionandtraining,andmeetingswithotherfacilitatorsthroughsupportgroupsandlearningcollaboratives.Thesupervisionandgroupsessionsshouldservemultiplefunctionsincludingprovisionoftraining,provisionofemotionalandsocialsupport,andcollaborativelearningamongfacilitatorsthatsupportsdiffusionofinnovationsacrossthecommunityofpracticesservedbythefacilitators.Individualswhoprovidethesupervisionshouldbecompetentinempowermentstrategiesandusethesestrategieswhensupervisingthefacilitators.Bydoingthis,thesupervisormodelstheempowermentapproachesthatthefacilitatorinturnshouldbeusingtosupporthisorherpractices.
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Mostoftheprogramsreportingtrainedtheirfacilitatorsin‐house.Oneprogramalsoutilizedexternaltrainingresources.2.19Howmuchdoesitcostperpracticetoprovidefacilitationsupport?Costsforpracticefacilitationvarywidelyanddependonthenumberofservicehoursanddegreeandleveloftrainingofthefacilitator.Costsrangefromalowof$5,000toahighof$50,000perpractice.Themajorityofmeetingparticipantsreportedanaveragecostperpracticerangingfromunder$5,000to$15,000.Atpresent,facilitationprogramsarefundedmainlythroughfederalgrantsandcontracts,foundationgrants,fundingfromstateMedicaidorMedicareprograms,andhealthplans.Amongprogramsrepresentedatthemeeting,themostfrequentsourceoffundingwasfederalgrantsorcontracts(44%),followedbyfoundations(33%).Oneprogramreceivedsupportthroughastatecontract,andoneprogramwassupportedthroughacountylevelcontract.Fewerprogramsweresupportedbyfundingfromhealthplans.Nonewerefundedthroughdirectpaymentbypracticesthemselves.Thelatermaybeareflectiononthelackoffinancialresourcesofthepracticesoralackofperceivedvalueforfacilitationbythepractices.TherecentlyproposedNationalPrimaryCareExtensionServiceandtheHITECHRECsarelikelytomakeuseoffacilitationservicesandmayprovideasourceoflongertermfundingforfacilitationservices.PermemberpermonthfundingthroughhealthplansandCMSisanother,potentiallylong‐termsourceoffundingfortheservices.Finallyinthecontextofpaymentreformwhereimprovementactivitiesundertakenbypracticesarecapableofproducingrobustfinancialreturnsoninvestment,atsomepointpracticesthemselvesmaybecomeinterestedindirectpurchaseoffacilitationservices.2.20 Howshouldfacilitationprogramsbeevaluated?Themajorityofprogramsrepresentedatthemeetingconductformalevaluationsoftheirprograms’outcomes.Ofthosereporting,themostcommonlymeasuredoutcomeswerequalitymeasures(HEDISetc)(100%),followedbyassessmentsofdegreeofimplementationoftheCCM(77%),changesinorganizationalcapacity(66%),changesinpatientsatisfaction(55%),cost(55%),impactonPCMHlevel(44%),andchangesinprovidersatisfaction(44%).Only22%ofprogramsreportingindicatetheyevaluatetheimpactoffacilitationonpatientoutcomes.Participantsagreedthatevaluationsoffacilitationinterventionsshouldfocusonpractice‐levelvariablessuchasimprovementsinprocessesofcare,qualitymetrics,patientexperience,andchangesinapractice’sorganizationalcapacitytoimprovecarequality.Othermetricsmightincludechangesinpatientandstaffsatisfaction,andchangesinthehealthcareorganization’sfinancialviability.Patientoutcomes,althoughtheultimategoalofQIinterventions,werenotconsideredappropriateoutcomemeasuressinceasignificantamountoftimeisoftenrequiredforchanges
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incarequalitytomanifestinimprovedpatientoutcomes.Inaddition,theconnectionbetweenimprovementsonqualitymetricsandimprovedpatientoutcomesisstillnotconfirmed.Goalattainmentscalingandstrategiesthatallowforevaluationtailoredtothepractice’sgoalsandneedsmaybeappropriatetousewhenevaluatingfacilitationinterventionsthatarebasedonpractice‐definedgoalssincetheyallowsformoreflexibilityindefiningoutcomes,andallowforcomparisonacrosspracticeswithdifferentgoals.Inordertoadvancethefield,Itmaybebeneficialtoidentifyacoregroupofsharedoutcomemeasuresthatcouldbeusedtocompareoutcomesacrossdifferentfacilitationprograms.Thiswouldhelpdeterminewhatapproachesarethemosteffectiveunderwhatconditionsandwithwhichpractices.2.21 Dodifferencesinpracticesize,locationorstructureimpacttheeffectivenessoffacilitation?Facilitationprogramsrepresentedatthemeetingsupportavarietyofpracticetypes.Mostprovidefacilitationservicestopracticeslocatedinurbanenvironments,morethanhalfsupportsuburbanpractices,andmorethanhalfsupportruralpractices.Themajorityprovideservicestopracticeswithonly1FTEprimarycareprovider,85%supportsmallpractices(upto5FTEPCPs),71%supportmediumsizedpractices(upto10FTEs),and71%supportlargerpractices(11ormorePCPFTEs).Eighty‐sevenpercentofprogramssupportresidencytrainingsites,62%percentworkwithCommunityHealthCentersandFederallyQualifiedHealthCenters,50%supportprivatepractices,25%workwithfacultypractices,and12%withpublichealthcenters.Participantsagreedthatvariationsinthewayapracticemakesmoney(feeforservicevs.capitated),organization(CommunityHealthCenter,otherstaffmodel,independentsoloorgrouppractice),professionalmix(MD,useofmid‐levels,nursingstaff)andsize(small,mediumandlarge)allaffectthemotivationanddriversforimprovementinthepracticeincludingthebusinesscaseforengaginginimprovement,theselectionofimprovementgoals,thefeasibilityofthesegoals,andtheresourcesavailabletosupportimprovementactivities.Participantsagreedthatthesevariationshaveimportantimplicationsforthescopeoffacilitatorknowledge,facilitatorgoalsandstrategies,butalsobelievethatthecoresetoffacilitatorskillsremainconstantacrossthesevariations.2.22 Whatresearchquestionsshouldbeansweredaboutfacilitationinorderincreaseitseffectiveness?Researchwillplayanimportantroleinguidingdevelopmentofeffectivepracticefacilitationinthefuture.Researchquestionswereidentifiedfromrecommendationsbyparticipantsandthroughdiscussionatthemeeting.Questionswereidentifiedinsixareas:researchapproaches,effectiveness,cost,organization/structure,reach,andknowledgeneededtoscale
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upfacilitationservices.Itwillbeimportanttodeterminewhichamongthesewouldbegoodtoknowbutnotessential,andwhichareessentialtoadvancethefield.2.23Suggestedresearchquestions Researchapproaches
Sharedmeasuresshouldbeidentifiedforuseacrossprograms.Whatsharedmeasurescanbeusedforevaluatingacrossallfacilitationinterventionsthatcansupportcrossprogramcomparisonsthataremeaningfulinansweringarangeofquestionsabouttheeffectivenessofdifferentinterventionapproaches?
