Integrating Chronic Care and Business Strategies in the Safety Net
Chapter 3: An Approach to Practice Coaching
In this chapter we describe the approach used by two coaches as they worked together with nine randomly selected primary care teams to improve quality of care. Feedback from the teams and reflections on how to alter and improve the intervention are also included. The described approach illustrates how the principles described in Chapter 2 were put into action. The goal of coaching was to lay the foundation for implementation of the Chronic Care Model (CCM). This was done by tutoring practices in the CCM and quality improvement methods and acquainting them with the toolkit, which they could continue to use to guide their improvement activities after coaching ended. The tools and steps below provide a template for a practice coaching intervention, but organizations can and should adapt the pace and content of the work to fit their needs.
In a Nutshell
Who was coached? Nine randomly selected primary care teams at two public hospital outpatient clinics located in California, USA. Both clinics were designated Federally Qualified Health Centers, serving disproportionately low-income and uninsured residents.
Who were the coaches? Two quality improvement professionals external to the public hospital systems with expertise in teaching the Chronic Care Model and Model for Improvement and leading teams through quality improvement initiatives efficiently. Two coaches were used because of their complementary skill sets. One acted as the regular point of contact with teams. The other provided specific technical assistance around topics including selecting and monitoring performance measures, integrating self-management support into the routine visit, and developing and using registries.
How was coaching structured? The coaching intervention was low intensity. The out-of-town coaches made two site visits and communicated with practices by phone two to three times a month and by E-mail on a weekly basis. Practices submitted monthly reports to coaches. Coaches spent a total of 10 months working with the clinical organizations, six months of which was spent directly working with practices.
What roles did coaches play? The coaches served as motivators, content experts, and team facilitators. The practices were expected to take the ownership of their quality improvement initiative. Coaches acted as resources providing a broad outline of areas to address but letting the team decide sequencing and level of effort expended.
What did coaches do? Coaches taught the CCM and Model for Improvement cycles, organized teams and team meetings, worked with leadership to reduce barriers to accomplishing the work, guided the selection of clinical measures, reviewed monthly reports, helped prioritize changes, introduced tools from the toolkit, provided examples from other settings, and acted as a resource and motivator.
- Phase I: Laying the Foundation for Success (4 months).
- Phase II: Active Practice Coaching (6 months).
Phase I: Laying the Foundation for Success
The first phase of coaching took about four months and focused on laying the foundation for working with the practice teams. During this time, the coaches had three primary responsibilities:
- Introducing themselves to leadership of the organization and explaining the program and its goals, benefits, and requirements.
- Learning about the organizational context of each site, including the system barriers and facilitators of quality improvement.
- Getting Acquainted with the members of each team and generating momentum for the start of the project. There were three major activities conducted in this phase.
There were three major activities conducted in this phase:
Activity 1: Form Coaching Team
Your organization or initiative may have an existing group of coaches or quality improvement staff available to it, or you may be considering hiring a coach. For this quality improvement initiative, we sought coaches with experience implementing the Chronic Care Model, including population-based care using registries, self-management support, and planned care. Coaches also should have some content knowledge about the business side of a medical practice, including operational and financial functions. We wanted individuals who would flexibly fit with a practice as well. While one person may have all these skills, we were lucky enough to have access to two coaches who together had a variety of expertise and perspectives.
Activity 2: Get Acquainted With Leadership
The coaches first contacted both the executive or middle-level leadership that initiated the quality improvement effort, as well as the local leadership ultimately responsible for implementing the work.
The primary goal of these informal conversations was for the coaches and leaders to get acquainted and discuss expectations and initial thoughts about the initiative. The following questions can be helpful conversation starters: What are you expecting to achieve during this initiative? What do you think will be the biggest barriers to success? What are you expecting to receive from us?
During these conversations, leaders were asked to provide insight into how the goals of the project would be best achieved at their site and what additional staff members should be contacted. These conversations began to develop what should be a solid and trusted working relationship between the site leadership and the coaches. The meetings also:
- Ensured that important stakeholders were brought in early, enhancing buy-in and creating the opportunity to address major problems or misconceptions early.
- Opened lines of communication directly between leaders and coaches.
- Enabled coaches to outline some of the basic requirements for successful participation, including the ability to generate population-based clinical data for monthly reports.
- Provided valuable information for coaches as they went on to develop their tactical approach; for example, when and with whom to schedule meetings for maximum attendance.
- Enabled coaches to integrate their effort with other existing system initiatives, minimizing unnecessary duplication of effort.
