The Effects of Major Disruptions on Practice Participation in Facilitation During a Primary Care Quality Improvement Initiative

Abstract

Background: Disruptions in primary care practices, like ownership change, clinician turnover, and electronic health record system implementation, can stall quality improvement (QI) efforts. However, little is known about the relationship between these disruptions and practice participation in facilitated QI.Methods: We explore this relationship using data collected from EvidenceNOW in a mixed-methods convergent design. EvidenceNOW was a large-scale facilitation-based QI initiative in small and medium primary care practices. Data included practice surveys, facilitator time logs, site visit field notes, and interviews with facilitators and practices. Using multivariate regression, we examined associations between disruptions during interventions and practice participation in facilitation, measured by in-person facilitator hours in 987 practices. We analyzed qualitative data on 40 practices that described disruptions. Qualitative and quantitative teams iterated analyses based on each other's emergent findings.Results: Many practices (51%) reported experiencing 1 or more disruptions during the 3-to 15-month interventions. Loss of clinicians (31.6%) was most prevalent. In adjusted analyses, disruptions were not significantly associated with participation in facilitation. Qualitative data revealed that practices that continued active participation were motivated, had some QI infrastructure, and found value in working with their facilitators. Facilitators enabled practice participation by doing EHR-related work for practices, adapting work for available staff, and helping address needs beyond the explicit aims of EvidenceNOW.Conclusions: Disruptions are prevalent in primary care, but practices can continue participating in QI interventions, particularly when supported by a facilitator. Facilitators may benefit from additional training in approaches for helping practices attenuate the effects of disruptions and adapting strategies to help interventions work to continue building QI capacity.

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

“…Practice facilitation was 1 of the methods of support for change provided to practices in the EvidenceNOW initiative . Facilitators worked with clinicians and staff in each practice to help define and meet improvement goals and tracked the amount of facilitation they delivered to each practice . Duration of facilitator engagement and number of facilitation hours were combined into 4 facilitation dose levels, as previously described …”

“… 38 Duration of facilitator engagement and number of facilitation hours were combined into 4 facilitation dose levels, as previously described. 38 …”

What AHRQ Learned While Working to Transform Primary Care

“…Slightly more than one-half of EvidenceNOW practices experienced 1 or more disruptions during their participation, impeding some practices' engagement in practice transformation activities and their ability to improve cardiovascular care. [27][28][29][30][31][32] These examples brought home to AHRQ the importance of planning for emerging challenges that can occur at multiple levels in practice improvement work. In practical terms, this means that improvement initiatives should be designed to build capacity and resilience.…”