Practice facilitation is a scarce resource and it is important to make careful and informed decisions about where to direct it. It is important to avoid spending valuable facilitation time attempting to facilitate change in a practice that is not ready or able to benefit from the support. This is not only a waste of a valuable resource, but also frustrating to both the practice facilitator and the practice (Knox, 2010; Knox, et al., 2011).
Figure 12.1 presents a model that can be used to triage facilitation resources. It reflects the view of some experts in practice facilitation that resources should focus on practices most likely to benefit from facilitation.
|Resources should focus on practices that are most likely to benefit from facilitation.|
Two categories of practices might receive little benefit from practice facilitation: those operating in survival mode that cannot effectively implement any of the strategies the practice facilitator suggests, and practices that are already functioning very effectively and have fewer opportunities for improvement. The latter group, however, is a valuable resource as a supply of role models and professional mentors to practices undertaking improvement work and as a source of “best practices” to spread. The two remaining levels, functioning practices and low-functioning practices, are most likely to benefit from practice improvement facilitation and are the likely audience for your work.
Source: Knox L, ed. Report. on the AHRQ 2010 consensus meeting on practice facilitation for primary care improvement. (Prepared by LA Net through a subcontract with the University of Minnesota under Contract No. HHSA290200710010 TO 3.) Rockville, MD: Agency for Healthcare Research and Quality; 2010.
You might not want to follow the triage model for several reasons. For example, in a rural community with few primary care providers, it may be critically important to shore up and support whatever practices are in the area, even if they are so preoccupied with daily operations that it is difficult to engage them in improvement activities. Because they lack the basic administrative and clinical systems needed to function effectively, the form and expectations of facilitation efforts will have to be different with these practices.
Conducting an assessment of a practice’s readiness for facilitated improvement work is an important first step when enrolling practices in an intervention. Readiness assessment is an inexact process, and at this point, somewhat informal. It is helpful to talk to other practice facilitators and to your program supervisor as you begin to assess practice readiness, especially if you have limited experience working with practices at this time.
Initial Readiness Assessment
Determining a practice’s readiness to implement an intervention is a critical first step to beginning facilitation. Figure 12.2 contains an informal list of criteria that participants in the 2010 AHRQ Practice Facilitation Consensus Meeting found useful for assessing a practice’s readiness to undertake improvement work with a practice facilitator (Knox, 2010).
__ Practice or organizational leadership is interested in specific or general improvement as evidenced by request for assistance or receptivity to receiving facilitation to support improvement.
__ Practice or organizational leadership is willing to participate in ongoing communication with the practice facilitator and participate on the quality improvement team.
__ Practice or organization is willing and able to identify an “improvement” champion who will be the practice facilitator’s point person.
__ Leadership is willing to provide protected time for key staff to engage in improvement work.
__ Team members are willing to meet regularly as a quality improvement team, and members follow through with this plan.
__ Team members are willing to gather and report data on practice performance on key metrics.
__ Practice has sufficient organizational and financial stability to avoid becoming too distracted or overwhelmed by competing demands or financial concerns.
__ Practice is not engaged in other large-scale improvement projects and does not have other demanding competing priorities.
The last item on the Checklist evaluates practices for “improvement fatigue.” Due to the many parallel improvement and transformation activities taking place in health care today, practices can be overwhelmed by change and reluctant to engage in additional improvement work. In these cases it may be possible for the practice facilitator to integrate the other improvement projects and leverage this activity, or it may be more appropriate to delay this intervention.
Practices that meet most of these basic readiness criteria are thought to show evidence of readiness for working with a facilitator on practice improvement. This does not mean that every practice meeting these criteria will be successful in a facilitated improvement intervention, nor does it mean that practices that do not meet these criteria will fail. These criteria simply provide a starting point for thinking about the readiness of practices interested in engaging in improvement work with a facilitator.
Three-Month “Real-Time” Readiness Assessment
Practices that appear “ready” and are enrolled in the intervention should be reassessed at 3 months to confirm readiness. In addition to items on the Checklist for Assessing Practice Readiness, this assessment should consider the following:
- Attendance at project meetings, including leadership presence at kickoff and initial meetings.
- Progress in developing quality improvement plans.
- Follow-through on action items.
As a practice facilitator, you have several courses of action to consider with practices that do not meet readiness criteria at 3 months:
- Continue the intervention. You may believe that as the practice builds its relationship with you and as you create priority for improvement in practice leadership and build the practice’s capacity for improvement, their engagement in the improvement process will increase.
- Consider stepping back from active intervention with the practice until a later time when they are better prepared to engage.
- Ramp up the intensity of the intervention, often by bringing in an academic detailer (i.e., peer support) to help problem solve and create buy-in among practice leaders.
You will need to discuss these options with your supervisor or fellow practice facilitators before making a decision.
Knox, L, ed. Report on the AHRQ 2010 consensus meeting on practice facilitation for primary care improvement. (Prepared by LA Net through a subcontract with the University of Minnesota under Contract No. HHSA290200710010 TO 3.) 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. HHSA2902009000191 TO 5). Rockville, MD: Agency for Healthcare Research and Quality; December 2011. AHRQ Publication No. 12-0011. Available at: http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/pcmh_implementing_the_pcmh___practice_facilitation_v2. Accessed April 4, 2013.