Practice Facilitation Handbook
Module 1. Practice Facilitation as a Resource for Practice Improvement
Practice facilitation, sometimes also referred to as quality improvement coaching, is an approach to supporting improvement in primary care practices that focuses on building organizational capacity for continuous improvement (Knox, 2010). As a practice facilitator, you will establish a long-term relationship with your practices, becoming a resource for ongoing quality improvement (QI) and evidence translation.
This module provides a brief overview of practice facilitation. For a more indepth discussion, see Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide (Knox, et al., 2011). The guide can be accessed at: http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/pcmh_implementing_the_pcmh___practice_facilitation_v2.
Who Are Practice Facilitators?
Practice facilitators (also known as a practice coaches, QI coaches, and practice enhancement assistants) are specially trained individuals who work with primary care practices “to make meaningful changes designed to improve patients’ outcomes. [They] help physicians and quality improvement teams develop the skills they need to adapt clinical evidence to the specific circumstance of their practice environment” (DeWalt, et al., 2010). As a practice facilitator, you need competencies in four areas:
- Interpersonal skills to build support for and facilitate change;
- Methods for accessing and using data to drive change;
- QI and change management strategies; and
- Health information technology (IT) optimization.
In addition, you will need expertise in the specific content of an intervention (e.g., patient-centered medical home [PCMH] transformation, guideline implementation).
Practice facilitators work with primary care practices “to make meaningful changes designed to improve patients’ outcomes.
—DeWalt, et al., 2010
Practice facilitators are generalists who support QI and other related activities in a practice or health care organization. They may work alone or lead a practice facilitation team made up of the facilitator, a health IT expert, and a data manager, as well as additional experts. These may include individuals with expertise in specific clinical or technical content required by the intervention.
You may also engage physicians, chief executive officers, nursing staff, and others from practices that have already worked with a practice facilitator or that have already undergone improvement in the desired areas to serve as peer mentors to the practice. For example, let’s say you are supporting implementation of advanced access (a method of shortening wait times for appointments). In addition to providing general facilitation support to your practice, you may engage a consultant with expertise in this area as a member of your practice facilitation team. This consultant can provide support to a practice undergoing this specialized transformation.
When a team approach is indicated, as generalist and lead facilitator, you will form and manage this team to ensure that a practice has the resources it needs to make the desired changes. Your role will be to identify individuals with the needed expertise, engage them, and then manage the team to ensure it meets the needs of the practice and is also used in the most cost-effective manner.
Figure 1.1. Four core competencies of practice facilitators
The goal of your work with practices is to build their capacity for continuous quality improvement and their ability to implement new evidence-based treatments and bring health service models into practice. The ultimate aim of all of these activities is to improve patient outcomes and experience and lower the overall costs of care.
To build these capacities, as a facilitator, you will help your practices establish QI teams, create improvement plans, assess practice systems and processes, develop performance monitoring systems, and use strategies such as benchmarking to motivate practices to change and compare their performance to other similar groups. You will provide training to your practices on QI approaches such as the Model for Improvement and assist them in using methods such as Plan Do Study Act cycles to test, spread, and sustain changes in the practice. You will also provide training to your practices on the contents of specific improvements or engage experts such as academic detailers to provide this training.
You will also:
- Map workflows and assist practices in redesigning them to support desired changes.
- Help staff modify policies and procedures to ensure sustainability of changes.
- Identify exemplar processes in your practices and spread them to others.
- Identify resources your practices need to implement improvements that extend beyond the scope of your skills or the particular facilitation intervention.
- Help practices integrate all of the improvement work occurring within them into a cohesive whole.
- Form and maintain a long-term relationship with your practices.
In addition to your work building capacity for change in the practice, you will work toward specific improvement goals. These improvement goals may be:
- Determined by the practice;
- Determined by your facilitation program; or
- As often is the case, specified by the funder for the intervention.
These goals can vary significantly in their complexity. Some are tightly focused on improving care for a specific condition, such as implementing treatment guidelines for chronic kidney disease. Others are focused on whole practice transformation, such as implementing tenets of PCMHs or the Care Model (go to Module 16). The scope and complexity of the desired changes will dictate the type and intensity of support you will need to provide to the practice.
Facilitation Intensity and Length
Facilitation interventions vary in length and number of support hours delivered. These are typically linked to the particular goals being pursued in the intervention and the existing capacity of the practice at the start of the intervention. Complex improvement goals will require more hours of support and a longer delivery schedule; goals that are more narrowly focused or are smaller in scope will require fewer hours or shorter duration.
Practices with higher levels of capacity for improvement will require less support, and therefore a less intensive intervention schedule. Practices with little existing capacity for improvement will require more. Efforts to introduce a particular practice guideline might require only a few months of support. Whole practice transformation such as that required by the PCMH may require a year or more. That said, intensity of services often depends on funding realities.
As a practice facilitator, you will provide support to your practices based on the particular facilitation process and intervention model your program is using. Within this framework, you will want to tailor your approach to suit the needs of each practice based on its size, organizational structure, patient population, geographic location, and health care context.
Ideally, you will form a long-term relationship with the practices that extends beyond a single project or QI initiative. In the best sense of the word, you will become a long-term resource for the practice, not employed by them but available to them as needed to support implementation of new health service models, treatments, and improvements to patient care.
Onsite and Virtual Facilitation
Experts consider some degree of onsite support, with a predictable schedule of onsite visits by the facilitator, to be almost essential to successful facilitation as it helps to establish and maintain an effective working relationship between you and your practice. Some interventions will need intensive onsite support while others may allow for a combination of onsite and virtual support. Virtual support can include check-in sessions and trainings on basic information on QI and new models of clinical care delivery. Onsite support is more appropriate for activities such as:
- Internal capacity building for ongoing QI, practice assessment, and data collection,
- Workflow mapping and redesign,
- Implementation of complex changes, and
- Conflict resolution.
