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

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

ElizabethStewart,PhD UniversityofTexasAdditionalcontributorsMargieGodfrey ClinicalMicrosystemsResourceGroupZsoltNagykaldi OklahomaPhysiciansResearch/ResourceNetworkKateColwell LyleJ.Fagnan OregonRuralPracticeBasedResearchNetwork

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

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.

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

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

Name Location WebsitePBRNClinicalMicrosystems NewHampshire http://www.clinicalmicrosystem.org/ColoradoResidencyFacilitationProject

Colorado Contact:PerryDickensonPerry.Dickinson@ucdenver.edu

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

Name Location Website

SanFranciscoDepartmentofPublicHealth

California Contact:TomBodenheimerTBodenheimer@fcm.ucsf.edu

ThemapbelowdisplayslocationsofsomeofthemajorfacilitationeffortscurrentlyunderwayintheU.S.andCanada.Figure1.PartialmapoffacilitationprogramsinU.S.andCanada

AboutThisProject In2006AHRQcontractedwiththeRANDCorporation,GroupHealth’sMacCollInstituteandtheCaliforniaHealthCareSafetyNetInstitutetodevelopatoolkittosupportimplementationoftheChronicCareModel(CCM)insafetynetpractices.TheresultingdocumentandtoolkittitledIntegratingChronicCareandBusinessStrategiesintheSafetyNetwaspublishedin2009andcontainsresourcestoguidepracticesthroughkeychangestoimplementtheCCM.Itisavailableonlineathttp://www.ahrq.gov/populations/businessstrategies/businessstrategies.pdf.

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

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.

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).

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

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

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).

Figure3.Anexampleofachangemodelwith8keydrivers

2.4 Shouldfacilitationbemadeavailabletoallpracticesoronlythosethatmeetcertaincriteria?Participantsviewedfacilitationasascarceresourceandmostsuggestedthatpracticeswillvaryinthedegreetowhichtheycanbenefitfrompracticefacilitation.Themajoritybelievedastrategyisneededforselectingpracticesthatshouldreceivefacilitationservicesinordertoensurethattheresourceisdirectedtopracticesmostlikelytobenefit.Asorganizations,practicescanbeseenasfunctioningatdifferentlevelsofeffectiveness–exemplar,functional,low‐functional,andsurvival.Inaddition,theymayvaryinlevelofeffectivenessacrosstheirinternalsystems‐administrative,clinical,qualityimprovement,andconnectionstothecommunity.ApracticemaybefunctionalinadministrativeandQIsystems,exemplaryincommunityconnectionsandlow‐functionalinclinicalsystems.Figure4defines

fourlevelsoffunctioningwithinapracticeacrossfiveinternalsystemsthatareaddressedduringfacilitation.Figure4.Thepracticefacilitationecology

Participantssuggestedthatpracticesthathavealreadyachievedhighlevelsofqualityontheirownarenotlikelytoreceivesignificantadditionalbenefitfromfacilitationandsoarenotlikelyrecipients.However,thesepracticesshouldbeactivelyengagedaspartnersinfacilitationinterventionstoserveas“exemplars”andapotentialsourcefor“bestpractices”thatmightbespreadtopracticesthathavenotyetachievedsimilarlevelsofeffectivenessintheirownsystemsandwork.Attheotherendofthespectrum,practicesthatareexperiencinghighlevelsofdisorganizationororganizationalstressarenotlikelytobenefitorbeabletotakefulladvantageofafacilitationinterventionandsoarealsonotlikelycandidates.Differentprogramsusedifferentcriteriafordeterminingeligibilityforfacilitationservices.TheOklahomaHealthcareAuthorityfocusesitsfacilitationresourcesonpracticesthatserveahighvolumeofpriorityorhighneedpatients.Otherstargetsmallerpracticesandpracticesnotengagedinotherformsofimprovementsupportsuchascollaboratives.Stillotherstakeatheorybasedapproach,focusingfacilitationresourcesonearlyadoptersandopinionleaderswithintheclinicalcommunityaspartofadeliberatestrategytosupportspreadofinnovationandmaximizedisseminationofthefocusedimprovements.

