Quality Improvement in Primary Care
External Supports for Practices
By Erin Fries Taylor, Deborah Peikes, Kristin Geonnotti, Robert McNellis, Janice Genevro, and David Meyers
Why is quality improvement important for primary care practices?
Engaging primary care practices in quality improvement (QI) activities is essential to achieving the triple aim of improving the health of the population, enhancing patient experiences and outcomes, and reducing the per capita cost of care, and to improving provider experience. In an effort to create a high-value health care system in the United States, many providers, insurers, delivery systems, and quality improvement organizations are focused on improving the performance and safety of primary care. One prominent approach to redesigning primary care, the patient-centered medical home (PCMH), requires primary care practices to have a systematic focus on QI and safety. (Please access the Agency for Healthcare Research and Quality's definition of the PCMH here).
Primary care practices with a strong QI orientation continually seek to improve their own performance and the outcomes of their patients. This QI orientation guides practices to set priorities for areas to improve and the work needed to achieve these goals. The specific areas that practices choose to address through ongoing QI efforts, and the methods they use to address them, are likely to vary based on the practice's concerns, circumstances, and resources. Some examples of specific areas that might be priorities for practices include improving the identification, monitoring, and followup of patients with diabetes, or improving the delivery of recommended preventive services for all of their patients.
Engaging in ongoing QI is likely to be a new activity for many primary care practices, and even the most determined practice is likely to need new skills to meet its improvement goals. These skills include identifying areas for improvement, understanding and using data, planning and making changes, and tracking performance over time. External supports—defined here as the various forms of technical assistance, learning activities, and tools and resources provided by organizations outside the practice—can assist practices in undertaking QI.
What external supports can help practices with quality improvement?
Four categories of external supports, which can be used alone or in combination, can assist practices with QI:
- Data feedback and benchmarking provide practices with information on their performance, as compared to external benchmarks (such as regional or national averages), and help target areas for improvement.
- Practice facilitation (or coaching) by external organizations helps practices develop skills and organize their approach to QI, provides QI tools and expertise, and helps them troubleshoot challenges or barriers.
- Expert consultation (also called peer-to-peer mentoring) provides practices with specific evidence-based knowledge from clinicians and staff outside the practice.
- Shared learning or learning collaboratives provide a community in which practices can share challenges, lessons learned, and best practices and draw motivation and inspiration.
Table 1 at the end of this brief provides more information on these supports and links to resources.
What types of organizations provide QI support to primary care practices?
Although there is currently no nationwide system to support QI by practices, area health education centers (AHECs), health information technology regional extension centers (RECs), quality improvement organizations (QIOs/QINs), practice-based research networks (PBRNs), public and private insurers, primary care professional organizations, and others provide these types of supports to some primary care practices in some geographic areas. These supports are currently typically financed by Federal grants and contracts, State programs, multipayer and single payer initiatives, and foundations.
Example: AHRQ IMPaCT Grantees' Work to Support Quality Improvement in Primary Care
In 2011, AHRQ launched the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative, awarding four cooperative grants to support State-level QI efforts. Grants were awarded to projects in New Mexico, North Carolina, Oklahoma, and Pennsylvania. These programs used primary care extension agents to assist small and medium-sized primary care practices with primary care redesign, and also provided technical assistance to 13 other States to support their transformation efforts. For more information about the projects, select link here.
Selected examples of IMPaCT's work to support practices with QI activities:
- New Mexico deployed practice coaches to add new practice improvement strategies targeted toward small and medium-sized primary care practices. This approach complemented its existing IT component of primary care practice transformation, which the State-designated REC provides. In addition to practice transformation, the program also promoted collaborations to improve community health, with a focus on addressing social determinants of health. Select link here for more information.
- North Carolina launched two learning collaboratives, among other activities, to enhance its infrastructure to support primary care practices. The regional leadership collaborative helped regional teams develop skills to: (1) lead successful QI initiatives, and (2) increase coordination and collaboration among local medical home care networks and AHEC's working toward shared objectives. Select link here and here (PDF File, 80 KB) for more information on North Carolina's range of activities.
- Oklahoma created the infrastructure for a statewide primary care extension system, intended to support local primary care needs. With counties and local partners as the foundation, the infrastructure now supports continuous QI, connects practices and communities to resources, and encourages innovative primary care delivery models. Select link here and here for more information.