- Provided the executive and local leadership with enough information to be able to present the initiative to their own clinical teams. Having local leaders, rather than the coaches, motivate and introduce their teams to the effort from the very beginning sets the tone that this quality improvement work is owned by sites. The role of the coach is to support those local leaders and the teams' efforts as they move forward.
Activity 3: Orient the Practice Team to the Work
After the coaches talked with the site leadership, they introduced the effort in detail to the local practice team undertaking the quality improvement initiative. All the stakeholders who would be involved in the effort from front desk staff to physician leaders were invited to participate in this project introduction.
The more staff participating in this call, the better. For many of the practice team members, this may be the first that they have heard that they are expected to participate in a new way of working. For this reason, every effort should be made for local leadership to introduce the program. Local leaders can frame the importance of the project, provide an overview of their expectations, and offer resources to support the team.
An agenda of the phone call where the coaches and local leadership introduced the program to the practice team is in the Appendix. Note that half of the agenda is devoted to introductions and time for questions and answers. All attendees should be given a chance to participate, regardless of their position in the organization. Setting this example early can facilitate later team development.
After orienting the team undertaking the quality improvement effort, it is important for the coaches to stay in close communication with them. To build and sustain momentum, not more than three or four weeks should elapse between the time of these introductory conversations and the onsite launch of the initiative. While an effort to speak with each member of the participating practice team should be made during Phase I, do not be surprised to meet new team members during Phase II, active practice coaching. There is no substitute for an in-person orientation to get people engaged.
Phase II: Active Practice Coaching
The second phase of the project was active practice coaching and lasted about six months. The six month design was an attempt to provide inexpensive and time-limited technical assistance to help teams get started. We know that six months of technical assistance is short compared to other quality improvement initiatives, and it may be insufficient for teams with little or no prior experience with quality improvement. This phase consisted of five activities.
Activity 1: Introduce Prework and Prepare Practice Team for Site Visit
As with the practice team orientation call, all members of the team and the practice leadership should participate in this meeting to introduce prework and prepare the practice team for the first site visit. In this AHRQ pilot, we conducted this call about three weeks before the learning session, allowing the site time to complete those elements of the prework that had to be done before we arrived: the clinical assessment, the financial assessment, and the Assessment of Chronic Illness Care (ACIC). Participants included the medical director of the site, administrative director of the site, physicians, nurses, medical assistants, front desk staff, and ancillary clinical staff, including dietitians and nurse care managers.
The primary purpose of this call was to discuss the plan for the upcoming site visit and to introduce the prework to the teams. However, it is likely that some new staff will participate, so it may help to conduct a brief refresher of the project and allow time for questions and answers about the general aims of the program before jumping in. Reminding the team that this is just a refresher and they can talk with other team members or leaders or E-mail questions may help keep this portion of the agenda short. For a sample agenda of the practice team site visit preparation call, go to the Appendix.
You'll notice in the companion toolkit that one of the first steps for teams when they are working to improve quality is to select measures that are important to them. Data gathered during prework is primarily for the teams' use during the learning session to decide what areas of care they first want to improve. In addition, the data provide a baseline to measure progress, an important tool for engaging senior leaders. Finally, the data provide the coaches with some insight into the needs of the teams with whom they are working. Introduce teams to the prework assessments. Examples of each of the prework assessments are available in "Integrating Chronic Care and Business Strategies in the Safety-Net" toolkit. They include:
- Clinical Assessment: Clinics start on their quality improvement journeys by selecting and measuring the outcomes for a subpopulation of patients. In the case of our initiative, the sites worked with diabetic patients, so the clinical assessment provided a baseline of clinical quality for each team's diabetic population. It is to be filled out to the extent possible through automated data. If a clinic does not have automated data, a small chart review may be necessary. Each team is expected to complete this assessment before the coaches arrive for the learning session. A copy of this assessment, called Quantitative Monthly Diabetes Report Template, is available in Key Change 2.3 in the toolkit.
- Financial Assessment: In our experience, the financial functions and performance of a practice are often fairly far removed from the daily clinical practices. In order to capitalize on possible reimbursement and cost-saving opportunities, sites can complete a financial assessment before the coaches arrive for the learning session. If multiple provider teams within one site are being coached, only one financial assessment is needed. A copy of this assessment, called Finance Collaborative Prework, is available in Key Change 2.1 in the toolkit.