Reach
Whichpractices/providersarewillingto/notwillingtoparticipateinafacilitationinterventionandwhy/whynot?
Whichhealthplansandotherpotentialpurchasersarewillingto/notwillingtofundfacilitationservicesfortheirprovidersandwhy/whynot?
Whatistheirrelativesatisfactionwithfacilitationvs.otherapproaches?
Effectiveness
Whatfacilitationmodelsaremosteffectivewithwhatoutcomesandtypesofpractices?o Internalvs.external?o Teamvs.individual?o Interventionswithpractice‐definedvs.externallydefinedgoals?o Shorttermvs.long‐term?o Lowintensityvs.highintensity?o Distancevs.on‐sitefacilitationvs.combination?Whatisoptimalmix?o Facilitationaloneorincombinationwithotherinterventions?o Practice‐ledagendavs.externallydefinedagenda?o Boostersornoboostersessions?
Prescribed/scriptedinterventionvs.responsive? Howdopracticesize,paymentmix,structure,location,patientpopulationaffectthe
impactoffacilitation? Whatistheminimaleffectiveamountoffacilitationforachievingwhatoutcomes? Whatistheoptimalfacilitatortopracticeratioandunderwhatconditions? Howlongaretheeffectsoffacilitationmaintained? Arethere“sleepereffects”forafacilitationintervention? Whichismoreeffective,facilitationorcollaborativesoracombinationandunderwhat
conditions? Whatadditionalvaluedoesfacilitationbringtocomprehensiveimprovementefforts?
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Effectivenessindisseminatingcomparativeeffectivenessfindings
• Canfacilitationbeusedtodisseminate/translatecomparativeeffectivenessfindingsinprimarycare?Ifso,whatmodelsaremosteffectiveunderwhatconditions?
• Whatfindingsareappropriatetodisseminateusingfacilitation?Whatarebestdisseminatedusingothermethods?
• Whatistherelativecostbenefitcomparedtootherstrategiesofdissemination?• Isfacilitationalonesufficientordoesitneedtooccurinthecontextofamore
comprehensivedisseminationeffort?
Staffing,StructureandManagement• Whataretheadvantagesanddisadvantagesofdifferentorganizationalstructuresfor
housingfacilitationprograms?Aretherepotentialbestpracticesinthisarea?• Whatstructures/resourcesareneededtohelpfacilitatorsdisseminatelearningwith
eachotherandotherpractices?Aretherepotentialbestpracticesinthisarea?• Whatisthebestwaytotrainandsupervisefacilitatorsthatiscosteffectiveand
potentiallyscalable?Aretherepotentialbestpracticesinthisarea?• Arefacilitatorswithclinicalbackgroundsmoreeffectivethanthosewithout?• Shouldatrainingandcareerpathbecreatedforfacilitators?Ifso,whatshouldthislook
like?Aretherepotentialbestpracticesinthisarea?• Whatreportingsystemsandstructuresareneededtoassurethequalityoffacilitation
services?Aretherepotentialbestpracticesinthisarea?Cost
Whatdoesafacilitationinterventioncost? Whatcostsavingsorincreasesdoesitproduceatthepracticelevel?Thesystemlevel? WhataretherelativecostsandbenefitsoffacilitationcomparedtootherQI
approaches?
Bestpracticesinscalingfacilitationservices
WhatarethelessonslearnedfromothercountriesusingfacilitatedimprovementatstateorregionallevelsthatcaninformdevelopmentofasimilarworkforceintheU.S.?Infunding,structure,workforcedevelopmentandmanagement,selectionofpractices,modelofintervention,andcrossprogramcollaboration?
WhatarethelessonslearnedfromstatewideeffortsintheU.S.toprovidefacilitatedimprovementthatcaninformdevelopmentoffacilitationservicesinotherstates?
Whatarelessonslearnedfromotherindustriessuchasagricultureandautomotivesinfacilitatedimprovementthatcaninformdevelopmentofafacilitationinfrastructureforprimaryhealthcare?
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3.REFERENCES
BaskervilleN.2009.SystematicReviewofPracticeFacilitationandEvaluationofaChronicIllnessCareManagementTailoredOutreachFacilitationInterventionforRuralPrimaryCarePhysicians.Dissertation.http://uwspace.uwaterloo.ca/handle/10012/4298
BodenheimerT.2006.PrimaryCare:WillitSurvive?TheNewEnglandJournalofMedicine355:
861‐864.ColemanK,PearsonM,WuS.IntegratingChronicCareandBusinessStrategiesintheSafety
Net.APracticeCoachingManual.Editor:CindyBrach.Prepared for Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road, Rockville, MD 20850. April 2009. AHRQ Pub. No. 09-0061-EF
DeWaltD.IPIPPracticefacilitationregistryandhandbook.Underdevelopment.Personal
communicationOctober,2010.FraserB.2010.QualityImprovementCoachCompetencies:BuildingQualityImprovement
Capacity&CapabilityinPrimaryHealthcare.QualityImprovement&InnovationPartnership.www.qiip.ca.
NuttingP,CrabtreeB,StewartE,MillerW,PalmerR,StangeK,JaenCR.EffectofFacilitationon
PracticeOutcomesintheNationalDemonstrationProjectModelofthePatient‐CenteredMedicalHome.AnnFamMed2010;8(Suppl1):s33‐s44.
