Leading with the heart led to trust 

by Kilian Kimbel, 2019

I started working on the Healthy Hearts Northwest project in 2015. In my 11 years with Kaiser Permanente Washington Health Research Institute, I had never worked on a quality improvement research project, let alone one invested in recruiting and providing practice facilitation with over 250 small- to medium-sized primary care clinics spread across the Pacific Northwest within 3 years!  This work has deepened my knowledge of research, taught me about health care practice transformation, and showed me that each are profoundly human at core.

One of my first roles was tracking and managing the study’s survey data collection alongside other team members.  Although my heart has some sort of affiliation for wanting to input numbers and formulas into tiny boxes, I didn’t realize just how close to the data I would get.

I reached out to our enrolled clinics to remind and encourage them to fill out surveys.  Compared to my previous experience interviewing patients, it was much more complex to ask busy provider teams to fill out multiple, lengthy instruments they sometimes didn’t have the ability or capacity to answer. Our enrolled clinics fielded big asks daily, and I learned that at the end of the day answering research questions might not be a priority for busy practitioners.

Besides ensuring practices had practical and applicable incentives for completing surveys, I also tracked response rates and held a close watch on the data itself, posing questions to our practice facilitators (PFs, or coaches) as needed.  My favorite part of data cleaning was reading open-ended responses.  These are generally at the end of a survey and provide opportunity for respondents to say what they really think.  These are included in surveys so that researchers might gain better understanding of context, as well as limitations of the instrument itself.  Open-ended responses can also shed light on external factors such as lack of resources outside of the respondent’s control, which may not be reflected in the 1-10 scale.

Here are some quotes from our baseline practice and staff member surveys:

  • “Some questions were impossible to answer. Staff are too busy to track down to get information. I don’t know how to run reports for some of the information requested and don’t have the time to research how to do it. We are an office of 5 in total.”
  • “Sorry, but I do not have a report that shows me the demographic breakdown of our patients.”
  • “We do not have reports available to us to accurately complete all of the requested information.”

After I read these I wanted to say to our study’s principal investigator: “This isn’t going to work! How can we expect practices to complete a survey that requires them to access data they don’t have the ability to pull, and not because they don’t want to, but because they simply don’t have the resources or assistance to do so?”

I couldn’t know at that time that these answers would aid in the project’s understanding of practice abilities, barriers, goals and aspirations, and that they would create a direction for quality improvement.  It’s important to note that survey feedback also touched on positive themes:

  • “We believe we provide exceptional care, however we do not have a consistent method of tracking and reporting the care we provide. We are excited to work together with Healthy Hearts to improve the care we provide and the methods with which we gather and report that data.”
  • “Change is difficult, but we have had a lot of changes in a short time, after the negative attitudes dispel the clinic, we will get the work done and changes will happen, continued encouragement may be needed in the beginning.”
  • “Our staff do follow medical guidelines and best practices we simply don’t have all the policies and procedures for medical care we want in place, but the medical staff are all on board with establishing and helping develop these for our practice.”

I felt encouraged by that input to continue reminding practices to complete their surveys.  By remembering that continued encouragement could lead to change, I was able to connect my work to the project’s quality improvement strategy.  That helped me to trust the process. I learned not to expect immediate engagement, nor to interpret engagement levels based on low (or slow) survey response rates.

In addition to supporting multiple practices on many different levels, our practice coaches took on the role of survey data collectors. They were the unspoken heroes on our project – as messengers of our research agenda, and as teachers that persevered and opened doors to contributions that spread from clinic to clinic.  As we neared the end of survey data collection and I read the second set of survey responses, the coaches’ magic and the value of clinic participation in Healthy Hearts Northwest (H2N) became clearer to me:

  • “Very helpful to have Healthy Hearts NW to be involved and support us with outside resources, graphs, and comparison with national averages, encourages us to improve!”
  • “H2N has been a delight to be affiliated with. Professional and devoted staff that help with a wide array of modern clinical and technical challenges.”
  • “A slow start but overall a great program. Really helped the team focus. Facilitators were able to help the team think out of the box and also see the positives. Thanks!”

I jumped into Healthy Hearts Northwest feet first, not knowing what would or could happen, and in the end survived!   Despite the hurdles, and competing priorities and barriers, I saw that change happened, slowly but surely.  I believe everyone on our team helped someone or something to change.

I witnessed our incredible coaches have magical impact on clinics in Washington, Oregon, and Idaho and I’m hopeful that the knowledge they shared won’t be forgotten.  This project reinforced for me just how powerful simple acts of support are.  And how every heart needs kindness.