- Assessment of Chronic Illness Care: This survey assesses how well teams are set up to deliver high-quality chronic illness care according to the elements of the Chronic Care Model. This survey is to be completed by each individual of the clinical team before the coaches arrive for the learning session. A copy of this survey, called Assessment of Chronic Illness Care, and a companion Scoring Guide are available in Key Change 2.1 in the toolkit.
This short prework call also provided an important opportunity to prepare the teams for what to expect during the coaches' first site visit. Be sure to allot time to discuss:
- Completing the administrative process assessment: This fun, poster-sized assessment assesses how well administrative processes such as answering phones and rooming patients are working. This tool is a poster-sized template that can be printed and hung on the wall. All staff and even patients are invited to place a checkmark in the box that corresponds to their perception of the processes. This assessment is completed during the coaches' first visit. A copy of this assessment, called Primary Care Practice: Know Your Processes, is available in Key Change 2.1 in the toolkit.
- Conducting the observational assessment: The observational assessment is designed to give coaches a sense of how the practice works with patients. During the assessment, coaches will spend a couple hours looking at the practice supports for high-quality chronic illness care: how clinical information systems and decision support are used; whether planned visits, self-management support, and linkage to community resources are conducted; and how leadership supports the team.
- Developing the agenda for the learning session. Before conducting this call, you should have a good sense of how you plan to structure the learning session. For more information about the learning session, go to Activity 2 below. It may be helpful to share your vision and a proposed agenda for how you expect the day to go. This gives teams something to look forward to and prepare for.
- Reaching coaches with questions. It is likely the teams will have questions between this meeting and the first site visit about how to complete the prework, what to expect during the learning session, or other topics. Be sure to talk explicitly about how teams can reach you effectively, be it phone or E-mail.
Activity 2: Conduct the Observational Assessment (1/2 day) + Learning Session (1/2 day)
Because the coaches did not live in the same U.S. cities as the teams they were coaching, they conducted the observational assessment and the learning session as part of the same trip. The observation assessment was conducted the afternoon of one day, and the learning session was conducted the following morning. Finding a meeting time with the team for an hour one day and then for a full morning the following was challenging. Breaking up these two functions may facilitate scheduling.
Clinical observation can be a valuable way for coaches to get a sense of how the clinic functions on an average day. In observing the flow of patients with a fresh eye, the coaches were able to identify areas where enhanced chronic illness care, such as self-management support, could be integrated with the existing operations and staffing. Using an organized observational tool helped to focus our observations in the midst of a very busy setting.
- The day began with a one-hour meeting with the team. During this meeting the coaches discussed expectations, collected prework, and administered another tool: Know Your Process (Key Change 2.1 in the toolkit). You will find the Assessment Day Agenda in the Appendix.
- Coaches then observed the practices, using a standard tool to guide their observations. A copy of the Clinical Observation Assessment tool is provided in the Appendix.
- The coaches gathered the information from all assessments, including their observations, and organized it to be useful for the teams to use in setting their improvement agenda.
The learning session served as the big project kickoff; it was the first time the coaches met with all the teams and the site leadership face to face. The expressed purpose of the learning session was to provide an orientation to the Chronic Care Model and Model for Improvement and to help the teams get started making small-cycle changes. However, the meeting also served as a way to generate momentum for the project, and as a fun introduction to redesigning clinical care. An agenda for the learning session is in theAppendix..
The coaches attempted to keep the learning session interactive, dynamic, and useful. All the baseline assessment data were presented conversationally, with coaches briefly presenting the results of the assessments and then leading the teams through a discussion about the results. Feedback sometimes got heated. Redirecting pointed questions back to the team by asking, "What do others think?" helped to diffuse energetic responses. It also set the tone that the coach is there not to fix all the practices' problems externally, but to support the team to fix their own problems. In addition, didactic presentations were kept short and substantial time was allotted for the teams to figure out how to get started doing small cycles of change. Coaches attempted to model teamwork by encouraging shy participants to speak up and share opinions. Specific content covered in the learning session is presented below.
- Teaching the Chronic Care Model. The Chronic Care Model is the organizing framework around which this toolkit and coaching intervention were designed. The CCM is an evidence-based model that can help teams provide proactive, population-based care. For more on the Chronic Care Model, see the companion toolkit Key Change 1.2, Chronic Care Model Primer. Videos and PowerPoint® presentations of the Model should be short, specific, and interactive. Additional examples of presentations are available at http://www.improvingchroniccare.org.