GoeschelCA,Pronovost,PJ.HarnessingthePotentialofHealthCareCollaboratives:Lessons
fromtheKeystoneICUProject(AdvancesinPatientSafety:NewDirectionsandAlternativeApproachesed.,Vol.1‐4).Rockville,MD:AgencyforHealthcareResearchandQuality.2008.
AHealthCareCooperativeExtensionService:TransformingPrimaryCareandCommunity
HealthKevinGrumbach;JamesW.Mold.JAMA.2009;301(24):2589‐2591.InstituteforHealthcareImprovement(IHI).TheTripleAim:OptimizingHealth,CareExperience
andCostsforPopulation.http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htmaccessedJune29,2010.
InstituteforHealthcareImprovement(IHI).TheBreakthroughSeries:IHI’sCollaborativeModel
forAchievingBreakthroughImprovement.IHIInnovationSerieswhitepaper.Boston:InstituteforHealthcareImprovement.2003.
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IntegratingChronicCareandBusinessStrategiesintheSafetyNet.(PreparedbyGroupHealth’sMacCollInstituteforHealthcareInnovation,inpartnershipwithRANDandtheCaliforniaHealthCareSafetyNetInstitute,underContractNo./AssignmentNo:HHSA2902006000171).AHRQPublicationNo.08‐0104‐EF.Rockville,MD:AgencyforHealthcareResearchandQuality.September2008.
KiloC,WassonJH.2010.PracticeRedesignandthePatient‐CenteredMedicalHome:History,
PromisesandChallenges.HealthAffairs29(5):773‐778.KitsonA,HarveyG,McCormackB.1998.Enablingtheimplementationofevidence
basedpractice:aconceptualframework.QualityinHealthCare,7:149‐158.NagykaldiZ,MoldJW,AspyCB.2005.PracticeFacilitators:AReviewoftheLiterature.Family
Medicine37(8):581‐588.QualityImprovement&InnovationPartnership(QIIP).QualityImprovementCoach
Competencies:BuildingQualityImprovementCapacity&CapabilityinPrimaryHealthcare.http://www.qiip.ca/user_files/QIIP%20‐%20QI%20Coach%20Competencies%20Launch%20Jan‐10.pdf,accessedJune30,2010.
SolbergL.Improvingmedicalpractice:Aconceptualframework.AnnFamMed.2007May‐
Jun;5(3):251‐6.USAID.2008.EvaluatingHealthCareCollaboratives:TheExperienceoftheQualityAssurance
Project.http://www.encompassworld.com/publications/EvaluatingHCCollaboratives.pdf,accessedJune27,2010.
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APPENDICES
AppendixA.CrosswalkbetweenICICPilotStudyandConsensusMeetingAppendixB.LessonsLearnedinPracticeFacilitationandPracticeImprovementSharedby
ParticipantsAppendixC.InventoryofResourcesProvidedbyParticipantsAppendixD.Tablesummarizingprogramcharacteristics(Underseparatecover)
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Appendix A
Crosswalk between ICIC Pilot Study and Consensus Meeting Note: The two groups essentially agreed in all areas except the issue of internal vs external location of coaches. In many cases the Consensus Study Panel modified, extended or expanded upon the conclusions of the ICIC Pilot Study, as shown in the table below.
Category Pilotstudy ConsensusmeetingCoachingvs.Collaboratives
Coaches,asopposedtolearningcollaboratives,arebetterabletocustomizetheinterventiontotheneedsoftheteam.Morestaffcanparticipateinthepracticeimprovementsessionswithminimalimpactonpatientaccess.However,thereareelementstothelearningcollaborativesthatyoulose,includingasenseofnormalizingthechangeprocess,brainstorming,support,camaraderie,andnationalphysicianleadership.Bothtypesofprogramsprovideaformalstructureforteamstofigureouttheirownissues,andthismaybethemostimportantsharedcharacteristicofeffectiveQIprograms
Facilitatinglocallearningcollaboratives(2‐3localpracticesmeetingoverlunchtoshareideas)isacorefunctionofcoachesandcanprovidethecamaraderie,peerpressureetc.usuallyobtainedfromcollaboratives
Coachingasstandaloneinterventionorusedincombinationwithotherimprovementstrategies
Notaddressed Facilitationismosteffectiveifitoccursinthecontextofamorecomprehensiveimprovementprocessthatinvolvescollaborativesandpaymentreforminparticular
Relationships Practicesvaluedtherelationshipwiththecoach On‐sitepresenceisimportantinordertocreatetheserelationships.Theyaredifficulttocreateandsustainusingdistancetechnology
Preparingapracticetouseacoach
Clearlydefiningthecoaches’roleandregularlycheckingexpectationsisimportant.Somesitesperceivedthecoachesasconsultantswhoweretheretocomeinandsolveaproblem,whileothersviewedthemasresources.Clearlydefiningtheroleoftheexternalcoach,howtheyaretopartnerwithinternalleaders,andwhoisexpectedtodowhatworkisanarrangementthatneedstobemutuallyandcontinuouslyagreedupon
Proximityofservices Theformatofcoachingmightbetterbeon‐siteiffundingisavailable.Theformatofcoachingmightbetterbeon‐siteiffundingisavailable.Becausepeoplefeelbetterandaremoremotivatedwhentheyseeacoachinpersonanditiseasiertocommunicateanddiscuss.Whileface‐to‐faceinteractionsareimportantincoaching,emailandtelephonecommunicationsforquestion‐and‐answerorforproblemsolvingcouldsupplementface‐to‐facecoachingCoachingshouldincludemoreface‐to‐faceinteractions
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Category Pilotstudy Consensusmeeting
Durationandintensity
Increasingthecoachingmeetingtooneandahalfhoursinsteadofonehourmightbeabetterlengthtoallowtimeformorecommunicationandideaexchanges.Forthetimedistribution,moreintensivecoachingisneededatthebeginning;then,itcouldbecomelessintensivewhenpeopleareself‐sufficientAsix‐monthinterventionperiodisshort,especiallyforteamswithnoQIexperienceandnorealteamorientation.CoachingintensitymayneedtobegreateratthebeginningContinuecoachingforalongerperiodoftime