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.

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,

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.

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

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

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

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.

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

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.

Figure5.Typicalstagesofapracticefacilitationintervention

2.16 Whatindividualsmakethebestfacilitators?Practicefacilitatorsneedexcellentinterpersonalandcommunicationskills.Inadditiontheyneedtheabilitytoapproachapracticeinacollaborativeandhumblemannerwithoutusingqualityimprovementjargon,andshouldbecomfortableandeffectiveworkingwithindividualswithvaryinglevelsofeducationfromhighschoolleveltomastersanddoctoraldegrees.Likelytheyalsoneedtounderstandempowermentconceptsatadeeplevel.Participantsweresplitonwhetherafacilitatorneedspriorexperienceworkinginaclinicalsettingoraclinicaldegreetobeeffective.Whilesomefeltthatthisexperiencewasessentialforthefacilitatortobeeffective,othersfeltthatthisknowledgeandexperiencecouldbeacquiredonthejobandthatextensiveclinicalexperienceinsomeinstancesmightimpedeeffectivefacilitation.IndividualswithbackgroundsinPublicHealth,SocialWork,Nursing,CounselingandPsychologywerethoughttobewellsuitedforfacilitationbecauseoftheirbasicskillsandknowledgein

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

• 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

• 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.

Table5.ApartiallistofPFtrainingcurriculaandresources

Source Title Year WebsiteOklahoma

Practice‐BasedResearchNetwork

(PEA)PracticeEnhancementAssistantManual

2009‐2011

www.okprn.org

DartmouthCoach‐The‐

DartmouthClinicalMicrosystemImprovementCurriculum 2006

www.clinicalmicrosystem.org

HealthcareResearchand

Quality

IntegratingChronicCareandBusinessStrategiesintheSafetyNet:ApracticeCoachingManual

2009www.AHRQ.gov

IMPACTBCPracticeSupportProgramFacilitatorHandbook 2007

www.impactbc.ca InstituteforHealthcare

ImprovementPrimaryCarePracticeCoach

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.

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

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

upfacilitationservices.Itwillbeimportanttodeterminewhichamongthesewouldbegoodtoknowbutnotessential,andwhichareessentialtoadvancethefield.2.23Suggestedresearchquestions Researchapproaches

Sharedmeasuresshouldbeidentifiedforuseacrossprograms.Whatsharedmeasurescanbeusedforevaluatingacrossallfacilitationinterventionsthatcansupportcrossprogramcomparisonsthataremeaningfulinansweringarangeofquestionsabouttheeffectivenessofdifferentinterventionapproaches?

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?

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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APPENDICES

AppendixA.CrosswalkbetweenICICPilotStudyandConsensusMeetingAppendixB.LessonsLearnedinPracticeFacilitationandPracticeImprovementSharedby

ParticipantsAppendixC.InventoryofResourcesProvidedbyParticipantsAppendixD.Tablesummarizingprogramcharacteristics(Underseparatecover)

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

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

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

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

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

Category Pilotstudy Consensusmeetingissues/needsasneeded.Returnto#1andrepeat

Namingthefield Notaddressed Nameofinterventionandprovidersshouldbedeterminedbypreferenceoftheenduser(practices),andbyitsabilitytosupportacademicdiscourse/research/publications

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.

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

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

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.

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.

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.

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)

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

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AHRQ Research and Budget Priorities

AHRQ Quality Indicators NQF Update

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AHRQ Composite Measures Workgroup

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AHRQ Medication Reconciliation

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Prepared for: Agency for Healthcare Research and Quality (AHRQ) ahrq

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Ahrq Patient Satisfaction Survey

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AHRQ Update

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