Article Figures & Data
Tables
Characteristics Study Practices
N = 44Coaching organization, n (%) Qualis Health 23 (52.3%) Oregon Rural Practice and Research Network (ORPRN) 21 (47.7%) Location, n (%) Rural 21 (47.7%) Urban 23 (52.3%) Number of clinicians, n (%) One (solo) 8 (18.2%) 2 to 5 22 (50.0%) 6 or more 14 (31.8%) Average panel size for full-time clinician, median (IQR) 1,000 Number of patient visits per week at practice, median (IQR) 140 Organizational type, n (%) Federally Qualified Health Center 8 (18.2%) Health/Hospital system 14 (31.8%) Indian Health Service/Tribal Organization 0 (0.0%) Independent 22 (50.0%) Specialty, n (%) Family Medicine 39 (88.6%) Internal Medicine 1 (2.3%) Mixed 4 (9.1%) Abbreviation: IQR, interquartile range.
- Table 2.
Implementation Strategies Used by Practice Facilitators with Primary Care Practices
Percent of practices with which practice facilitators used the strategy (n = 44) Implementation Strategy At Least Once During the Study Q1 Q2 Q3 Q4 Q5 Commonly Used (Present in > 80% of sampled practices) Develop and/or implement tools for quality monitoring 100% 93% 93% 77% 63% 63% Assess barriers that may impede implementation 95% 70% 63% 61% 43% 43% Assess for readiness or progress 93% 75% 45% 36% 39% 27% Develop and support teams 91% 41% 52% 73% 49% 55% Conduct educational meetings 86% 53% 43% 23% 11% 16% Moderately used (present in 20 to 80% of sampled practices) Use data experts 75% 45% 50% 34% 30% 11% Distribute educational materials 73% 30% 39% 34% 32% 23% Capture and share local knowledge and promote network weaving 66% 18% 32% 18% 23% 27% Identify and prepare champions 61% 32% 20% 25% 9% 23% Conduct ongoing training 59% 27% 18% 30% 14% 16% Prepare patients/consumers to be active participants 45% 9% 16% 16% 20% 18% Assess facilitators that enhance implementation 36% 27% 9% 5% 0% 5% Train for leadership 32% 18% 7% 7% 5% 0% Promote adaptability 30% 2% 18% 9% 7% 11% Rarely used (present in <20% of sampled practices) Conduct educational outreach visits 14% 5% 5% 5% 0% 0% Involve patients/consumers and family members 14% 9% 2% 0% 2% 2% Facilitate relay of clinical data to clinicians 11% 7% 2% 2% 2% 0% Remind clinicians 11% 0% 5% 9% 2% 0% Tailor strategies 11% 0% 5% 9% 2% 0% Obtain and use patients/consumers and family feedback 9% 7% 2% 2% 0% 2% Build a coalition 9% 0% 2% 0% 5% 2% Identify early adopters 7% 5% 2% 5% 0% 0% Develop/use a formal implementation blueprint 7% 2% 2% 0% 0% 2% Audit and provide feedback 7% 0% 5% 2% 2% 0% Make training dynamic 2% 2% 0% 0% 2% 0% Inform local opinion leaders 2% 0% 0% 0% 0% 2% * Present in the first five quarters, for practices with data in the first five quarters of the Healthy Hearts Northwest (H2N) study.
- Appendix Table 1.