Thereisarangeoffacilitationschedulescurrentlyinuserangingfromintensive,dailyencountersfor24days,toweeklyencountersoccurringover6to10months.Mostinterventionsaveragebetween90and120hoursregardlessofschedule.Littleresearchevidenceexiststosuggestminimaldosagerequiredtocreateeffect,althougharecentmeta‐analysisoftheeffectsoffacilitationsuggeststhatmorefacilitationproducesgreatereffectsThereissomesuggestionthatintensive(daily)short‐termfacilitationschedulesmayworkinsomeenvironments,mostlikelylargerorganizationsandpracticesthathavegreaternumbersofstaff,andbelesseffectiveandevenpotentiallydisruptiveforsmallerpractices
WorkinginthecontextofotherQIactivitiesoccurringinthesamepractice
Coachingcanreallyjump‐startthespreadofimprovementespeciallywhensomeonehasalreadyparticipatedinaQIinitiative,likeacollaborative,andhasknowledgetheywouldliketosharebutnoformaltimeorplacetodothat.HarnessingtheirexperienceandknowledgeaspartofthecoachinginterventioncanbepowerfulFrequently,therearemultipleprojectsgoingone,whichmeansbeingopentoorseekingsynergyfromthediverseefforts
PracticesinvolvedinseveralQIeffortsmayexperience“changefatigue”whichcanhavenegativeeffectsonQIefforts,includingeffortsinvolvingtheuseoffacilitators
Locationofcoachintheorganization:Internalvs.externalcoaches
Aninternalcoachwhoknowsthecoachedsystembettermightbeacomplementto,orcounterpartfor,anexternalcoach,butwedonotknowwhetheraninternalcoachwillbeabetteralternativetoanexternalcoachAninternalcoachmightbeadded
Internalcoachesarethoughttobelesseffectivethanexternalonesforavarietyofreasonsincluding:a)competingdemandsofpatientcaredistractfromQIwork;andb)lackofsufficientpsychologicaldistancefrompracticetoprovideguidance/feedbackInternal“champions”mightbedevelopedwhocanworkwiththefacilitatorandserveasaresourcetothepracticewhenthefacilitatorisunavailable
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Category Pilotstudy ConsensusmeetingEmbeddedfacilitatorsareindividualswhoareemployedbyanorganizationoutsideofthepracticebutthatspendextended,consistenttimeinthepracticesuchthattheyareperceivedbythepracticeasaregularmemberofthepracticeteam
Typesofcoaches Coachingcanalsobeateamactivity,wherebytwoormorecoachesbringcomplementaryskillstointeractionswiththepractice
Facilitatorscanbegeneralists(projectmanagement,basicQIskills,targetedareasofexpertisesuchasuseofdatasystemstosupportpopulationhealthmanagement)orspecialists(targetedareasofexpertisesuchasHITimplementation).Inaddition,facilitationcantakeplaceinthecontextofateamofcontentexperts,patientsandothersorganizedandledbyageneralistfacilitator.Theteamapproachmaybethemostfeasiblegiventhebreadthanddepthofknowledgethatwouldberequiredforanyoneindividualtobeableaddresstheneedsofmostpractices
Readiness CoachingneedstocomeattherighttimeintheQIprocess.PeopleneedtoseeaneedforitSpecifictoCCM:Startwherethehealthcenteris…understaffedpracticesoverburdenedwithdemandcouldnotsuccessfullyimplementtheCCM.Practicesmusthaveclearlydefinedpatientpanelsassignedtowell‐definedcareteamsbeforeanymajorpracticechangecanprogress
Practicesrequireacertainlevelof“readiness”inordertobenefitacceptablyfromanimprovementinterventioninvolvingafacilitator.Readinessshouldbeassessedbeforeacceptingapracticeforfacilitationservices.Elementsofreadinessinclude:leadersthataresupportiveandengagedandcommittedtotheimprovementprocess;theabilitytoprovidetimeforstaff/providerstoworkonimprovementactivities;amongothers;notexperiencingadisruptiveleveloforganizational/financialdisorganization/distressAssignmentofpracticepanelsandcreationofcareteamswere
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Category Pilotstudy Consensusmeetingseenbygroupasapotential“goal”forafacilitationintervention(e.g.facilitationmaysupportpre‐workneededtoimplementCCM)
Whichpracticesshouldreceivefacilitationsupport?
…practiceswithengagedleadersandlong‐termqualityimprovementgoalsaremorelikelytoembracethechangescoachesnurture….programsusingcoachesmaywanttotargetpracticesunlikelytobeabletoengageinqualityimprovementontheirown..practicesthat:arenotpartoforsupportedbyalargersystem;cannotattendqualityimprovementcollaboratives;requireadditionalmotivationorcontainpocketsofresistanceorinertiathatblockspreadoftheCCM
Facilitationresourcesshouldbereservedforthosemostlikelytobenefitthemost.Notallpracticesshouldreceivefacilitation.Exemplarypracticesareunlikelytoreceivesignificantadditionbenefitfromafacilitatorinareaswheretheyarealreadyachievingataboveaveragelevels.Highlydysfunctionalpracticesarealsounlikelytobegoodcandidatesforfacilitationasthepracticeisfocusedonsurvivalasopposedtoimprovement
Roleofleadership Identifyaleaderon‐sitewhoisaccountable,creative,flexible,andempowered.Itisthefunctionofleadership,nottherolethatmatters.Itisnotimportantifitisanurseoradministrator,physician,orexecutive;someonehastobeauthorizedandresponsibleforthedailyoversightoftheprogramandtobeabletoworkwithleadershiptoremovebarriers.Thelocalleadershipwillfunctiontoorganizemeetingstofacilitateteamwork,provideguidanceandhelptoredesigncare,andencouragephysiciansandstafftotrynewthingsTheactivesupportofallrelevantleadershipisimportant.Thisentailsclearlyassessingthehierarchyofaccountabilityand,ifmultiplesilosexist,tryingtorecruitandalignallleaders
Itisnotenoughtoworkjustwithpracticeleadership.Individualsthroughoutsystemandatalllevelsmustbeinvolvedfortheinterventiontobeeffective
