Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study

Abstract

PURPOSE Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODSWe conducted a sequential mixed methods study, analyzing data from Eviden-ceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTSPractices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators.CONCLUSIONS Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

“…This included robust regionwide facilitator infrastructure (ie, having facilitators located geographically throughout the region) and the knowledge of how to support and deploy a facilitator workforce effectively. Studies show that the ability to support a facilitator workforce is connected to facilitator effectiveness, 33,34 and when combined with network infrastructure this likely explains the association we see between Cooperative experience level and facilitation amount; facilitators visited practices more when they lived in closer proximity to their practices, and when they had the tools to be helpful. Practices likely wanted more facilitator visits from effective facilitators.…”

“…For clinicians and clinical teams, particularly clinician-owned practices that see a need to improve practice capacity and clinical quality, working with a facilitator who is supported by an experienced Cooperative can help the practice work through an improvement process. 34 The benefit of working with an external facilitator is less clear for hospital-and health-system-owned practices or those practices that have internal quality improvement support. This is a novel finding worthy of further investigation.…”

Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout

“…Substantially changing quality metric performance is dependent on practice structural characteristics and the ability to change processes and capabilities as part of improvement initiatives . For example, regular quality improvement–focused team meetings, the presence of medical home recognition, use of standing orders, and presence of cardiovascular disease registries and electronic health record (EHR) prompts are associated with better performance on aspirin, blood pressure, and smoking cessation clinical quality measures .…”

The Value of Funding a Primary Care Extension Program in the United States

“…Only 2 of the 7 EvidenceNOW cooperatives had substantial prior experience. 6 These cooperatives recruited a more diverse and dispersed group of practices in greater need of support (ie, with lower baseline capacity and clinical quality), delivered substantially more 6 and higher quality facilitation, 9 and their practices made greater gains in improvement capacity and clinical quality than practices in the other 5 cooperatives. 6 While AHRQ displayed leadership with the EvidenceNOW initiative, we believe that national implementation would need to be led by the US Department of Health and Human Services (HHS), as it will require a national platform, collaboration among federal agencies guiding health care, and long-term funding.…”

“…Only 2 of the 7 EvidenceNOW cooperatives had substantial prior experience . These cooperatives recruited a more diverse and dispersed group of practices in greater need of support (ie, with lower baseline capacity and clinical quality), delivered substantially more and higher quality facilitation, and their practices made greater gains in improvement capacity and clinical quality than practices in the other 5 cooperatives …”