- Reviewing Assessment of Chronic Illness Care. By the time of the learning session, the coaches should have received all the ACIC surveys back from the team members who completed them as part of the prework. To score the ACIC, see the companion toolkit Key Change 2.1, Assessment of Chronic Illness Care. Presenting these scores back to the group in aggregate or as blinded individual surveys gives the team members a chance to identify and discuss areas of strength and opportunities for improvement. Practices may feel discouraged when they realize how many elements of the CCM they do not currently address. Coaches familiar with quality improvement methodologies know that teams do best when they start with small changes. Reassure teams that they can make progress without addressing every element of the CCM at once. As the day progresses, teams will have a chance to discuss where they might be able to achieve early successes.
- Model for Improvement. Like the Chronic Care Model, the Model for Improvement is an important organizing framework for this intervention. If the Chronic Care Model is what the teams are going to work on, then the Model for Improvement is how the teams are going to do the work. Plan-Do-Study-Act cycles are the key component of the Model for Improvement, and there are many creative ways to present this content, including games. For more information on the Model for Improvement, see the companion toolkit Key Change 1.2, A Model for Accelerating Improvement. Don't be concerned if not everyone "gets it" all at once. This is just an introduction; these concepts are best learned by doing.
- Observational Assessment Results and Group Discussion. During this time, coaches present qualitative feedback to the teams about what they observed during their observational assessment. A good approach is providing an overview of what you observed the teams doing well and then identifying areas where easy enhancements could be made to better address patient needs. For example, if patients are routed through some sort of nurse- or medical assistant-led checkout process before leaving the office, perhaps goal setting or action planning could be integrated. This exercise is most helpful when coaches can point out potential solutions simultaneously with potential areas for improvement.
- Where to Start. After learning about the concepts behind the Chronic Care Model, teams often wonder how to get started. Here, the coaches introduced a menu of starter ideas, areas that the team might like to address first. This was not a prescriptive list, but it was meant to start discussion. This was the most valuable and important aspect of the learning session: the time teams had together to brainstorm Plan-Do-Study-Act (PDSA) cycles and how they would make the program run. You can find the "Change Your Practice Menu" of starter ideas and the "Getting Started Logistics" tools in the Appendix.
- The Toolkit. The companion toolkit provides a sequenced approach to help teams improve care. It also provides content and tools for almost any related topic of interest from selecting a registry to trying out planned visits. During this session, coaches provided an interactive overview of the toolkit with a special emphasis on its approach to the business case for improved care. The toolkit is available to teams free of charge online at both http://www.improvingchroniccare.org and http://www.ahrq.gov. Team members can use any of the tools or review content on the Web without printing out a heavy binder.
- Monthly Reporting. Coaches also briefly introduced the monthly reports teams were required to submit to them. Key Change 2.3 of the Integrating Chronic Care and Business Strategies in the Safety Net toolkit provides examples of the Quantitative Monthly Diabetes Report Template and the Narrative Monthly Report Template that the teams completed. These monthly reports serve several functions. They provide a tangible deliverable and an opportunity for the teams to ask questions of the coaches in a systematic way. The reports also provide a template for the teams to look at changes in health process and outcome measures as a result of their work. They also demonstrate evidence of improvement to be used to engage leadership or other teams in spread.
- Planning Future Team Meetings. In order for teams to successfully make changes in how they deliver care, regular time needs to be set aside for the team to gather together. This can take the shape of a weekly one-hour meeting or a series of short, daily huddles. Either way, it is important to establish a time to share what has been learned, develop new ideas to test, and maintain momentum. Because trying to get started on a new initiative in the midst of a very busy clinical schedule can be challenging, the time set aside by the coaches must be more than just didactic presentations. It must be value-added planning time for the teams as well.
- Evaluation. In the spirit of continuous quality improvement, the coaches asked the teams to evaluate them after the learning session. The evaluation form, "Tell Us What You Think," can be found in the Appendix.
Activity 3: Coaching Through Regular Team Meetings
After the learning session, teams start trying to improve care using PDSA cycles. The coaches participated by phone in the team's regular weekly or biweekly meetings, though in-person participation could also work. The expectation was that a team leader would facilitate the meetings, but the coaches were available before the meeting to brainstorm an agenda, during the meeting to provide suggestions and ideas, and after the meeting to reflect on how to best move the project along. The team leader can be anyone on the team who is able and interested in convening team meetings, maintaining momentum for the initiative, and overseeing the implementation of change ideas. Some teams have one person who acts as the team leader, such as the medical director of the practice or the office manager. Other groups rotate team leadership among team members. For more information about leadership, see Key Change 1.1 in the toolkit, Organize your lead quality improvement team.
