Engagement of Small to Medium-Sized Primary Care Practices in Quality Improvement Efforts

Tulay G. Soylu; Alison E. Cuellar; Debora G. Goldberg; Anton J. Kuzel

doi:10.3122/jabfm.2021.01.200153

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Figure 1.
Descriptive results: engagement across 7 domains. Notes: An ordered scale is from 1 to 3 (3 was the highest, 1 was the lowest response). Sample varies due to the removal of “N/A” or “Unknown” response categories. Responsiveness to external support, overall team assessment, leadership assessment, and team engagement (n = 195). Overall practice response at coach visit (n = 184), staff engagement (n = 162), and clinician engagement (n = 152). Clinician includes MD, DO, NP, PA. Staff includes RN, LPN, MA, front desk, back office, billing, practice manager. Clinician vs staff engagement: Spearman’s correlation coefficient rank test: P = .0001.
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Figure 2.
Readiness to change (mean score) by practice, Heart of Virginia Healthcare, (n = 195). Notes: Readiness was measured by the “readiness” questionnaire¹¹ with a 5-point Likert scale instrument (5 = Strongly agree to 1 = Strongly disagree). The survey was conducted at baseline.

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Table 1.

Baseline Sample Characteristics, Heart of Virginia Healthcare, 2016-2017 (n = 195)

Outcome	Mean (SD)
Engagement, mean (SD)
1) Responsiveness to external support	2.22 (0.8)
2) Overall practice response at coach visit	2.71 (0.6)
3) Overall team assessment for the HVH activity	1.76 (1.1)
4) Assessment of site leadership	2.76 (1.1)
5) Team engagement	1.32 (0.1)
6) Clinician engagement	2.22 (0.7)
7) Staff engagement	2.40 (0.7)
Key independent variable
Readiness, mean (SD)	3.83 (0.3)
Practice characteristics	%
Practice ownership, mean %
Independent	32
Hospital owned	56
Federally qualified health center	12
Practice size, number of clinicians, mean %
2 to 5 clinicians	69
6 to 10 clinicians	17
11 and above clinicians	14
Practice specialty mix, mean %
Single specialty practice	72
Multispecialty practice	28
Medically underserved area, mean %	64
Recognized as a patient-centered medical home, mean %	52
Part of an accountable care organization, mean %	62
Participation in Million Hearts Initiative, mean %	8
Percentage of patients aged 60 years and above, mean %	27

Notes: Mean (SD). Summary statistics display the number of observations at baseline (near the HVH started) across the 7 engagement items. Assessed on an ordered scale from 1 to 3, in which high scores indicate higher levels of engagement (recoded as: 3 = “high”, 2 = “moderate”, and 1 = “low”). Sample varies due to the “N/A” or “unknown” data removal. Practice characteristics (n = 195). Clinicians include physicians (MD, DO), nurse practitioners, and physician assistants.

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Table 2.

Engagement Questionnaire Items*

#	Engagement Measure	Purpose of the Questionnaire	Scale
(1)	Practice responsiveness to external support	HVH coach support was assessed by asking: “How would you rate the practice’s responsiveness to the external support provided?”	3 = High 2 = Moderate 1 = Low
(2)	Overall practice response at coach visit	Assessed the engagement level of the practice during the coach’s visit.	3 = High 2 = Moderate 1 = Low
(3)	Overall team assessment for the HVH	Assessed the level of practice team involvement for the HVH related activities.	3 = High activity 2 = Moderate activity 1 = Low activity
(4)	Assessment of site leadership	Assessed the engagement level of practice leadership (lead physician or practice manager) during the HVH.	3 = High leadership support (job descriptions and/or performance evaluations are tied to QI) 2 = Moderate leadership support (some coordination of projects exists; QI work is somewhat integrated into daily routines) 1 = Low leadership support (leadership is involved, but no organized improvement structure)
(5)	Team engagement	Assessed the level of team engagement for the HVH project.	3 = High 2 = Moderate 1 = Low
(6)	Clinician engagement	Assessed the level of clinician engagement (physician, nurse practitioner, physician assistant) during the HVH.	3 = High 2 = Moderate 1 = Low
(7)	Staff engagement	Assessed the engagement level of staff (ie, registered nurses, medical assistants, practice managers, billing personnel, receptionists, back office workers, licensed nurse practitioners) during the HVH.	3 = High 2 = Moderate 1 = Low

QI, quality improvement; HVH, Heart of Virginia Healthcare.
The order of the engagement instrument scale was from 1 to 3, a positive response receiving the highest score of engagement: 3 = “high,” 2 = “moderate,” and 1 = “low.”
↵* The engagement instrument was developed by the EvidenceNOW (2016) for this purpose. (Source: US Department of Health and Human Services. Agency for Healthcare Research and Quality (AHRQ). EvidenceNow: advancing heart health in primary care, 2016¹¹).

