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Research ArticleOriginal Research

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

Tulay G. Soylu, Alison E. Cuellar, Debora G. Goldberg and Anton J. Kuzel
The Journal of the American Board of Family Medicine January 2021, 34 (1) 40-48; DOI: https://doi.org/10.3122/jabfm.2021.01.200153
Tulay G. Soylu
From the Health Services Administration and Policy, Temple University, Philadelphia, PA (TGS); Department of Health Administration and Policy, George Mason University, Fairfax, VA (AEC, DGG); Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (AJK).
PhD, MHA, MBA
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Alison E. Cuellar
From the Health Services Administration and Policy, Temple University, Philadelphia, PA (TGS); Department of Health Administration and Policy, George Mason University, Fairfax, VA (AEC, DGG); Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (AJK).
PhD, MBA
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Debora G. Goldberg
From the Health Services Administration and Policy, Temple University, Philadelphia, PA (TGS); Department of Health Administration and Policy, George Mason University, Fairfax, VA (AEC, DGG); Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (AJK).
PhD, MHA, MBA
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Anton J. Kuzel
From the Health Services Administration and Policy, Temple University, Philadelphia, PA (TGS); Department of Health Administration and Policy, George Mason University, Fairfax, VA (AEC, DGG); Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (AJK).
MD, MHPE
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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.

Tables

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    Table 1.

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

    OutcomeMean (SD)
    Engagement, mean (SD)
     1) Responsiveness to external support2.22 (0.8)
     2) Overall practice response at coach visit2.71 (0.6)
     3) Overall team assessment for the HVH activity1.76 (1.1)
     4) Assessment of site leadership2.76 (1.1)
     5) Team engagement1.32 (0.1)
     6) Clinician engagement2.22 (0.7)
     7) Staff engagement2.40 (0.7)
    Key independent variable
    Readiness, mean (SD)3.83 (0.3)
    Practice characteristics%
    Practice ownership, mean %
     Independent32
     Hospital owned56
     Federally qualified health center12
    Practice size, number of clinicians, mean %
     2 to 5 clinicians69
     6 to 10 clinicians17
     11 and above clinicians14
    Practice specialty mix, mean %
     Single specialty practice72
     Multispecialty practice28
     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.

    • View popup
    Table 2.

    Engagement Questionnaire Items*

    #Engagement MeasurePurpose of the QuestionnaireScale
    (1)Practice responsiveness to external supportHVH 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 visitAssessed the engagement level of the practice during the coach’s visit.3 = High
    2 = Moderate
    1 = Low
    (3)Overall team assessment for the HVHAssessed the level of practice team involvement for the HVH related activities.3 = High activity
    2 = Moderate activity
    1 = Low activity
    (4)Assessment of site leadershipAssessed 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 engagementAssessed the level of team engagement for the HVH project.3 = High
    2 = Moderate
    1 = Low
    (6)Clinician engagementAssessed the level of clinician engagement (physician, nurse practitioner, physician assistant) during the HVH.3 = High
    2 = Moderate
    1 = Low
    (7)Staff engagementAssessed 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).

    • View popup
    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)
    Readiness1.18 (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 MUA1.02 (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 ≤ 600.99 (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)
    PCMH1.01 (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 ACO0.53 (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 Initiative0.90 (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)
    N195184195195195152168
    • 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.

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The Journal of the American Board of Family     Medicine: 34 (1)
The Journal of the American Board of Family Medicine
Vol. 34, Issue 1
January/February 2021
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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
The Journal of the American Board of Family Medicine Jan 2021, 34 (1) 40-48; DOI: 10.3122/jabfm.2021.01.200153

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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
The Journal of the American Board of Family Medicine Jan 2021, 34 (1) 40-48; DOI: 10.3122/jabfm.2021.01.200153
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