Table 3.

Practice-based Research Network (PBRN) Coordinator Perspectives on Local Learning Collaborative (LLC) Feasibility

Coordinator statement
LaNet■ Despite initial success at launching several LLCs (had at least one meeting), they were not sustainable. Lack of a critical mass of participants including the Wave I expert resulted in discussions that were superficial and of minimal use, leading to a decrease in enthusiasm for future participation. The primary barrier was the demands of patient care, as clinicians had limited control of schedules, and clinics were often understaffed as all were federally qualified health centers. In response, LANet offered virtual LLCs on a standing bi-weekly schedule, inviting all LANet site champions (not just those originally in the LLC), and arranging for a primary care physician who was expert in CKD to provide perspective on clinical care and guideline implementation. While maintaining continuity across sessions through agendas and minutes was not feasible, LANet created a central database for information on practice goals and progress that was updated after each session. This information was used by the LANet meeting facilitator to stimulate discussion and encourage sharing of lessons learned. These modifications increased participation as well as participant satisfaction.
MAPRN■ MAFPRN formed seven LLCs (14 practices; six in urban settings, six in rural settings, and two in the suburbs). Many Minnesota clinicians are familiar with sharing and discussing performance data, based on several years of QI strategy discussions based on data available to health systems and the public. While LLCs were open to administrators and other staff, they were only in attendance at the three in-person LLCs, compared to the four using web-based meetings due to distance between practices. Web-based meetings, especially among clinicians unknown to each other, appeared to decrease the sense of urgency generated through in-person meetings, with attendance likely suffering. For these meetings the PF was on site with a Wave II practice, and scheduled additional meetings with staff to provide further information as needed. As large health systems dominate care delivery in Minnesota, a challenge to participation was lack of alignment between health system and PBRN research priorities. Overall, the LLC experience for MAFPRN clinicians was useful for improving CKD patient care.
OKPRNHalf of OKPRN's eight LLCs were located in rural/small cities and others were mostly suburban. For three of the LLCs, the close proximity of the practices provided easy access to meetings, as practices were either in the same building or nearby. Three others shared the same health system infrastructure, with system modifications shared more easily among practices. Most meetings were scheduled in-person, however due to the press of patient care and other competing demands, only those in close proximity managed to attend and to bring other staff members with them. For others, conference calling was the usual default that allowed at least some participation. Meetings were usually scheduled at lunch time, planned and organized by the PF, and included lunch purchased by the Wave I clinician if the meeting was in person. The PF typically rotated attendance at one of the practices. Early sessions were recorded (with permission) to assess adherence to the meeting protocol and general direction of discussions. Two factors supported successful LLCs: prior personal relationships and geographic proximity. Most clinicians were known to each other and brought these relationships as an asset to LLC meetings. When prior relationships did not exist, LLCs were formed based on either common medical system or use of the same EHR. Practices close geographic proximity had the best attendance rates and staff participation, and in-person meetings compared to conference calls were easier to maintain over time.
WREN■ Seven LLCs formed by WREN were a mix of rural and urban practices; not enough practices were recruited to form the eighth. Four were comprised of members of the same health care system or were co-located and able to meet in person. Geographic spread for the other three was too large for in-person meetings to be feasible, so they met using telephone conferencing. Although videoconference and Skype were attempted, they were not favored and were discontinued. Positive aspects of LLC participation included sharing of successes by Wave I clinicians with other LLC participants that resulted in implementation of these strategies within the Wave II practices. For example, a patient education document developed by an inner-city Wave I clinic was shared with all WREN practices and other participating PBRNs. Additional help was provided by the sharing of EHR enhancements and these continued after the project ended. Barriers to LLC success included both PF and leadership turnover. Two Wave I PFs and the original project coordinator were unavailable during Wave II, and this essential continuity was lost. In addition, some Wave I practices were more actively involved recruiting for the LLCs, which resulted in only seven successfully formed. For many practices this was their first WREN project, which meant that PBRN staff were facilitating the intervention at the same time they were building new relationships with staff. Thus, some of the intervention strategies were delayed and may not have had sufficient time to impact change in outcomes.
  • CKD, chronic kidney disease; QI, quality improvement; EHR, electronic health record.