Corecompetencies InterpersonalskillsandemotionalintelligenceFamiliaritywithdatasystemsAbilitytounderstandandexplaindatareportsindifferentwaystodifferentstakeholdersSomeclinicalunderstandingandcredibilityKnowledgeofandexperiencewiththeCCMKnowledgeofandexperiencewiththeMOIUnderstandingofperformancereportingandmeasurementGeneralqualityimprovementmethodsGroupfacilitationskillsProjectmanagementskillsKnowledgeofpracticemanagementand/orfinancialaspectsofthepracticeExperiencewithandunderstandingoftheoutpatientclinicalsetting
‐Basicknowledgeoprimarycareandthehealthcareenvironment
‐theoriesofpracticechange,‐Generalcommunicationandfacilitativeskills,‐generalQIstrategiesandmethods‐Skillsinaccessingandusingdataforassessmentsandtomotivateandguidechangeactivities
‐Skillsinmanagingfacilitationteamsandbrokeringknowledgeandotherresourcesforpractices
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Category Pilotstudy Consensusmeeting‐Deeptechnicalskillsinkeydriversofimprovedoutcomes(populationmanagement,plannedandteambasedcare,standardizedcare,patientpartnerships)
‐Deeptechnicalskillsinkeydriversoforganizationalcapacity(executiveandleadershipcoaching,teambuildinganddevelopment,sustainableQIsystemsbestpractices)
‐Self‐managementandprofessionalism
Keyfunctionsoffacilitators
ReachimprovementgoalsConvenegroupsofstaffSetagendasandserveastaskmastersSkillsbuildersandtrainersKnowledgebrokersSoundingboardstogiverealitycheckProblemsolversChangeagentswhopromoteadoptionofspecificpracticesBenchmarking
‐Keepthepatientinthecenterofthepatient‐centeredimprovement
‐Providedeeptechnicalsupportintargetedareas
Conclusionsaboutcoaching
CoachingisanecessarybridgetothetoolkitCoachingmotivatesandpromptspeopletomakechangesCoachingextendsthehorizonsoftheteamsCoachinghasapositiveeffectonteambuildingCoachingcreatesanemotionalbond
Coachingprovidesdirecttechnicalassistanceincoreareasneededtoproduceimprovement–useofdatatosupportpopulationmanagement,panelmanagement,benchmarking
Costs $20,500persite,10months,mainlydistancecoachingmodel $5000‐$40,000persitedependingonintensity,duration
Phasesofcoachingprocess
Relationshipbuilding,assessmentFormingteamActivecoachingwithclinicalassessment,financialassessment,assessmentofChronicCare
Orientationandreadinessassessment,buildingcapacitytousefacilitatorPracticeassessmentacrosskeysystems:clinical,administrative,IT,community
QIinfrastructuredevelopment/engagementActivefacilitation:Workingw/teamonpractice‐ledprojectsActivefacilitation:Workingwithteamon“indicated”projectsGraduatedwithdrawalTerminationReengagementonnew
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Category Pilotstudy Consensusmeetingissues/needsasneeded.Returnto#1andrepeat
Namingthefield Notaddressed Nameofinterventionandprovidersshouldbedeterminedbypreferenceoftheenduser(practices),andbyitsabilitytosupportacademicdiscourse/research/publications
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AppendixB
LessonsLearnedinPracticeFacilitationandPracticeImprovementSharedbyParticipantsLessonslearnedaboutpracticecharacteristicsandreadiness
1. Primarycarepracticescomeinanincrediblevarietyofshapesandsizes.Thecapacitytoinnovateandtoadoptexternallyderivedinnovationsvarytremendously,howevermostprimarycarepracticesoperateunderconditionsthatnearmaximumcapacitybutleavelittletimeforqualityimprovementactivities.
2. Smallpracticesdonothaveathousandpointsofveto,soifyoucangettheleadphysicianinagrouptoagreetodosomething,itcanhappen.However,theydooperateonahierarchyofneedsandwhilebasiccareandworkloadareimportant,financialsecuritytoasmallindependentpracticereallyunfortunatelysometimestrumpsthepatientcare.
3. Businessinteractionsareafactoflifeinmanysmallpractices,manyarefamilyrunsmallbusinessesandanytypeofinterventionmusttakethisintoaccount.
4. Wecannotriskeveryone,noteverypracticeisgoingtosurvive,andnoteverypracticeshouldsurvive.
5. Thechangehastobeahighpriorityforthepracticeandyoudohavetobuildthebusinesscase.Becausewehaveheardthecommentbackofwhybotherwiththenursecoachesifyouarenotgoingtochangethebottomline?So,Ithinkyouhavetothinkaboutthebigbusinesscase.Ithinkintermsofthecharacteristicsofthepractice,theyhavetobereadyforchange,thereneedstobesupportfromseniormanagement,andwefoundthatchangewasinanenvironmentwheretherewasteamorientation.
6. Practice“desire”tochangeispredictiveofsuccess.Thestakeholderscanagreetopracticecoaching,butresistchange.Providerleadershipiscritical,theymustbeanactiveparticipant.Mustcaremoreabout“transformation,”than“transaction”.
7. FederallyQualifiedHealthCenters(FQHCs)havefederallymandatedqualityinitiativesandreportingrequirementsandareburdenedbynewchanges
8. LargerpracticespresentnewchallengesastheyhaveexistingQIstrategies,changeslower,registryimplementationcanbeamassiveundertaking,provider“buy‐in”varies,andhaveadministrativebarriers.
9. Forcommunityclinicsfinancialincentivestendtobeverymotivating,becausetheyoftendon’thavethisinthatscarceenvironment.
10. Itisverydifficulttopredicthowsuccessfulanypracticemightbewithsustainablebehaviorchange,they’llsurpriseyouineitherdirectiongoodorbad.
11. Therearedifferentpracticesandyoumustfigureoutifapracticewantsacoachorneedsacoach.Thepracticesthataremoresuccessfulofcoursearetheonesthathavethebestleadershipandthepracticesthatareleastsuccessfularetheoneswiththeworstleadership,butitsnotjustleadership.Wehavefoundthatifyoudon’tdealwithallthedoctorsinthepracticeandallthestaff,ifyouhavegoodleadershipbutifyouhavesomedoctorsthataretotallyandcompletelyresistant,itisprobablynotworthitworkingwiththatpractice.