Coaching through these regular meetings, as opposed to establishing separate meetings either individually or as a group, has many advantages. First, since the teams are already meeting, coach participation is efficient. If the teams have questions, especially at the beginning as they work on PDSAs, they can get coaching help and ideas right way. Participating in team meetings also enables the coaches to see how the project is progressing. If, for example, key members of the team are not attending, the coaches can talk with leaders who may be able to encourage attendance.
Initially, the coaches provided substantial guidance, but over time, the meetings shifted to be led and managed much more independently. From the beginning, an important goal was for the teams to own the meetings and to perceive the coaches as a support but not an active "implementer" or team member. Coaches do not and cannot know the local politics and organizational context as well as the team members do, and they are only available to the teams for a limited time.
The coaches also provided ad hoc support to individual members of the teams through E-mails and phone calls. Often this involved providing a link to a specific tool or a recommendation for a speaker or training on a topic of interest. Sometimes, the coach acted as a listening ear when people felt frustrated or unable to move forward. The coaches took on various roles throughout the six-month active coaching phase of the project: observer, trainer, meeting participant, report-reviewer, and ad hoc resource. These roles changed as the needs of the teams changed.
Having clear, well-communicated boundaries about what is and is not the job of the coach is important. Coaches should:
- Be in a position of offering ideas, not imposing what they want to get done.
- Help the teams actually implement what they learn.
- Set up systems for the benefit of the clinic and its staff, not the organizing group, the coaches, or even the leadership.
Finally, there is only so much a coach can do. To be successful, coaching has to be sufficiently supported and matched by good leadership, sufficient resources, and a clear idea of the desired outcomes. Some organizations and teams are just not ready or able to make good use of a coaching resource.
Activity 4: Communicating With Leadership
In addition to participating in team meetings via phone, or occasionally in person, coaches also worked with local and executive leadership, communicating about the project, highlighting challenges and successes, and helping leaders think about how they could contribute to the success of the effort. Sometimes this meant drawing attention to resistant staff or broken systems that impeded the ability of the team to move forward; other times it was encouraging leaders to ask and follow up with the teams about their work.
Activity 5: Closing Out Coaching
Our intervention was deliberately low-intensity and lasted six months, though certainly you could continue coaching if interest or funding were available. In preparation for the last team call, teams were asked to discuss two things: first, reflect on the initiative and how it affected their relationships both with patients and coworkers, and two, think through how the effort would be sustained after the coaching component ended. During the meeting, the teams presented on these topics and the coaches reminded the teams about available resources, including the companion toolkit.
Suggested Modifications to our Practice Coaching Approach
The aforementioned coaching intervention was evaluated as part of AHRQ's "Integrating Chronic Care and Business Strategies in the Safety Net" project. RAND assessed the implementation of the intervention through site visits to the two participating medical centers and interviews with key informants. Below we offer the following suggestions for modifying the practice coaching intervention.
- Coaching should include more face-to-face interactions. Due to the ease of communication and discussion, the pilot site participants believed that they would benefit from more frequent in-person contact with the coaches. Although for the most part the telephone calls and E-mail functioned well, some participants felt their enthusiasm was dampened when the coaches could not be reached.
- An internal coach might be added. The participants felt that sometimes the external coaches' advice was too general and not applicable to their particular organizational setting. In one site, a physician who had prior experience using the Chronic Care Model was consulted by others about how to implement specific changes. Hence, many participants suggested that an internal coach who knows their system better and is more readily available could complement an external coach. It was also noted that an internal coach should be given sufficient time and clear responsibility, so as not to cause antipathy among other staff members.
- Coaching intensity may need to be greater at the beginning. The meeting and coaching time allotted was perceived to be insufficient for participants to learn, ask questions, and exchange information. The participants commented that they needed more help at the beginning and suggested greater intensity of coaching until they became self-sufficient. It was also suggested that everyone in the practice who plays a role in CCM implementation should be invited to the first in-person coaching meeting. Some recommended that the coaches provide a more specific timeline for changes.
- Coaches should be more proactive and creative in introducing the toolkit. The interviewees suggested that coaches be more proactive in introducing the toolkit. The learning session could allot more time to reviewing the toolkit to increase users' understanding of its contents. One participant suggested that the coaches could create scenarios to demonstrate how and when to use the toolkit. Others suggested that the coaches remind them to use the toolkit.
- Continue coaching for a longer period of time. We designed the coaching intervention to get the practice team started in CCM implementation, but the coaching was perceived to be worth continuing beyond the six-month timeframe.