Executive Summary: Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators
In an effort to create a high-quality health care system in the United States, many payers, providers, delivery systems, and other organizations are using quality improvement (QI) initiatives to improve the performance of the Nation’s primary care practices.1 QI requires practices to assess performance continually, to plan changes and monitor their effects, and to refine as needed.
External organizations that support primary care practices to build and sustain QI capacity may be QI organizations, regional extension centers, professional societies and payers, and health care organizations that own or contract with practices. The professionals from these organizations who support practices have a variety of titles; the term used here is practice facilitators. This paper was written for practice facilitators and the organizations that train and deploy them to support primary care practices in undertaking QI efforts.
The paper distills the wisdom of experts who have honed their approaches through working with thousands of practices on QI and practice redesign initiatives. Section 1 provides a conceptual background and framework for how to engage primary care practices in QI. Section 2 provides practical strategies for practice facilitators to gain initial buy-in from practices, as well as tips for maintaining meaningful and sustained engagement in QI efforts.
Section 1: A Framework for Thinking About How to Engage Practices in QI
Before attempting to engage a practice in QI initiatives, practice facilitators must understand a practice’s willingness to change and organizational stability and resources. Together, these concepts describe a practice’s readiness to engage, which can help a facilitator determine whether it is an appropriate time to work together and, if so, allows facilitators to tailor the approach in a way that best suits the practice’s needs. Facilitators can use assessment tools to determine a practice’s overall readiness for undertaking QI efforts.
A practice’s undertaking of QI activities can be viewed through the lens of Prochaska’s transtheoretical model of behavior change (1992), which identifies five stages of change: precontemplation (no intention to change a behavior in the near future); contemplation (desire to change a behavior, but ambivalence about pros and cons); preparation (pros beginning to outweigh cons, and action intended); action (change beginning, but relapse still likely); and maintenance (new behavior attained and maintained). The role of the practice facilitator is likely to vary depending on a practice’s level of readiness.
Section 2: Strategies for Engaging Practices in QI Efforts
Several strategies may be helpful in building relationships, gaining initial buy-in, and maintaining that buy-in for meaningful and sustained QI work.
Build trusted relationships with practices. Possible strategies include:
- Partnering with groups trusted by the practice
- Working with early adopter practices with opinion leaders on staff to establish credibility in the community
- Using practice facilitators who will be seen as credible to practices based on their clinical experience or transparent approach
- Approaching conversations as “respectful negotiations” rather than telling practices what to do
- Ensuring openness and transparent communication about QI goals and processes with all practice staff
Target the most appropriate person in the practice. Identify those individuals responsible for decisionmaking and try to gain buy-in from these people, regardless of their titles. Then work to engage others in the practice with the help of key opinion leaders.
Tailor the message, depending on whether the audience is clinicians or other staff. Use effective messaging strategies specific to each audience, and consider peer-to-peer education as an effective tool for delivering these messages to clinicians and staff.
Use appropriate messaging techniques, such as: 1) data feedback and benchmarking, 2) identification of areas in which the practice is facing challenges and provision of solutions, 3) identification of a practice’s core values and demonstration of how QI can help deliver care aligned with these values.
Maintain buy-in for sustained QI efforts with strategies such as:
- Ensuring that everyone who can influence change is brought on board.
- Starting with an “early win.” Encourage the practice to choose a first QI project that is relatively easy and will produce benefits quickly.
- Harnessing the power of patient engagement by adding patient partners to QI teams, revising mission statements, and celebrating wins for patients and families.
To engage practices effectively, facilitators should assess the practice’s readiness to engage, develop tailored strategies appropriate for the practice, and maintain practice buy-in for meaningful and sustained engagement in QI efforts.
The full white paper from which this executive summary is drawn includes a list of resources on quality improvement in primary care, practice facilitation, tools and manuals for practice facilitators, and practice assessment tools. The white paper is available on AHRQ’s PCMH Resource Center Web site at http://pcmh.ahrq.gov/sites/default/files/attachments/QI-strategies-practices.pdf.
- We use the phrases “QI initiatives,” “QI activities,” and “QI efforts” here to refer broadly to both specific QI initiatives and broader efforts undertaken toward practice redesign and transformation. Go back