Practice Facilitation Handbook

Module 6 Appendix

Table of Contents

A. Change Process Capability Questionnaire (CPCQ)

How would you describe the approach to quality improvement in your medical group or clinic

  strongly disagree somewhat disagree neither agree or disagree somewhat agree strongly agree NA
1. Clinicians in our medical group/clinic believe that high quality care is very important 1 2 3 4 5 8
2. We have greatly improved the quality of care in the past year 1 2 3 4 5 8
3. We choose new processes of care that are more advantageous than the old to everyone involved (patients, clinicians, and our entire medical group/clinic) 1 2 3 4 5 8
4. Our resources (personnel, time, financial) are too tightly limited to improve care quality now 1 2 3 4 5 8
5. Our medical group/clinic operations rely heavily on organized systems 1 2 3 4 5 8
6. The thinking of our leadership is strongly oriented toward systems 1 2 3 4 5 8
7. Our medical group/clinic attaches more priority to quality of care than to finances 1 2 3 4 5 8
8. The clinicians in our medical group/clinic espouse a shared mission and policies 1 2 3 4 5 8
9. The clinicians in our medical group/clinic adhere to medical group/clinic policies 1 2 3 4 5 8
10. Our medical group/clinic leadership is strongly committed to the need for quality improvement and for leading that change 1 2 3 4 5 8
11. Our medical group/clinic has well-developed administrative structures and processes in place to create change 1 2 3 4 5 8
12. Our medical group/clinic is undergoing considerable stress as the result of internal changes 1 2 3 4 5 8
13. The working environment in our medical group/clinic is collaborative and cohesive, with shared sense of purpose, cooperation, and willingness to contribute to the common good 1 2 3 4 5 8
14. The clinicians in our medical group/clinic are very interested in improving care quality 1 2 3 4 5 8
15. We have many clinician champions interested in leading the improvement of care quality 1 2 3 4 5 8
16. Our medical group/clinic understands and uses quality improvement skills effectively 1 2 3 4 5 8
17. The leaders of our efforts to improve care quality are enthusiastic about their task 1 2 3 4 5 8
18. Our medical group/clinic has a well-defined quality improvement process for designing and introducing changes in the quality of care 1 2 3 4 5 8

Our medical group/clinic has used the following strategies to implement improved care quality…

  strongly disagree somewhat disagree neither agree or disagree somewhat agree strongly agree NA
19. Providing information and skills-training 1 2 3 4 5 8
20. Use of opinion leaders, role modeling, or other vehicles to encourage support for changes 1 2 3 4 5 8
21. Changing or creating systems in the medical group/clinic that make it easier to provide high quality care 1 2 3 4 5 8
22. Removal or reduction of barriers to better quality of care 1 2 3 4 5 8
23. Organizing people into teams focused on accomplishing the change process for improved care 1 2 3 4 5 8
24. Delegating to non-physician staff the responsibility to carry out aspects of care that are normally the responsibility of physicians 1 2 3 4 5 8
25. Providing to those who are charged with implementing improved care the power to authorize and make the desired changes 1 2 3 4 5 8
26. Using periodic measurement of care quality for the purpose of assessing compliance with any new approach to care 1 2 3 4 5 8
27. Reporting measurements of individual or care unit performance for comparison with their peers 1 2 3 4 5 8
28. Setting goals and benchmarking rates of performance quality at least yearly 1 2 3 4 5 8
29. Customizing the implementation of any care changes to each site of care 1 2 3 4 5 8
30. Use of rapid cycling, piloting, pre-testing, or other vehicles for reducing the risk of negative results from introducing organization-wide change in care 1 2 3 4 5 8
31. Deliberately designing care improvements so as to make physician participation less work than before 1 2 3 4 5 8
32. Deliberately designing care improvements to make the care process more beneficial to the patient 1 2 3 4 5 8

B. Case Example


The practice OnlyOneforMiles is interested in working with you to implement panel management and to improve their diabetes care. The CMO is excited about the project and responds to your emails to them about the project within a day. You schedule a meeting with him. You ask him to identify key individuals who might participate on the Care Model project team for the intervention period. He says okay. When the day of the meeting comes, Dr. Enthusiasm shows up for the meeting. But no one else is with him. You ask where the others are and he says that everyone was too busy that day to join.
As the two of you visit about project expectations, he mentions that the CEO is not interested in participating and is concerned the project and changes will make the practice lose money. The practice is also implementing its EHR in the next two months and so staff and clinicians are stretched thin. Despite the challenges, the practice is financially fairly stable, and has a low rate of clinician and staff turnover. The practice recently began to transition to care teams from traditional physician-centric models, which has been causing some conflict, but so far things are going okay with that change.

Dr. Enthusiasm is excited about working with you as he thinks it complements the change to care teams and might help improve them. He also thinks that the practice should try to implement panel managers and wants a practice facilitator to help. He wants to know next steps to starting work with you. Dr. Enthusiasm’s practice is located in a semi-rural community and is one of the only sources of primary care for low-income patients in the region.

C. Sample data inventory form




Information being collected (summary – Optional: attach copy of variables collected to this form)

Source for data

For what patients or activities?

For what purpose? (Fed gov, payer, practice internal QI, other - provide details)

Data source/Method?(Electronic registry (name), paper survey, etc) Provide name and details

When?(Daily, monthly, quarterly)

Being used in QI or clinical care at practice?


Location of data and person in charge of data collection?

What information on race/ethnicity is being collected? (be specific – list variables)

HOW is race/ethnicity info being collected? (pt completes form, verbal question by receptionist, etc.)

EXAMPLE: Diabetes lab data, PHQ 9 data, visit data Manual entry from PHQ9 forms; auto input from billing system; auto input from lab feed All diabetic patients at practice Report to County PPP program; BPC disparities collaborative I2I registry, Excel Spreadsheet Daily as able Partial: Patients w/ elevated PHQ 9s are flagged on a monthly basis and names are given to director of behavioral health Computer in main office; Mary Gonzales Ethnicity: Hispanic/non-Hispanic



African American


Native American

Entered from information provided by patient on “first visit form”

LA Net Data Inventory Form, 2010

Return to Module 6

Page last reviewed May 2013
Page originally created June 2013
Internet Citation: Module 6 Appendix. Content last reviewed May 2013. Agency for Healthcare Research and Quality, Rockville, MD.
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