12. Coachingteamsthatdonotwanttobecoachedisnotagoodplacetobe.
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Lessonslearnedaboutpracticeresponsetofacilitation
13. Ourexperiencehasbeenisthatpracticesneedandusuallywantallthehelpthatcanget,thebiggestconcernsremaintimeandmoney.
14. Italwaysharderthanwethinktoengagephysicians,itisevenmoredifficultifwedoitasasinglepair.
15. Wemustaddressthebusinesssideofpracticecoachinginordertoreachdoctorswhoarebusyanddonothavealotofextrareserve.
16. Dowereallyunderstandtheabilityorneedorwantofpractitionerstochange?17. Practicesjustcan’ttakeonapracticecoachifitisn’tfunctional.
Lessonslearnedaboutwhatfacilitationcando
18. AccordingtoSolbergforapracticetobeabletoimplementanewprocessofcare,changemustbeahighpriority,thepracticemusthavethecapacitytochange,andthepracticemustbeabletoimplementthespecificchangesrequired.Practicefacilitatorsorcoachesseemtobeabletoinfluenceall3components;buteachcomponentrequiresdifferentcoachingskillsandapproaches.Practicecoachingistheonlyinterventionthatwe’vefoundthatseemstobeabletoimpactinpractices’overallchangecapacityandwearestillnotsurehowtoenhancethateffect.
19. Forsustainablechangewebelievepracticesneedtobecomelearningorganizations.Inordertodothat,justasthephysicianpatientrelationshipneedstochange,sodoestherelationshipbetweenthefacilitatorandthepractice.Rightfromthestarttheyshouldrealizethisisnotamedicalconsultingmodel,theyarenotapassiverecipientsofyourinformation.Thefacilitatorgoingtoyou,fixingyourproblem,thenleaving‐weallknowthatdoesn’twork,butthat’swhatmanyofthemthink.Theyneedtoknowthattheanswerlieswithinthemandyouaregoingtohelpthemgetthere.
20. Ispracticeimprovementfortheclinicians,patientsorpayers?
Lessonslearnedaboutthesufficiencyoffacilitationinsupportingimprovement
21. Practicefacilitationbyitselfitsprobablyinsufficient,itprobablyneedstobeapieceofamulti‐componentQIprocess,wethinkthatprocessshouldincludeperformancefeedback,academicdetail,HITsupport,andalocalgrounding.
22. Practicefacilitationalsoneedstobeembeddedwithinasystemdisseminationandfusingintoinfrastructure‐muchlikecooperativeextensionthatwillreducethetimeinvolvedinestablishingrelationships.Itshouldbeongoingandthetimeandcostsinvolvedintravelforthecoacheswillallbelocal,itwillalsomakethemmoreavailablewhenpracticesarereadyforassistance.
23. Anyindividualentity,unlessthatentityhasasignificantimpactonthepractice,isnotenoughtoleveragechange.
24. Coachingandthedesiredchangeworksbestprobablywhenitisnotinisolation.SotheactivityofgettingpractitionerstogetherandworkingonqualityimprovementPDSAcyclesorMicrosystemsorwhateverparticularmethodsyouuse,canleadtochangeif
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youhavealltheingredientsthatyoudefine,priority,capacityandthewilltotakeiton.Thenyouwillbeabletoseesomeimprovement.Youneedthesystemchangestosupportitinorderforittobereallypowerfulandhavealotofimpact.
25. Practicecoaching,wethinkworksbestinthecontextofotherthingsgoingon.Wehavetriedsendingjustthelonepracticecoachouttothepracticewithoutanyothercollaborativesgoingonandwe’veseenthatitishardertomovethepracticealong.We’vecometobelievethatpracticecoachingneedstobehappeninginthecontextofotherqualityimprovementactivitiessothatyoubuildinthesocialconnectionsacrosspractices.
26. Howeveryougoaboutinitiatingpracticechange,ultimately,ifyoureallywanttotransformpractices,whetherthepracticehastwodoctorsor700,yougottohaveleadershipthat’scommittedtothechange,andknowshowtomakechangesthatfitwiththestyleoftheorganizationthatitleads.ForanymeaningfulchangestobesustainedbeyondthebeginningIthinkithastohavecommittedleadersinchargeofit,insteadofanoutsidefacilitatorcominginandworkingwithacoupleofcommittedstaffmembersorasinglephysician.
27. IactuallydonotbelievethatthequalityimprovementisaslinkedtofinancesasIheardpeoplesay.Itmakessenseifyoucandosomepayforperformancebutthat’snotsystemlevelchangeatapracticelevel.Iwillchallengetheassumptionthatyouneedtotackleorputtoomuchemphasisonthefinancialaspect.
28. Alotofthecoachingthatwearetalkingaboutdoingisunlearningbehaviorsthathavebeenentrenchedintopeople’sstylesandpracticesovermanyyears.Wemaybeneedtothinkabouttohowtoteachthepeopletodoitrightthefirsttimeandthereforemightneedtothinkaboutgoingbacktomedicalschoolandcertainlyresidency.Itwilltakealongtimetochangethepracticethatway,butotherwiseweareconstantlygoingtobechasingourtails.
29. Wehavetothinkaboutwhenitmakessensetoinvestincertainkindsofinterventionsforeitheraparticularchangeorforamoresystemwideculturalchange.
30. NurseCaseManagementneedstobecloselytiedtoPracticeCoaching.NotallhighriskmembersarecaredforbyapracticeinPracticeCoachingsite,whichmakesthismorecomplex.Memberengagementisenhancedwhenapracticeisrecommendingparticipation.
31. Collaborationisneededbetweenprivatepayers,StateHealthDepartments,MedicalSocieties,PracticeResearchNetworks,Federal(Medicare)Programs,FederalRegulatorsandOthers.
Lessonslearnedabouttheprocessandcontentofcoaching
32. Practicefacilitationshouldnotbeginwithanyprescribedgoals,mustdowhatisimportanttoeachindividualpractice.
33. Theaimisimportantanditwilldeterminewhattypeofpracticecoachneedstogoout.34. ItisimportanttohavetherightHITtools.Thisisactuallyhavingdashboardsandthings
thatareprovidingfeedbacktopracticesinrealtime,notanexternalpersongivingthedoctorfeedbackandtellingthemwhattheyaredoingpoorlyandhowtheyaregoingto
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helpthem.ThosearesomesubtledifferencesbutIthinkimportantintermsoftheapproach.
35. ThemoreIlookatitthelessdifferencethereisbetweentranslationalresearchandqualityimprovement.Thatfinelinekeepsgettingfinerandfiner.