Practice facilitators help promote a culture of learning and QI within practices and set the stage for continuous quality improvement that extends beyond the period of active facilitation. Practice facilitators can be thought of as “catalysts for change,” supporting transformation at the individual, team, organizational, and systems levels (Department of Health and Community Services, 2006). In addition to general skills in QI, change management, data collection, and optimization of health IT systems, some may acquire expertise in specialized areas such as supporting attainment of meaningful use of health IT to improve patient care. Table 1.1 lists some of the key activities practice facilitators undertake when working with their practices.
Evidence on Practice Facilitation
While some believe practice facilitation is a relatively new approach to supporting practice improvement, its origins can be traced back at least 20 years. It was used from 1982 to 1984 in the Oxford Prevention of Heart Attack and Stroke Project in England as the primary intervention to help clinicians improve screening for cardiovascular disease (Fullard, et al., 1984; Department of Health and Community Services, 2006). Evaluations of the project demonstrated the value of facilitation support for improving clinical processes and cardiovascular care.
Following this early success, England became an early adopter of practice facilitation and used it as part of a comprehensive approach to support primary care. In the 1990s, Australia, Canada, the Netherlands, and the United States also began using the facilitation model to support practice improvement (Nagykaldi, et al., 2005).
Since then, organizations such as practice-based research networks, State health departments, professional associations, and health plans have begun using practice facilitation to support QI, as well as knowledge generation and discovery in primary care practices. Settings range from small, private practices to large multispecialty group practices, from urban to rural to frontier settings, and from safety net to non-safety net providers. The common element of all practice facilitation programs is the use of specially trained individuals who establish long-term relationships with practices and work to help them implement the targeted improvements.
The evidence base demonstrating the effectiveness of practice facilitation as a method for improving primary care practice is growing. Nagykaldi, Mold, and Aspy completed the first review of practice facilitation in 2005. Analyzing 25 studies of practice improvement conducted between 1966 and 1984, the authors found that practice facilitation contributed to increases in the delivery rates of preventive services. It also improved relationships and communication among providers, assisted clinicians with chronic disease management, provided professional education, and facilitated system-level improvements. However, the part directly attributable to practice facilitation could not be determined, as most of the studies included practice facilitation as one part of a multicomponent intervention.
More recently, Baskerville, Liddy, and Hogg (2012) published a meta-analytic review of 22 studies involving 1,429 practices in which they found evidence of the effectiveness of practice facilitation compared to nonintervention controls. Primary care practices receiving practice facilitation were almost three times as likely as control practices to adopt evidence-based guidelines.
The researchers also shed light on factors associated with greater practice facilitation effect. For example, the researchers found that as the number of practices supported by a facilitator increased, the effect size of facilitation decreased. In addition, practice facilitation interventions delivering a higher dose of support (e.g., total number of hours and duration of the intervention) were also associated with larger effects.
Sustainability of Change
Studies have also examined the sustainability of changes implemented using practice facilitation support. While an early study found that the effects were not sustained past the intervention period (McCowan, et al., 1997), multiple studies conducted since then have found that the effects of practice facilitation were sustained for as long as 12 months postintervention (Dietrich, et al., 1994; Hogg, et al., 2002; Stange, et al., 2003; Hogg, et al., 2008).
As early as 1995, Bryce and colleagues evaluated the impact of an audit facilitator on patterns of diagnosis and treatment of childhood asthma in 12 practices. At a 2-year followup, there were significant increases in asthma consultations, new diagnoses of asthma, and reaffirmation of past diagnoses in intervention versus control practices.
Others have looked at the cost effectiveness of practice facilitation. Hogg, Baskerville, and Lemelin (2005) examined the cost savings associated with practice facilitation in reducing inappropriate and increasing appropriate screening tests in 22 primary care practices serving approximately 100,000 patients. The team conducted a cost-consequences analysis. Within the Canadian context, the intervention resulted in an annual savings per physician of $3,687 and per facilitator of $63,911. The estimated return on intervention investment was 40 percent.
Patient-Centered Medical Home Implementation
Most recently, researchers have studied the impact of practice facilitation on efforts to meet PCMH criteria. The National Demonstration Project (NDP) study compared two implementation approaches: facilitated and self-directed. Thirty-six family practices were selected for the study that were deemed ready and highly motivated to adopt the NDP model of the PCMH. The practices were randomly assigned to self-directed or facilitated change conditions. The practice facilitation intervention was mainly delivered remotely with one or two onsite visits over the course of the study.
The research team found that facilitation increased the practices’ capability to make and sustain change and increased their adaptive reserve, their organizational capacity to engage in ongoing QI (Nutting, et al., 2010). Differences in actual PCMH implementation were not significant by group. This likely reflects the fact that both groups were already highly motivated and ready to change and the practice facilitation intervention was primarily virtual, so of relatively low intensity.
Department of Health and Community Services, Government of Newfoundland and Labrador. Guiding facilitation in the Canadian context: enhancing primary health care. St. John’s, Newfoundland: Department of Health and Community Services; 2006.
Knox L, ed. Report on the AHRQ 2010 consensus meeting on practice facilitation for primary care improvement. (Prepared by LA Net under Contract No. HHSA2902007100110.) Rockville, MD: Agency for Healthcare Research and Quality; 2010.
Knox L, Taylor EF, Geonnotti K, et al. Developing and running a primary care practice facilitation program: a how-to guide (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO5.) Rockville, MD: Agency for Healthcare Research and Quality; December 2011. AHRQ Publication No. 12-0011.