Facilitators support change in practices by focusing a practice’s attention on the process of change and by empowering members of the practice to engage in the change process together. They work to create an environment that supports continuous improvement and introduces values such as respect, inclusion, and neutrality; and where people feel they are involved in the decisionmaking process. Facilitators help demystify improvement methods, evaluation, and research and support data-driven and evidence-based decisionmaking and actions. They create opportunities for practices to learn from each other and help create communities of practice that bring together peers to share best practices and lessons learned. They use participatory methods and have expertise as adult educators and facilitators of change (Department of Health and Community Services, 2006).
Most facilitation interventions pass through a series of predictable stages. Figure 3.1 shows the six stages of most practice facilitation interventions.
Source: Adapted from Knox, 2010.
The first stage involves recruiting practices to participate in improvement and evaluation of their readiness to engage in this work. This phase takes place before active facilitation starts and will typically involve you and other members of your program. It includes several activities:
- Inviting practices to participate in improvement work,
- Conducting an assessment of the practice’s ability to undertake the proposed improvement effort,
- Completing preliminary paperwork such as executing business associate agreements that will allow you to access clinical data for measuring and monitoring practice performance,
- Setting goals with the practice early, and
- Identifying the champion for the improvement effort at the practice and beginning to build a working relationship with him or her.
Stage 2 is the launch of the formal intervention. Typically, it involves an initial meeting with the project champion, you, and other individuals from the practice whom the champion and practice leaders have identified as important to the improvement effort. In this phase, you will work with the project champion to identify his or her quality improvement (QI) team and help ensure that the team includes representatives of staff in operational areas that will play a role in implementing the desired improvements.
You will help convene and facilitate a kickoff meeting for the improvement effort and will work with the QI team to further define and refine the improvement goals identified during stage 1. In this meeting you will also work with the QI team to understand your role and goals as the facilitator or the roles and goals of your team if you use a team approach to facilitation. If the improvement project involves implementation of new treatments or care processes, you may also include a physician academic detailer (a peer from another practice who shares experiences and effective strategies) in the meeting.
Effective facilitation is based on effective relationships. You will need the trust and respect of the practice to succeed. Many of the strategies that sales people use to develop and maintain customers can be useful as you get to know a new practice.
Keeping a card deck with information about each clinician and staff person in the practice can be helpful in remembering the preferences, concerns, and interests of the individuals with whom you will work. Creating a map of the practice and key locations within it can also help. As one expert says, “You’ll know when you’ve established an effective relationship with a practice when they give you the combination to the back door.”
|Effective facilitation is based on effective relationships.|
During stage 3, you will work with the QI team to conduct an initial assessment of the practice in areas related to the improvement effort. You will help the team review and use these data to finalize their goals and performance indicators for the effort.
One of your roles will be to help the practice identify a few easy goals to begin with that can allow you and them to build skills in using the Model for Improvement (MFI) and Plan Do Study Act (PDSA) cycles to test and spread change. It also will help them use tools such as a key driver model (see Module 14) to focus on and select from among the thousands of changes possible those that are most likely to be “high yield” and lead to the greatest improvements for the practice and its patients.
Stage 4 is the heart of the facilitation intervention. One of your earliest and most important jobs in this phase is to help practices build their capacity to generate performance data on the metrics that matter to them and their patients. For many, this step is uncomfortable at first. Clinicians and staff often resist performance reporting, afraid they or their practice will be singled out as underperformers. Most have very legitimate concerns about the accuracy of the data that are used in performance reports.
|Choose “high yield” changes that are the most likely to improve outcomes for patients and the practice.|
During this stage, you will assist the practice in monitoring its progress toward its improvement goals by conducting monthly chart audits and other assessments and providing feedback to the QI team on the results. To do this, you will need to know how to access data from registries and different electronic health record (EHR) systems, as well as how to conduct paper chart audits. You will need to know how to manage and conduct simple analyses of data, and you will need to have a solid understanding of the role of denominators and numerators in performance reporting.
Another important activity you will engage in during this stage is workflow mapping. You will map existing workflows and assist the QI team and practice to redesign various workflows to support desired improvements. You will train the team in the MFI and assist them in designing and carrying-out PDSA cycles to test changes. (See Module 4.) You will train staff and clinicians on key change concepts, provide support and training to staff to build skills and knowledge for assuming new roles or activities, and engage expert consultants and academic detailers to provide additional support, training, and mentoring when needed.
|Practices often need an “early win” to build confidence and positive expectations about their ability to change.|
You will work with the EHR and registry managers to create reporting systems designed to monitor performance in the targeted areas. In addition, you will work with them to introduce modifications to the practice’s EHR and related workflows to support care innovations such as panel management and use of care teams. When you and the practice’s IT staff cannot produce the desired modifications, you will help the practice engage their vendor or will add facilitators with expertise in EHR optimization to your team. The additional facilitators can provide technical assistance to the practice in this area.
Finally, you will help keep the QI team and practice on track with the improvement work and ensure that it does not get lost in the crush of busy workweeks. You will help convene meetings and ensure that they are well facilitated, help the practice create systems for holding team members accountable for deliverables, and help manage and mediate conflicts and disagreements that often arise during change.
Once a practice has achieved its desired changes, attention will drift to other issues. Your job in stage 5 will be to assist the QI team and practice leadership to maintain their gains by creating the conditions needed to sustain the changes long term. You will help them continue performance monitoring and determine how the performance data will be used to ensure that the changes are sustained. You will work with them to incorporate the changes into the practice’s or organization’s policies and procedures, job descriptions and evaluations, and staff orientation and training.
Stage 6: Completion and Transition to Maintenance
While most active facilitation interventions last for less than a year, a priority of your work should be to establish a long-term relationship with your practices. Your ability to achieve this relationship will be determined by your program and by available funding. But the promise and power of practice facilitation lies in the relationships facilitators establish with their practices and the fact that these relationships remain in place over time. Long-term relationships enable a facilitator to rapidly and efficiently re-engage with a practice as needed to support implementation of newly developed treatments, guidelines, and models of care.
In the final stage of an active intervention with a practice, you will focus on closing out the existing improvement intervention and ensuring that:
- The practice has access to all the resources and tools engaged to support the improvement work,
- The practice develops a clear and empowering narrative or “story” about the improvement effort that it can incorporate into its history and organizational memory, and
- The QI team and practice at large have an opportunity to reflect on and react to this story.
Finally, you will work with the practice to transition from active facilitation to maintenance where you will no longer work with the practice on a regular basis, but instead will check in once every 3 to 4 months. To do this, you will first need to help identify someone who can serve as an internal facilitator for the practice and provide extra training and support to this individual. You will work with this person and the QI team to identify the next set of goals that they may want to work on, which should include continued monitoring of the improvements recently put in place.
You will next want to create a means of maintaining a relationship with the practice while they are not part of an active facilitation effort. This might involve sending periodic emails to the QI team, or if appropriate, engaging them to participate as academic detailers or “exemplars” to another practice that is in active facilitation. You also could drop by every few months to check in.
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.