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Research ArticleOriginal Research

Successful Trial of Practice Facilitation for Plan, Do, Study, Act Quality Improvement

Kent F. Sutton, Erica L. Richman, Jennifer R. Rees, Liza L. Pugh-Nicholson, Macie M. Craft, Shannon H. Peaden, Monique Mackey, Jacqueline R. Halladay and Southeastern Collaboration to Improve Blood Pressure Writing Group
The Journal of the American Board of Family Medicine September 2021, 34 (5) 991-1002; DOI: https://doi.org/10.3122/jabfm.2021.05.210140
Kent F. Sutton
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Erica L. Richman
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Jennifer R. Rees
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Liza L. Pugh-Nicholson
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Macie M. Craft
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Shannon H. Peaden
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Monique Mackey
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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Jacqueline R. Halladay
the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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the University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research (KFS, ELR, JRH); Duke University School of Medicine, Durham, NC (KFS); University of North Carolina at Chapel Hill, North Carolina Translational and Clinical Sciences (JRR); University of Alabama at Birmingham, Birmingham, AL (LLP, MMC); Samford University, Birmingham, AL (LLP, SHP); East Carolina University, Greenville, NC (MM); Area L Area Health Education Center, Rocky Mount, NC (JRH).
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    Figure 1.

    Key Drivers of Implementation Domains and Supporting Activities for Plan, Do, Study, Act (PDSA) framework in Practice Facilitation. Abbreviations: BP, blood pressure; HTN, hypertension.

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    Figure 2.

    One Practice's Standardized Care Plan, Do, Study, Act Process using the Key Driver Implementation Scale.

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    Figure 3.

    Months of Active Practice Facilitation by Study Site, Facilitator, and Practice in the Southeastern Collaboration (SEC) to Improve Blood Pressure Control Trial. *PF 1a's practices were facilitated by PF 1b starting in study month 5; Pr = Practice; Site = University site in the SEC study. Abbreviation: PF, practice facilitation.

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    Figure 4.

    Percentage of Plan, Do, Study, Act (PDSA) cycles by months active in the overall sample (n = 128 PDSA cycles) in the Southeaster Collaboration to Improve Blood Pressure Control Trial.

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    Figure 5.

    Plan, Do, Study, Act (PDSA) Cycles by Key Driver Domain in the Southeastern Collaboration to Improve Blood Pressure Control Trial. Abbreviations: CIS, Clinical Information Systems; SCP, Standard Care Processes; OTC, Optimized Team Care processes; SMS, Patient Self-Management Support.

Tables

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    Table 1.

    Summary of Practice Facilitator Training

    Training Activity/ResourceDetails
    Practice Facilitator Certificate Program at Millard Fillmore College of the University at Buffalo of The State University of New York
    • Building organizational capacity in change management

    • Building core competencies in using quality improvement methods (engaging practice teams in PDSAs, using data to drive change, doing workflow analysis, and using the Chronic Care Model23

    • 40 hours of fieldwork with an experience practice facilitator mentor

    Motivational Interviewing Training
    • A half-day workshop on how to use motivational interviewing to encourage practice change, help patients with self-management support, and keep practices engaged in the research project

    Twice monthly practice facilitation 1-hour long work group calls (Year 1 to 4) (Year 5 reduced to monthly)
    • Videoconference calls to support PF work within the practice and to implement the study protocol, during which PFs shared and archived helpful resources

    • Specific training in health equity and how to guide practices to engage in PDSA activities that specifically focused on enhancing outcomes for African American patients

    Practice Facilitation Implementation Guide designed around the Key Driver Framework
    • Thirty-page “how to” study implementation guide for facilitators including ideas for PDSA activities to guide practices to select activities to implement, including those that focus on enhanced activities to better serve African American patients. The guide included background on the study, descriptions of the 4 Key Driver domains, and an inventory of potential QI activities nested within Key Driver domains

    Other professional development activities
    • Practice Facilitation professional development experiences and team presentations on early lessons and study findings

    • Attendance at The North American Primary Care Research Group's International Conferences on Practice Facilitation: November 2017, December 2018, and June 2019

    • PF, practice facilitation; PDSA, Plan, Do, Study, Act; QI, quality improvement.

    • View popup
    Table 2.

    Key Driver Implementation Scale (Descriptions Have Been Shortened for Publication)

    Clinical Information Systems (CIS). The practice…
        0currently does not review practice population data
        1trusts their BP data reports enough to consider implementing change activities
        2has access to reliable data on their patients with HTN
        3reviews BP data monthly, discusses how to make changes to improve processes to optimize BP control
    Standardized Care Processes (SCP). The practice…
        0no activity on following evidence-based protocols for HTN
        1has identified ≥ evidence-based protocol(s) for HTN, has begun customizing it for their practice
        2has no activity on following evidence-based protocols for hypertension
        3has established a workflow to implement ≥ 1 HTN protocol, and it has been tested it on a few patients
        4has implemented an evidence-based protocol for HTN, but not yet used with all patients
        5routinely fully implements ≥ 1 evidence-based protocol for HTN
    Optimized Team Care (OTC). The practice…
        0has no QI activities related to HTN
        1has occasional meetings/discussions about HTN QI, but no practice-wide understanding of QI
        2has a QI team that communicates regularly, plans tests, discusses results, knows project's focus/measures
        3QI team runs multiple tests simultaneously, communicates findings, and the entire office staff
    Self-Management Support (SMS). The practice…
        0currently has no activity on self-management support for patients with hypertension
        1staff understands the difference between patient education and self-management support
        2identifies HTN related SMS resources and incorporates the use of the resources into their workflow
        3develops tracking systems to monitor use of HTN-related SMS resources
        4care team collaborates with patients to sets, documents, and reviews HTN-related SMS goals
        5care team assess patients' confidence level related to managing their hypertension
    • HTN, hypertension; QI, quality improvement.