36. Physiciansmightnotreallybethepeopletodothepopulationmanagementandthecarecoordination.Ithinkweoftenassigncertainrolesandexpectationstothewrongpeople.
37. Ibelieveitisactualbehaviorchangethatwearedoingandthat’swhyyoucangetthequalityimprovementchanges.Ithinkthatbehaviorchangeiswhatwillmakechangesustainable.Sowhenwetrytojustfocusinononetask,coachtheminoneitem,itisnotalwaysassuccessful.
38. Ithinktherearehugecommonalitieswithpracticecoachingandwiththeself‐managementapproach.Itwouldbeveryinterestingtoseecrossoveronthat.
39. Costeffectivenessonthepathwaytoimprovequalitycarehastobepartofthediscussion.CosteffectivenessisdefinitelyamajorconcernforcommunityhealthcentersinAmericanandspecificallyinCalifornia.
40. Plan‐Do‐Study‐Act(PDSA)rapidcyclechangeisveryhepful.41. Itisachallengeasanexternalcoachtoreallystayontheoutsideandtodevelopthat
cultureinconjunctionwiththeteambutnotreallybepartofit.42. Weneedtothinkaboutthetaxonomyofcoaching;canwequantifyorevaluatewhat
theyactuallydo?43. Practicere‐designiscomplex.Ittakestime–paradigmshiftsarenotinstantaneous.You
mustdeveloptrustandsimpleprocessimprovement,theeasypart.44. Registryutilizationisoverwhelmingforsomeandduplicativeforsome.45. Patientcomplianceisacommonpracticeconcern.46. Youhavetoknowthatpractice,getinthereandknowwhotheyare,whattheydo,how
theyact,what’stheirhistory.Tomeit’saverypersonalthing,youreallyhavetoknowthemaspeople,notjustasthisthestructureorthatrole.Therolesomeonecarriesmaynotbetherolethattheyfunctionwithinthepractice,soitsreallygettingtoknowpeople.Thisalsosuggestslongertermexposuretogetthatknowledgeandthatintimacy.
47. It’steamtoteam,ortheorganizationthat’simplementingchange.Itisnotanisolatedindividualorphysician.Itisneitherendofthespectrum,sothat’sabigthing.
48. Wesawsomeeffectivenesswhenwedidworkbuildingonprojectsthatwereallreadyhappening.Theyhadsomemomentumlinkingthemtogether.
49. Seenalotofparallelswithselfmanagementsupportinourfaculty.50. Toacertainextentitboilsdowntosomesortofpersonaleffectiveness,artofthecoach,
andunderstandinghowtoengagepeople’sheartsandminds,andthetechnicalpiece.Allthosesystemthingsareimportant.
51. Weareprimarilyinthebusinessofbuildinginterpersonalrelationships,overtimechanginghabitsandchoices.Sowearearelationshipproductinaserviceindustryconstruct.Healthcareasawholeisincrediblyignorantaboutworkforce,ignoresitalmostentirelyasatopic.
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52. Ifyougointoapracticeandtrytoberealniceandjustkindofsupportpeopleonwhattheywanttodo,youarenotgoingtogetchangethat’sworthadarn.
53. Keyinqualityimprovementistobuildasustainablecapacityforqualityimprovementassistance.
54. Itisallaboutbuildingrelationshipsandthattakesaconsiderateamountoftime.55. Whenyougointoapracticetheyhavetotrulyknowthatcoachesareadaptable,and
thattheyarenotshowingupwitharigidagendathatwon’tbemodifiedbasedontheirwishesandtheirsuccesses
56. Thewholeissueofthecoachesbeingreallycompetenttodowhattheyaresupposedtodoisverymuchlikehealthcoachesforpatients.Ifyouhavealousycoachforapatient,itisgoingtobehorribleforthepatientandnothinggoodisgoingtohappen.It’sallabouthavingreallycompetentcoaches,becauseifyoudon’thavecompetentcoaches,itdoesn’treallymatterhowwonderfulyouareatbuildingrelationshipsandbeingnicetothepractices,tryingtohelpthem.Acoachisajobthatrequiresahugeamountofskill.
57. Havetosomehowcreatevalueandbuildthattrustwhichisrelationshipbased.58. Whileitisveryhelpfultohavecoacheswhohavelotsoftools,lotsofexpertise,we’ve
foundthatiftheysayanythingaboutthecoloroftheirbelt[useQIjargonordisplaytheircredentialsinQIprocesses],peoplewon’tlistentothem.Sotheyshouldbringtoolsforimprovementbuttheyshouldn’ttalksixsigma,theyshouldn’ttalkanyofthislingobecauseitjustdrivespeopleaway.
59. Weareconvincedthatthereisgreatpotentialforpracticecoachingtobeeffective.60. Ifwewantimproveachroniccareintervention,westartwithfixingourregistry,we
startwithfixingsystemchangesandthenwegototheoutliersandshowthemthedata.Thathasreallyhelpedusbecausethenallthepeerpressureisonbehavioralchangeandit’smuchmoreeffective.
61. Staffturnoverisproblematic.62. Salariedprovidersaregenerallylessmotivatedtoparticipate.63. Providersdon’treadmail.
LessonslearnedaboutHITandfacilitation
64. HITinitiativesareconfusingtopracticesasmanyareuninformedandwillrequirecollaborationofstakeholders(futurerolesareundefinedanduncertain).
65. HITisthewolfinsheep'sclothingofpracticetransformation.Itcreatesanopportunityforchange.
Useofdatainfacilitationandimprovementwork
66. Sharingdata–sharingdatabetweenproviders,sharingdatabetweenfacilities,sharingdatainourcoalitionamongclinics–motivateschange.
67. Itisextremelyimportanthowyouusemeasurementindata.Datamanagementcantransformhowyoudoclinicalchangeimprovement.
68. Havetousedataforimprovementbutyouhavetousethatdatatocreateintentionforchangeandvalueinthepractice.
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Developingandsupportingfacilitatorsandfacilitationprograms69. Justasphysiciansneedsupportandpsychologicallysafeenvironments,sodo
facilitators.Theyhaveanincrediblydifficultjobandwefound,bydefault,thatwhenthefacilitatorswereabletodebriefwithustheevaluationteam,inanenvironmentwheretheyweren’tbeingjudgedbyhowsuccessfultheirpracticeswere,theywereabletobecreativeandbrainstormandthinkofthingsthattheymightnothavethoughtofwithinamorebusinesstypeenvironment.
