Quick-Start Guide: Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
Contract No. HHSA290200900019I/HHSA29032006T
Mathematica Policy Research
- Kristin Geonnotti, Ph.D., Mathematica Policy Research
- Deborah Peikes, Ph.D., M.P.A., Mathematica Policy Research
- Erin Fries Taylor, Ph.D., M.P.P., Mathematica Policy Research
- Robert McNellis, M.P.H., P.A., Agency for Healthcare Research and Quality
- Janice Genevro, Ph.D., Agency for Healthcare Research and Quality
- Deborah Peikes, Ph.D., M.P.A., Mathematica Policy Research
- Erin Fries Taylor, Ph.D., M.P.P., Mathematica Policy Research
It can be challenging to engage primary care practices in quality improvement (QI) initiatives—a new endeavor for most practices—even when the potential benefits to the practices and their patients are clear. Because primary care clinicians and staff often feel intense time pressures, and because practices often operate on thin profit margins, the perceived costs of engaging in QI may seem to outweigh the anticipated benefits. Even when practices recognize the importance of improving their performance, or are financially incentivized to do so, they may not know where or how to begin QI activities, or how to make QI an integral and systematic part of their work. Even the most determined practice is likely to benefit from assistance in developing new skills to meet its improvement goals, including identifying areas for improvement, understanding and using data, planning and making system-level changes, and tracking performance over time.
This guide distills wisdom and best practices from experts who have honed their approaches through working on QI and practice redesign initiatives with more than 6,000 practices in 44 States. It is designed for people like you who support primary care practices in QI efforts, who we refer to here as practice facilitators.1 A white paper, Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators, provides more details, and a set of tools and resources, such as assessments that you can use with primary care practices. This guide presents a summary to support your work assessing practice readiness to engage in QI, as well as strategies that experts suggest might be helpful for meaningful and sustained QI efforts.
Understanding Practice Readiness to Engage in QI
A critical first step in facilitating QI efforts is understanding whether the practice is ready to engage. This helps you and the practice determine whether it is an appropriate time to work together and, if so, allows you to tailor an approach that best suits the practice’s needs. Readiness to engage has two components:
- Willingness to change is the motivation and receptivity that individuals in a practice demonstrate toward engaging in the QI process and working with a practice facilitator.
- Organizational stability and resources involves the presence of practice leadership, adequate financial and other resources (including time) devoted to making changes, a practice culture with a positive attitude toward change, and the absence of a disruptive level of organizational stress (Solberg, 2007; Cohen et al., 2004; Bodenheimer et al., 2004).
The experts we consulted emphasized four critical elements of readiness to engage:
- Practice Leadership: Practices need influential leader(s) to offer a clear vision of what needs to be accomplished and to redirect resources, staff, and time to new QI efforts. Practices also need effective day-to-day leadership of QI activities, which might come from anyone on the team.
- Resources: Although practices may share in cost savings that result from QI efforts, initial efforts to implement QI often introduce new costs, such as time demands on staff. Practices in stronger financial health or with outside financial supports are more likely to be able to engage in QI.
- Practice Culture: Engagement in these initiatives is more likely to be productive when clinicians and practice staff decide to participate because the QI efforts align with their fundamental norms and values—a practice with a positive attitude toward change may be readier to engage.
- Other contextual factors: These include structural characteristics—such as the size, age, and maturity of the practice and whether it is situated within a broader health system or is independent, and the way in which individuals in the organization communicate with each other.
Using Practice Assessments
You can use assessment tools to determine whether a practice is ready to engage in QI and how best to work with the practice staff.2
- Assess a practice’s broad readiness to engage in QI work, including its willingness to change and its organizational stability and resources.
- Track progress over time. You can use periodic assessments to track change and provide feedback to the practice on its performance over time, recognizing that significant practice change takes time.
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 efforts.
1. Set the stage for a future relationship with practices not yet ready to engage.
- Get a foot in the door. For practices not yet ready to engage, you can focus on how to make it easy for them to turn to you for support when they become ready. You can do this by acting as a consistent source of helpful information or sharing opportunities to engage in learning collaboratives or other events.
2. Build trusted relationships with practices.
- Establish a “relationship by proxy” by partnering with organizations already trusted by the practice. Working with organizations or community groups that the practice already knows and trusts, such as an Area Health Education Center (AHEC), a State primary care association, or a Practice-Based Research Network (PBRN), can help convince practices to extend that trust to you.
- Work with early adopters/opinion leaders. This is an effective way to establish credibility and can be a powerful motivator to other practices.
- Approach conversations as “respectful negotiations.”Approaches that simply tell practices what to do when setting priorities for QI initiatives are unlikely to be effective in the long run. A commitment to collaboration (and humility) will go a long way in supporting practice staff and working with practices to identify and achieve those QI goals most important to them.
- Ensure transparent communication. Encourage openness and transparency with practices when undertaking QI, perhaps even establishing a communication team as a subgroup of the QI team at the practice to ensure that the process is transparent to all practice staff.
3. Target the most appropriate person in the practice.
- Identify the most appropriate practice leaders with the most influence in a practice—regardless of their titles. Identify these leaders either formally or informally, as they will be the individuals responsible for decisionmaking and needing to be convinced that QI is an important and worthy undertaking.
