1. 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 R18HS from the Agency for Healthcare Research & Quality
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Kaiser Permanente Washington Health Research Institute

2. 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]
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3. 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
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4. 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.
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5. 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.
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6. 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.
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7. Healthy Hearts Northwest
831 Miles
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8. Healthy Hearts PF Training Session
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9. 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
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10. n=20 Items
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11. Topics Discussed

12. 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.
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13. 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.
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14. 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
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15. 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= (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)
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16. 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.
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17. 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.
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18. Thanks!
Acknowledgements:
Qualis Health and their Practice Facilitators
Oregon Rural Practice Research Network and their Practice Enhancement Research Coordinators (PERCs)
Contact Info:
Acknowledgements This project is supported by grant number R18HS from the Agency for Healthcare Research & Quality
Twitter: DrMParchman