- Pennsylvania conducted a survey of primary care providers across the State about what support they most needed. Top-ranked needs included identifying and coordinating behavioral health services, improving office efficiency, and implementing evidence-based guidelines, among others. Pennsylvania also convened a large cadre of partner organizations to collaborate on practice transformation, focusing on how to reach more practices in the State. Select link here for more information.
|External Support||Description||Role in Supporting QI Work||Sample of Available Resources|
|Data Feedback and Benchmarking||Data feedback gives practices and teams information on key indicators of processes and outcomes (patient quality of care, service use, cost, and experience), which are tracked over time to assess improvement.
Benchmarking allows practices and teams to compare their performance on selected measures to the performance of other practices and providers, or to national targets (e.g., 90 percent compliance with a standard).
|√ Provides motivation and direction for QI goals.
√ Helps identify gaps in services or overuse of services and potential areas for improvement.
√ Allows practices and teams to track changes in performance over time.
|Hysong S, Best R, Pugh J. Audit and feedback and clinical practice guideline adherence: making feedback actionable. Implement Sci 2006;1(9). Available at: www.implementationscience.com/content/1/1/9.
Jamtvedt G, Young JM, Kristoffersen DT, et al. Audit and feedback: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006(2):CD000259.
|Practice Facilitation / Coaching||Supportive services are provided to a primary care practice by an external facilitator or coach, with the goal of building internal capacity for QI activities and, ultimately, primary care redesign and transformation.
Facilitators help practices identify ways to implement an innovation or improvement activity within the practice's context.
|√ Helps practices learn how to improve by providing training in use of data and QI skills, sharing tools and resources, and lending QI expertise.
√ Provides a customized approach through one on one work with practices.
√ Supports practices in identifying and achieving improvement goals; helps practices prioritize and sequence QI activities and approaches (including use of data feedback and benchmarking, academic detailing/expert consultation, and learning collaboratives, as needed).
|Baskerville BN, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012;10(1):63-74. Available at: www.annfammed.org/content/10/1/63.full.
Grumbach K, Bainbridge E, Bodenheimer T. Facilitating improvement in primary care: The promise of practice coaching. New York, NY: The Commonwealth Fund; June 2012. Available at: www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jun/Facilitating-Improvement-in-Primary-Care.aspx.
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 TO 5.) AHRQ Publication No. 12-0011. Rockville, MD: Agency for Healthcare Research and Quality; December 2011. Available at: http://pcmh.ahrq.gov/sites/default/files/attachments/Developing_and_Running_a_Primary_Care_Practice_Facilitation_Program.pdf (PDF File, 49 KB)
|Expert Consultation||External clinician or other expert provides evidence-based knowledge to the practice team (often clinicians), with the aim of changing behaviors through sharing best practices.||√ Provides evidence and education through a credible external source and relates that evidence to the practice context.
√ Can help develop practices' interest in QI work, often by relating peer to peer.
AHRQ's Academic Detailing Project. Available at: http://effectivehealthcare.ahrq.gov/index.cfm/who-is-involved-in-the-effective-health-care-program1/about-the-academic-detailing-project/
|Shared Learning / Learning Collaboratives||Practice clinicians and staff come together, either in person or virtually, to receive training, share lessons and best practices, evaluate performance, and work individually and collaboratively to implement practice changes over time.||
√ Provides motivation and inspiration by creating a community for sharing challenges and successes peer to peer, and learning how others approach change and improvement.
√ Creates positive peer pressure to spur change across participating practices; an efficient way of reaching many practices at once.
√ Promotes culture of continuous QI (to the extent that learning is ongoing and broad based).
|AHRQ's PBRN Peer Learning Groups. Available at: http://pbrn.ahrq.gov/peer-learning-groups.
Bricker PL, Baron RJ, Scheirer JJ, et al. Collaboration in Pennsylvania: rapidly spreading improved chronic care for patients to practices. J Contin Educ Health Prof 2010;30(2):114-25. Available at: www.ncbi.nlm.nih.gov/pubmed/20564714
Fleischfresser S. Wisconsin Medical Home Learning Collaborative: a model for implementing practice change. Wisconsin Med J 2004;103(5). Available at: https://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/103/5/25.pdf (PDF File, 50 KB)
Goeschel CA, Pronovost PJ. Harnessing the potential of health care collaboratives: lessons from the Keystone ICU Project. In: Henriksen K, Battles JB, Keyes MA, et al., eds. Advances in patient safety: new directions and alternative approaches. Vol. 2, Culture and redesign. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. Available at: www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Goeschel_24.pdf (PDF File, 117 KB)