Why is External Facilitation Effective as an Implementation Strategy Why is External Facilitation Effective as an Implementation Strategy? Evidence for Tailoring in Primary Care Practices Parchman ML, Hsu C, Coleman K, Kaiser Permanente Washington Health Research Institute SIRC September 2017 Acknowledgements This project is supported by grant number R18HS023908 from the Agency for Healthcare Research & Quality Twitter: DrMParchman Kaiser Permanente Washington Health Research Institute

What is External Facilitation? Both a “role” and a “process” “A process of interactive problem solving and support that occurs in a context of a recognized need for improvement and a supportive interpersonal relationship.” [Powell 2015] “Facilitation is a goal-oriented, context dependent social process for implementing new knowledge into practice or organizational routines.” [Berta 2015] Twitter: DrMParchman

Facilitation Processes External facilitation of primary care has been proposed as a meta-routine that enhances absorptive or learning capacity: the practice’s ability to recognize the value of new knowledge, assimilate it, and apply it to patient care.* *Berta W, Cranley L, Dearing JW, Dogherty EJ, Squires JE, Estabrooks CA. Why (we think) facilitation works: insights from organizational learning theory. Implmentation Science. 2015;10:141 Twitter: DrMParchman

Facilitation links to Learning Theory A facilitation micro-process hypothesized to enhance internal absorptive capacity is “tailoring facilitation activities to local needs and circumstances.” This tailoring activity that some hypothesize explains the effectiveness of external facilitation in expanding the internal learning capacity of practices that leads to practice change and improved patient outcomes. Twitter: DrMParchman

Purpose Here we examine evidence of tailoring by the external facilitator to match the absorptive/learning capacity of smaller primary care practices for the purpose of building their quality improvement (QI) capacity. Twitter: DrMParchman

Setting Healthy Hearts Northwest (H2N): a trial of implementation strategies to build QI capacity in smaller primary care practices across Washington, Oregon and Idaho. All sites receive support from an external practice facilitator (PF) through monthly in-person visits and/or phone calls. Twitter: DrMParchman

Healthy Hearts Northwest 831 Miles Twitter: DrMParchman

Healthy Hearts PF Training Session Twitter: DrMParchman

QI/Learning Capacity QI/Learning Capacity self-assessed by practice QI team during initial visit by the PF across seven High Leverage Changes: Embedding clinical evidence into care Using data for improvement Establishing a QI process Identifying at-risk patients, Defining team roles Self-management support Linking to community resources Twitter: DrMParchman

n=20 Items Twitter: DrMParchman

Topics Discussed

Analysis Here we examined the association between QICA scores and the number and type of topics discussed. We also draw on field notes generated by the facilitators after each practice encounter. Twitter: DrMParchman

Results 209 smaller primary care practices across Washington, Oregon and Idaho. The mean QICA score was 6.55 (SD 1.49, range 3.3 to 10.8). Total topics discussed ranged from 1 to 18 with a mean of 5.2 (SD 2.9) median of 4.7. Twitter: DrMParchman

Practice Characteristics Mean (S.D.) or % Clinician FTE 4.5 (5.25) Clinician Owned 40% Rural 47% Medicare 24.6% Medicaid 24.3% QICA Score 6.55 (1.49) Total Topics Discussed 5.2 (2.9) Range 1 to 18 Twitter: DrMParchman

QICA Scores and Topics Discussed QICA Total Score Using Data to Improve Identify At-risk patients Team Roles and Tasks Total Topics r= 0.179 (p=.014) n/s HIT Topics r= .161 (p=.028) r= 0.26 (p<.001) r=0.16 (p=.03) QI Topics r= 0.171 (p=.019) r = 0.15 r= -0.15 (p=.04) These relationships remained unchanged after controlling for number of visits and length of visit with the external facilitator (*Note inverse relationship between team roles/tasks and #QI topics) Twitter: DrMParchman

Comments from External Facilitators “There's no recipe. Every team responds differently, every individual responds differently.” “It’s just kind of trying to figure out how to bring it up, how to approach it. How will people be the most receptive to getting over that barrier so we can then start working on the other stuff?” “I use larger concepts and apply them in different ways to get to something that they're more interested in.” Here are some quotes to pick from: ORPRN P7: it's different for every clinic. There's no recipe. Every team responds differently, every individual responds differently. If they're a single practice, a single provider practice, a larger clinic, part of a health system, it -- all of these things play into how people would react to even approaching the topic. So I mean, there -- realistically I don't think there is a strategy, at least not for me. It's just to kind of get the best picture I can of what's going on and if it will or not impact the work that I'm trying to do with them, and then if it will, trying to figure out how to bring it up, how to approach it. How will people be the most receptive to getting over that barrier so we can then start working on the other stuff? ORPRN P5: when you're thinking about challenges, investigating what they're interested in is another piece. So a practice that was -- and Steven, I think, had a practice very similar, was interested in not just checking the box on screening versus smoking and doing some counseling, but to actually look at, What are our quit rates? so being able to find ways to be -- to kind of address patient readiness for change, as well. So using larger concepts and applying them in different ways to get to something that they're more interested in, which was an outcome, rather than a process measure. QUALIS P5: But it's really to me been a lot of just listening, like (Participant 3) said, motivational interviewing: Tell me more why you feel about that. Have you ever thought about this? How would you fix that? QUALIS P2: Even like on the smaller scale too is offering -- if they're already doing QI, like examine what they're doing and where their gaps are, if they need a better tool or they need a different process perhaps. Being able to offer them different ways of looking at the work they're doing, different from what they -- For example, one clinic showed me like, "This is how we're going to track our nine measures for meaningful use" or whatever. And I noticed their spreadsheet didn't really work and so I created then a better spreadsheet and sent it to them. Twitter: DrMParchman

External Facilitation Conclusions: External facilitators tailor the support they provide to the learning capacity of individual practices. Implications for Policy or Practice: Implementation interventions that allow for facilitation tailored to the learning capacity of an individual practice may be more effective and explains why practice facilitation as an implementation strategy is effective. Twitter: DrMParchman

Thanks! Acknowledgements: Qualis Health and their Practice Facilitators Oregon Rural Practice Research Network and their Practice Enhancement Research Coordinators (PERCs) Contact Info: parchman.m@ghc.org Acknowledgements This project is supported by grant number R18HS023908 from the Agency for Healthcare Research & Quality Twitter: DrMParchman