How Type of Practice Ownership Affects Participation with Quality Improvement External Facilitation: Findings from EvidenceNOW

Abstract

BACKGROUND: Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives. OBJECTIVE: Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation. STUDY DESIGN: We used an iterative mixed-methods design. PARTICIPANTS, APPROACH, AND MEASURES:We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation. KEY RESULTS:In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: − 2.83, p < 0.01 for number of encounters, and − 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns. CONCLUSIONS: Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownershiprelated characteristics in future QI initiatives.

Association of Clinician Practice Ownership With Ability of Primary Care Practices to Improve Quality Without Increasing Burnout

“…It is notable that neither ACO participation nor participation in a demonstration project was significantly and independently associated with likelihood of being a practice that enhanced quality without increasing burnout. Additionally, despite evidence of differential engagement with facilitation by practice ownership type, adjustment for facilitation dose did not significantly affect the significant association between clinician ownership and practices improving quality without increasing burnout. Prior studies demonstrated that ACOs were associated with improved performance across multiple quality-of-care measures and practice facilitation was associated with improved chronic disease measures .…”

“…These findings add to a growing body of research suggesting positive satisfaction, engagement, and utilization outcomes among clinician-owned practices. In previous studies, clinician ownership has been associated with lower burnout, 5,22 greater participation in practice facilitation, 39 and better health care professional responses to change. 40 Physicians working in clinician-owned practices compared with non-clinician-owned practices were more likely to be satisfied with their EHRs, even after controlling for concrete resources such as availability of staff support for documentation.…”

“…Physicians working in clinician-owned practices compared with non–clinician-owned practices were more likely to be satisfied with their EHRs, even after controlling for concrete resources such as availability of staff support for documentation . In contrast, studies have suggested that hospital-owned practices have less clinician engagement and higher spending per patient, and physicians working in health systems or FQHCs described less sense of autonomy …”

“…Primary Care Practice Clinician Ownership and Quality Improvement Without Increasing Burnout Finally, given expected associations of practice facilitation with both staff well-being and quality performance as well as evidence of differential engagement with practice facilitation by type of practice ownership, 39 we conducted a sensitivity analysis to examine the extent to which adjusting for practice facilitation dose delivered affected significant associations between practice-level factors and likelihood of being a PD practice.…”

How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

“…Their clinical teams also had less autonomy and more burnout than clinician-owned practices. 35,36 Ownership changed how EvidenceNOW Cooperatives and their facilitators worked with practices, 37 and the amount of facilitation and the types of changes practices needed to make to improve clinical outcomes. 38 This combination of factors contributes to explaining the association between facilitation amount and Cooperative experience level, and, although not easily mutable, practice ownership must be considered when implementing and evaluating the value of large-scale quality improvement initiatives that involve external support.…”