Implementation Strategies Enacted by Practice Facilitators and Representative Quotes
Implementation Strategy Percentage of Practices with Which the Implementation Strategy Was Used at Least Once During the Study Representative Quote Commonly Used (Present in > 80% of sampled practices) Develop and/or implement tools for quality monitoring 100% “Meeting to demo proposed changes to the data visualization in [the data dashboard] and ask for feedback.” (139:1) Assess barriers that may impede implementation 95% “The group, particularly [NAME], is perseverating on the data for [the outcomes].They still haven’t shared it with us, stating it’s not accurate yet. [NAME2] and I have attempted to allay concern, but with little effect as of yet. The problem is that without the data, it’s prevented them from actualizing concrete ideas for addressing the [the outcomes]. Right now, we’re skirting the high leverage changes, which is definitely a good thing, but we’ve yet to relate them to the [the outcomes] specifically. I am hoping that by the next meeting we can make some moves on the measures.” (133:2) Assess for readiness or progress 93% “They have made clear progress and completed tasks that are building their foundation to make thoughtful change.” (131:2) Develop and support teams 91% “Clinicians are engaged and have a desire to keep moving with embedding QI into their practice framework. They have acknowledged they can incorporate other staff members of the practice to be included in this work and learn QI techniques, to help keep this infrastructure in place after the Practice Coach has completed this project with them. We will start including the Office Manager.” (215:2) Conduct educational meetings 86% “We discussed the data and perception of the data and how the clinics will use it to plan their model for improvement” (952:1) Distribute educational materials 73% “[NAME] to send the QI team the [outcomes] clinical evidence one-pagers once they are finalized.” (131:4) Capture and share local knowledge and promote network weaving 66% “I did share the tobacco-free readiness assessment that another practice of mine developed.” (135:8) Identify and prepare champions 61% “Considering needing a champion…[Doctor]. could be the person. She has shown great team spirit and initiative since arriving recently at [clinic] and is well liked and respected by peers.” (621:10) Conduct ongoing training 59% [NAME] and I will be doing a presentation on PDSA to the managers in the next couple of weeks.” (948:2) Prepare patients/consumers to be active participants 45% “We talked about how we could get patients thinking about lifestyle changes and how they may impact their [blood pressure] before meeting with the [clinician].” (137:7) Assess facilitators that enhance implementation 36% “Practice has a strong QI team and leadership support…. they have completed the integration of mental health and primary care successfully--strong in house cross functional team support with a focus on patient self-management, personal goal setting and motivational therapy.” (784:4) Train for leadership 32% “Facilitated a conversation with CEO regarding the loss of their QI manager and H2N. [NAME] decided to form a new QIC (Quality Improvement Committee) and add H2N to its ongoing agenda.” (527:3) Promote adaptability 30% “The team needs to address time limitations and rework their goals to be more aligned. We took the remaining duration of this meeting to discuss how that will look and plan out [hypertension] next steps.” (168:5) Rarely used (present in <20% of sampled practices) Conduct educational outreach visits 14% On [Date, experts] will co-host a conference call with experts and a few other clinicians like you with whom we have had these [cardiovascular disease] risk calculator discussions.” (540:3). Involve patients/consumers and family members 14% “Have three patients interested in inviting to the team. There are benefits to having patient involvement earlier in the QI process. Will consider inviting them to begin participating in March.” (152:4) Facilitate relay of clinical data to clinicians 11% “[NAME] will send out dashboards to clinicians at least a couple days in advance to allow them to reflect and digest the information and formulate questions/concerns, etc. in preparation for the clinician meeting.” (131:8) Remind clinicians 11% “[NAME] has put sticky notes on each clinician’s computer reminding them to use the health maintenance area within the [electronic health record] because people are often just clicking through without documenting the work that they are doing around these measures.” (687:7) Tailor strategies 11% “They are addressing the smoking measure by adding a full stand-alone sheet of tobacco related questions that align with their [electronic health record] entry… We dove in to talking about the advantages of the tobacco use form and how it can streamline clinician time in finding and addressing patients that actually are interested in quitting or talking about alternatives. It could also prompt scheduling a specific appointment to address cessation separate from their acute issue. We spoke about rolling this form out sooner than [date].” (557:10) Obtain and use patients/consumers and family feedback 9% “[NAME] brought up that several patients cannot afford their medications and she would like to somehow build questions into visits surrounding determining if patients can afford what they are prescribed, in a sensitive way.” (582:6) Build a coalition 9% “We spent the whole hour going over their QI plan and developing a new structure that would fit their current needs. They decided to have the [quality improvement] and [quality assurance] committees separate, but that they would report to each other quarterly on items that have cross over.” (1213:2) Identify early adopters 7% “Per [NAME] this is a huge part of how he orients his practice. He tries diligently to ensure this is done. This may vary across clinicians. I asked if we could discuss further how he does this so well with his patients at a later time. This could be very valuable info to spread across the practice.” (129:10) Develop/use a formal implementation blueprint 7% “First visit was consensus discussion and overview, second visit was building foundation for cross-sectional [quality improvement], and by the third visit we hope to review data together.” (1240:4) Audit and provide feedback 7% “Action: Audit 10 to 15 patient charts from the list 94 current smokers. Look to see if any smoking cessation counseling has been documented (this will help us determine if the documentation is being lost in the text/ is not in a field that the [electronic health record] can pull a report from)” (554:3) Make training dynamic 2% “[NAME] suggested using a delayed staff message that shows up on the day a patient is coming in and alerts the clinician to discuss the issue of importance. [NAME] has had success with this method, so [NAME2] wants to try it out and tweak as necessary.” (917:2) Inform local opinion leaders 2% “They also talked about identifying clinicians that are a problem and reaching out from clinician to clinician or owner to owner to try and resolve the issue.” (744:5)