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Table 3.

Adjusted Multivariate Ordered Logistic Regression (Odds Ratios and 95% CIs): Association of Practice Engagement and Practice Readiness and Practice Characteristics

	(1) Response to External Support* OR (95% CI)	(2) Response at Coach Visit* OR (95% CI)	(3) Team Assessment* OR (95% CI)	(4) Leadership Assessment* OR (95% CI)	(5) Team Engagement* OR (95% CI)	(6) Clinician Engagement* OR (95% CI)	(7) Staff Engagement* OR (95% CI)
Readiness	1.18 (0.47-2.98)	3.52 (0.98-12.56)	0.78 (0.28-2.19)	3.19 (1.10-9.24)^†	0.96 (0.39-2.39)	5.74 (1.79-18.42)^‡	1.19 (0.40-3.59)
Practice Ownership Independent Hospital FQHC	Reference 0.83 (0.43-1.59) 1.26 (0.35-4.52)	Reference 0.83 (0.34-1.99) 1.49 (0.18-12.30)	Reference 1.75 (0.87-3.53) 0.83 (0.22-3.07)	Reference 0.92 (0.45-1.91) 3.92 (0.92-16.72)	Reference 1.13 (0.59-2.18) 1.63 (0.43-6.09)	Reference 0.35 (0.16-0.76)^‡ 0.76 (0.16-3.65)	Reference 0.78 (0.36-1.69) 1.69 (0.33-8.74)
Practice size (# of clinicians)	1.69 (1.07-2.69)^†	1.20 (0.67-2.14)	0.71 (0.45-1.11)	2.32 (1.41-3.83)^‡	1.89 (1.18-3.02)^‡	1.07 (0.63-1.80)	2.07 (1.19-3.63)
Practice specialty mix (single/multi)	1.34 (0.67-2.68)	0.92 (0.38-2.28)	0.90 (0.42-1.93)	1.70 (0.77-3.77)	2.86 (1.37-5.60)	1.24 (0.53-2.88)	1.30 (0.58-2.93)
Practice serves in MUA	1.02 (0.46-2.26)	1.58 (0.49-5.10)	0.51 (0.22-1.20)	0.83 (0.34-2.03)	1.24 (0.56-2.77)	1.14 (0.47-2.80)	0.81 (0.31-2.11)
Percentage of patients ≤ 60	0.99 (0.98-1.00)	1.00 (0.99-1.02)	1.00 (0.98-1.00)	1.00 (0.99-1.02)	1.00 (0.99-1.02)	1.01 (0.99-1.02)	1.00 (0.98-1.01)
PCMH	1.01 (0.54-1.89)	0.97 (0.40-2.26)	0.81 (0.41-1.59)	2.14 (1.04-4.42)^†	1.12 (0.59-2.15)	1.57 (0.71-3.48)	1.58 (0.74-3.35)
Part of an ACO	0.53 (0.25-1.09)	0.39 (0.13-1.19)	1.01 (0.46-2.21)	0.76 (0.33-1.72)	0.69 (0.33-1.43)	0.48 (0.20-1.17)	0.22 (0.09-0.56)
Million Hearts Initiative	0.90 (0.31-2.59)	1.85 (0.37-9.27)	0.91 (0.30-2.78)	3.53 (1.06-11.76)^†	2.61 (0.92-7.43)	2.62 (0.68-10.19)	3.20 (0.80-12.72)
N	195	184	195	195	195	152	168

ACO, accountable care organization; FQHC, federally qualified health center; MUA, medically underserved area; PCMH, patient-centered medical home; OR, odds ratio; CI, confidence interval. The number of observations vary due to the removal of “N/A” or “unknown” response categories.
Multivariate ordered logit models at the practice level are displayed, controlling for practice ownership (independent, hospital owned, or FQHC), practice size, single- or multi-specialty practice, whether practice is located in a medically underserved area, percentage of patients 60 years and above, practice recognized as a PCMH, part of an ACO, and participation in the Million Hearts project.
↵* Assessed on a scale from 1 to 3, in which high scores indicate higher levels of engagement (recoded as: 3 = “high”, 2 = “moderate”, and 1 = “low”).
↵† P < .05.
↵‡ P < .01.