70. Wemustdevelopourinternalcapacityandcapabilityforthisworkasmuchaswehavetoassistteamstodothat.
71. Thechallengeinevaluatingeffectivenessthereinliesinhowwetrainourcoaches,howdowesupportthemsothattheycanthendothatforteamstheyworkwith.
72. Findingthatrightpersonwiththerightskillsetisreallychallenging.73. Findingtherightpersonanddefiningwhattheywillbedoingfromtheverybeginningis
reallyimportant.74. Coachesshouldunderstandthecultureofthehealthcenterandthebasicconceptsof
qualityimprovement.75. Ithinktheappropriatepersontoactintheroleofanursecoach,giventhecomplexity
oftheroleandthecomplexitiesofthepractices,shouldhaveanunderstandingofgrouppracticemanagementandknowledgeofevidencebasedguidelines.Theskillsetisimportantinthechangeprocessandhavingatalentforambiguityisreallyimportantinthatrole.
76. LeadershipandMedicalDirectorofprogram’srole:Needs“fulltime”attention,beamotivator,educator,goodcommunicator,bewellorganized,holdstaffaccountable,staywellinformedofnumerousperspectivesandinitiatives,andbetheExpert.
77. Fundingforpracticecoachingwilllikelycomefromavarietyofsourcesinatleasttwoforms‐ongoingsupportandprojectspecificsupport.
78. Wemustworkontheideaofwhoisthetrustedintermediaryforsmallpracticesinthecommunity.Isitthelocalmedicalsociety?Isitanindependentembeddedpracticeassociation?Whoisthatentity?
79. Whileitisverynicetohavetheluxurytohireexternalcoaches,wemighthavetotapintoexistingresources,andIthinkifyoucanprovideanetwork,education,andskillbuilding,thenmaybeyoucouldstartwithexistingresources.
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AppendixCInventoryofResourcesProvidedbyParticipants
NameofParticipant ResourceProvidedMikeHerndon CareMeasuresGuide2.0TrainingMaterials ClosingthePhysicianStaffDivideArticle HealthManagementProgramCollaborativePresentation HealthManagementProgramOverview HealthManagementProgramFlowChart DataUseAgreementForm PracticeFacilitationActionPlan PracticeFacilitationAgreement PracticeFacilitationDataFindingPresentationtoPractice PracticeFacilitationExpectations PracticeFacilitationInitialDataCollectionTemplates PracticeFacilitationOverviewandGuidelines PracticeFacilitationPracticeAssessment PracticeFacilitationProcessMap PracticeFacilitationTrainingGuide PracticeFacilitationTrainingSkillsChecklist PracticeFacilitationOverview(PowerPoint) PracticeFacilitationPhasesPlan PracticingExcellenceArticle RegistryauditandaccountabilitysheetKellyPheifer ActionGrantProposal Pay‐For–PerformanceProgramDiscussionPaper
StrengthinNumbersOverview:SupportingChronicCareandPrevention
StrengthinNumbersCoachingTool AccessQuickTipSheetforPhysiciansandOfficeStaff QuickReferenceGuidetoImprovingthePatientExperience PracticeSiteChangesTipSheets StrengthinNumbersStandardizationofTerms
DartmouthClinicalMicrosystemsPracticeChangeSatisfactionSurvey
SurveyonDoctor‐PatientCommunication ShortFormSurveyonExperienceswithyourDoctor ExperienceswithYourPersonalDoctorSurvey ExperienceswithYourSpecialistDoctorSurvey CQCImprovingPatientExperienceOverallChangePackageMaryRuhe Ruheetal,PracticeAssessment(Article)
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Bobiaketal,MeasuringPracticeCapacityforChange(Article) Ruheetal,FacilitatingPracticeChange(Article)
Stroebeletal,HowComplexityScienceCanInformaReflectiveProcessforImprovementinPrimaryCarePractices(Article)
Talliaetal,SevenCharacteristicsofSuccessfulWorkRelationships
5StagesofGroupDevelopment Ruhe,FacilitationHandbook EPOCHSStudy:ProjectFacilitationProgramOverview
Leonard,ThecriticalImportanceofTeamworkAndCommunicationinProvidingGoodCare(Article)
Stetleretal,TheRoleof“ExternalFacilitation”inImplementationofResearchFinding(Article)
KatySmith OfficeVitalSignsSurvey ListofPracticeEnhancementAssistantQuestionsoftheWeekSophiaChang SmallPracticeeDesignProgram:PhasingandGoals SmallPracticeeDesignProgram:Overview
ClareLibby
NeilBaskervilleDissertation:SystematicReviewofPracticeFacilitationandEvaluationofaChronicIllnessCareManagementTailoredOutreachFacilitationInterventionforRuralPrimaryCarePhysicians
AboutImpactBC(Materialsfromwww.impactbc.ca)BrendaFraserandTrishO'Brien
QualityImprovementandInnovationPartnership(QIIP):CoachCompetencies
QIIPCoachSelf‐AssessmentForm QIIPCoachTrainingandDevelopmentOutline QIIPCoachDescription
MichaelBarrAmericanCollegeofPhysicians(ACP)FormsonPracticeManagement
VideoofSmallPracticeinAmerica WebinaronACPMedicalHomeBuilder FinalReportforthePhysician'sFoundationforHealthSystems ACPInternist(ACPJournal)Jan08‐Staffing ACPInternist(ACPJournal)Feb08‐InvestinginEHRs
ACPInternist(ACPJournal)March08‐TheFrontOfficeBottleneck
ACPInternist(ACPJournal)April08‐ManagingRisk ACPInternist(ACPJournal)May08‐InOfficeLabTests ACPInternist(ACPJournal)June08‐AccessCathyCatrambone Catramboneetal,ANurseCoachQIIntervention(Article) VIPStudyNurseCoachMaterials
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DarrenDeWalt
ImprovingPerformanceInPractice(IPIP)ChangePacket:DetailsonIPIPanditsHigh‐LeverageChanges,MeasuresandScalesforPracticeChange
DeWaltetalAHRQPresentationSlides:IPIP‐Ontheroadtoalargescalesystemtoimproveoutcomesforpopulationsofpatients