    • View popup
    Table 3.

    Characteristics of the 32 Study Practices Exposed to Practice Facilitation Services

    Practice Characteristics Survey Items, [# Missing]n/Mean (%, SD, range)*
    Practice Size (mean, range)
    Number of full-time providers (MD/DO, NP, PA), 03.7 (0 to 21)
    Number of part-time providers (MD, DO, NP, PA), 00.9 (0 to 18)
    Number of other professionals (nurses, administrative/clinical support staff), 012.3 (2 to 53)
    Practice ownership type, [0 missing] (N, %)
    Private11 (34.4%)
    Federally qualified health clinic or look-alike15 (46.9%)
    Free Clinic1 (3.1%)
    Part of a hospital/health system5 (15.6%)
    Number of years practice has been in operation, 0 (N, range)16 (1 to 42)
    Payer mix [0 missing], (% and range)
    Medicare22% (0% to 60%)
    Medicaid23% (0% to 50%)
    Dual Medicare/Medicaid8.5% (0% to 30%)
    HMO, PPO, Commercial21% (0% to 72%)
    Uninsured24% (0% to 100%)
    Other2% (0 %to 17%)
    Has received patient-centered medical home recognition, [1] (n, %)10 (32%)
    Number of patient visits to providers per year, 0 (mean, range)11,928 (1 to 100,000)
    Practice busyness34 (0 to 10, where 10 is most busy), 0, (mean ± SD)7.5 ±1.7
    % African American patients, 0, (mean, range)57.5% (25% to 94%)
    % Hispanic/Latino patients, [4], (mean, range)10% (0% to 60%)
    Number of practices with prior quality improvement project experience with chronic disease focus 0 (n, %)27 (84%)
    • SD, standard deviation; HMO, health maintenance organization; PPO, preferred provider organization.

    • ↵* Data provided as absolute numbers or means and standard deviations (SD) for continuous variables and proportions as appropriate. Data rounded to tenths position.

    • View popup
    Table 4.

    Examples of Most Engaging and Durable PDSAs (PDSAs) Activities by Key Driver Domain

    Key DriverExample Activities
    Clinical Information Systems (CIS)
    • Creating a practice level list and monthly reports of patients with HTN and uncontrolled HTN

    • Creating lists of hypertensive patients without recent visits or with uncontrolled HTN at their last visit for outreach

    Standard Care Processes (SCP)
    • Instructing practice staff on guideline-concordant blood pressure measurements, including use of sound reduction equipment to provide a calm environment for patients during BP assessments and use of posters throughout the clinics demonstrating proper technique and engaging in refresher sessions to maintain focus on proper measurement technique

    • Working with staff to document BP in EHRs such that the data would populate HTN reports

    • Standardizing staff behaviors to repeat BP measurements for patients with SBP and DBP values ≥ 140 and/or ≥ 90 mm Hg

    Optimized Team Care processes (OTC)
    • Holding group QI meetings with attendance where data review and improvement activities were devised

    • Creating HTN control educational videos for patients related to nutrition, lifestyle, and medication adherence

    • Weekly huddles to identify patients with uncontrolled BP and those requiring extra support; instituting processes for making follow-up phone calls to check on patient's engagement in their own care and reporting out of office BP measurements back to staff

    • Having all clinic staff wear different HTN control messages on their clothing such that a unique message is shared by each staff member who interacts with patients during visits.

    Patient Self-Management Support (SMS)
    • Patients' use of BP log cards to document out-of-office BPs and instructing clinical staff on how to address noted BP trends that may be related to stress, lack of medication adherence, etc.

    • Use of refrigerator magnets to remind patients to check their BPs, know their goal BPs, and engage in healthy lifestyle activities

    • Use of “kudos” cards given to patients at subsequent office visits when BP's were improved

    • Use of “Teach Back” methods with patients

    • Engaging in patient goal setting activities

    • Providing a raffle in clinic waiting rooms to receive a home BP monitor as a way to promote home monitoring and self-management

    • BP, blood pressure; EHR, electronic health record; HTN, hypertension; SBP, systolic blood pressure; DBP, diastolic blood pressure; QI, quality improvement.

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The Journal of the American Board of Family     Medicine: 34 (5)
The Journal of the American Board of Family Medicine
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Successful Trial of Practice Facilitation for Plan, Do, Study, Act Quality Improvement
Kent F. Sutton, Erica L. Richman, Jennifer R. Rees, Liza L. Pugh-Nicholson, Macie M. Craft, Shannon H. Peaden, Monique Mackey, Jacqueline R. Halladay, Southeastern Collaboration to Improve Blood Pressure Writing Group
The Journal of the American Board of Family Medicine Sep 2021, 34 (5) 991-1002; DOI: 10.3122/jabfm.2021.05.210140

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Successful Trial of Practice Facilitation for Plan, Do, Study, Act Quality Improvement
Kent F. Sutton, Erica L. Richman, Jennifer R. Rees, Liza L. Pugh-Nicholson, Macie M. Craft, Shannon H. Peaden, Monique Mackey, Jacqueline R. Halladay, Southeastern Collaboration to Improve Blood Pressure Writing Group
The Journal of the American Board of Family Medicine Sep 2021, 34 (5) 991-1002; DOI: 10.3122/jabfm.2021.05.210140
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