- Bring practice staff on board gradually. You may not need to bring all staff on board immediately, but may find it more effective to work with key opinion leaders first, who can then help to bring others in the practice along by serving as champions and providing strong leadership, a clear vision, and the guidance necessary for full staff engagement.
4. Tailor the message.
- If the audience is composed of clinicians: Encourage them to consider how engaging in QI could help them rediscover a way of practicing medicine closer to the style they envisioned when they began their careers, using the strengths of other levels of clinical staff to care for patients and nonclinical staff to perform administrative work.
- If the audience is an office manager: Describe how more efficient, streamlined workflows and processes can benefit managers who may be accustomed to working in an extremely busy environment in which they perform many diverse functions.
- If the audience includes other staff: Some staff members may respond to the rewards of new challenges; others may respond to the promise of QI to reduce waste and streamline processes (most staff like going home on time). Consider how all staff members can contribute to the initiative.
Peer-to-peer education can be an effective tool in delivering these tailored messages to clinicians and staff. Ideally, you can look in the local community to partner clinicians and staff who have used successful QI approaches with practices just starting out together in a learning community or more informal network.
5. Use appropriate messaging techniques.
- Use data feedback and benchmarking. Providing practices with information on their performance compared to external benchmarks (such as regional or national averages), and helping to target areas for improvement requires thoughtful and effective communication. It is important to deliver this information in a nonjudgmental way, acknowledging strengths as well as opportunities for improvement.
- Engage in storytelling/painting a picture. Illustrating the ways in which practice facilitators can help practices engage in QI and ultimately function more smoothly can be an effective messaging technique.
- Identify “pain points” and offer solutions. Use a needs assessment to identify areas in which the practice is facing challenges and knows that change is needed; then, offer concrete solutions that can be accomplished through QI.
- Identify and draw on a practice’s core values and larger mission. Consider identifying a practice’s values and demonstrating how QI efforts will enhance its ability to deliver care aligned with these values.
- Emphasize broader changes in the health care field. Stressing that the field as a whole is headed toward ongoing QI and delivery system redesign (for example, publicly reported quality measures or financial rewards for improved patient outcomes) can help convince practices that engagement in QI is necessary and that they should prepare for these changes.
Maintaining Buy-In for Meaningful and Sustained QI Efforts
Although the strategies described above can help you gain initial buy-in by practices, it is crucial to employ techniques that maintain and further build a collaborative relationship with them. Several techniques can help you offer continuing support to practices as they develop QI capacity and infrastructure, and make QI an integral part of their organizations:
- Ensure that all people with the ability to influence change are brought on board. Even if you initially secured buy-in from those with formal power (e.g., a lead clinician), there may be others in the practice with informal power who should be engaged to maximize chances for success.
- Start with an “early win.” Many QI projects require extended periods of intense work before any positive results emerge, which may be discouraging for staff and erode initial buy-in. You might demonstrate an “early win” by encouraging the practice to choose as the first QI project one that is relatively easy to pursue and will produce benefits quickly.
- Adopt strategies to ensure long-term success and mitigate the risk of “change fatigue.” When practices try to engage in too many complex QI efforts concurrently, they run the risk of experiencing “change fatigue.” It is important to build capacity incrementally, providing positive encouragement and regular reflection on what the practice has accomplished, emphasizing that the process will take time.
- Harness the power of patient engagement. Engaging patients in QI efforts can help sustain practice buy-in for QI activities by helping to shape priorities for QI, narrowing down options for how to undertake improvement activities, and helping assess progress. This is also important in its own right, allowing practices to see how their current system works through their patients’ eyes and motivating them to implement changes that will improve patient experience.
- Consider working with multiple QI programs.Help practices understand synergies between the projects and incentive programs in which they participate and make them aware of opportunities for additional payment or to join local or statewide initiatives.
Engaging in QI and practice redesign activities allows primary care practices to work toward improved quality, better health, improved patient and provider experiences, and reduced cost of care. Practices can benefit from your support in guiding them through this process using the following strategies:
- Assess the practice’s readiness to engage.
- Develop tailored strategies appropriate for the practice.
- Maintain practice buy-in for meaningful and sustained engagement in QI efforts.
By offering support through a collaborative and productive relationship, your work can help improve the outcomes of primary care in the United States.
- Bodenheimer T, Wang MC, Rundall TG, et al. What are the facilitators and barriers in physician organizations' use of care management processes? Jt Comm J Qual Saf 2004 Sep;30(9):505-514.
- Cohen D, McDaniel RR, Crabtree BF, et al. A practice change model for quality improvement in primary care practice. J Healthc Manag 2004;49(3):155-168.
- Solberg L. Improving medical practice: a conceptual framework. Ann Fam Med 2007
These individuals may have a variety of titles, including practice facilitators, coaches, QI consultants, and extension agents. Here we refer to these external change agents as practice facilitators.
You can find a set of Tools and Resources in the accompanying white paper (Geonnotti et. al., 2014), including practice assessments that can be used to determine whether a practice is ready to engage.