“Thank you, Healthy Hearts, for helping us to come together monthly, opening up dialogue and supporting us through our growing pains. Also all the IT help. It is invaluable. I feel you have helped us be better practitioners, better nurses, and better overall: We will surely miss our monthly meetings with. We will carry on with our monthly meetings when you are gone because we recognize the value in them. Taking time for the betterment of all is valuable.” — Healthy Hearts NW clinic 

*****

Kilian Kimbel, BA, is a research specialist at Kaiser Permanente Washington Health Research Institute and former research interviewer in its Survey Research Program.

 

KEY MESSAGE
Encouragement can lead to change.  Kindness and persistence don’t only make for a better workplace, but can serve as powerful and effective quality improvement strategies.

 

Mixing quality improvement and research in one project can make for tricky data collection.  

By Elena Kuo, 2019

I’m a senior research associate at the Center for Community Health and Evaluation (CCHE)  at Kaiser Permanente WA Health Research Institute specializing in quantitative methods and program evaluation. While I work almost exclusively with my CCHE team, I jumped at the chance to join Healthy Hearts NW as a data scientist because I was intrigued by the project’s large scope.

My main role with the project was to keep the team on track with collecting two types of data: quality improvement (QI) and research. The QI data were clinical quality performance measures for cardiovascular risk factors, for example, blood pressure control, and the research data were surveys related to practice characteristics completed by office managers and members of the primary care clinic teams. I also cleaned the first round of data before passing it on to our programmers and biostatisticians for analysis and writing.

The main reason that practices enrolled in the study was to learn how to generate QI data. Becoming facile with reporting on clinical quality measures helped practices with reimbursement and other requirements. But as often is the case in our world, back at the home office we were collecting data to address research questions. This second type of data proved to be a bit harder to get.

Looking back, I can see where our approach worked well – and the areas where we could have been more effective.

1. Commit to continuous engagement
Our project kicked off with the task of recruiting practices, enrolling them into our study. But once we reached our goal of 250, we couldn’t just rest easy knowing we’d met our goal. Because our project spans multiple years, a few of our coaches left the project, over time some practices dropped out, some went dormant, etc. We were always in the position, one way or other, of engaging and retaining participants and partners in this work. With a long project, too, refinements can end up being made and then you need to get buy-in for those.

2. Tailor your outreach
Different types of outreach worked for different types of practices. For instance, email worked for only half of our practices.. I was surprised that many practices consider it super-high tech to be on email! Some practices were just getting their first electronic medical record when they enrolled in Healthy Hearts NW. . I’ve been using email for 20 years in my work, but this was a good reminder that it’s not typical across all industries.

When we needed something from a rural-based physician, such as a practice survey, faxing often worked best. From my perspective, it seems still common in rural areas. We learned that faxes are part of their workflow. They’re placed in providers’ inboxes and considered part of daily work. Here in Seattle we’re used to Skyping and video conferencing, but I’m not convinced that’s the case in a lot of outlying areas. Email tended to work for reaching urban practices, so we came to see a real distinction.

3. Streamline research data collection
Oh, this is a big one! We spent a lot of time and effort on outreach to get clinics to fill out practice surveys that we eventually concluded were much too long.

Initially our practice survey was nearly 50 questions long! When we started our project, a lot of people came up with really interesting questions for the survey and we included most of them. During the course of the project, however, we found out that just 12 of them got us the minimum amount of data we needed. In retrospect, we might’ve had more success collecting practice survey data if the instrument had been shorter and we could’ve advocated for brevity.

4. Make practice coaches your research partners
This is key. As part of our study intervention, each practice was supported by a “coach” or facilitator. We wanted to shield our coaches from too much nerdy science. We thought this segregation would allow them to concentrate on relationships and technical assistance, the bread and butter of practice coaching. But it had the unintended result of separating our coaches from the research part of our work. They worked tirelessly to create trusting relationships with their clinics, and we found that it was a tough project requirement for coaches to ask their practices to complete long surveys.

However, we did find that involving coaches in this data collection was absolutely essential, and in fact was not inconsistent with their work, since the insights provided by the survey results were often helpful to them. .

5. Budget for face-to-face meetings
Team cohesion is critical to the success of a long-term project where team members work in various organizations and live in different states. We had folks in home offices in three different institutions, and the coaches out in the field driving across Washington, Oregon, and Idaho. Still, we managed to regularly gather a couple of times per year, and these meetings really helped! After we met in person, I went from being an annoying “home office” data person bugging our practice coaches via email for data to a real person. It takes a lot of planning and resources to support in-person project meetings, but I don’t know if we could’ve pulled off this project without having established and maintained face-time relationships with one another.

*****

Elena Kuo, PhD MPH is a Senior Research Associate at the Center for Community Health and Evaluation at Kaiser Permanente WA Health Research Institute. Her interests include social determinants of health, health education, and increasing health equity for underserved and marginalized populations. Dr. Kuo received her master’s and PhD in Public Health Epidemiology from University of Washington, and her bachelor’s degrees in Biological Anthropology and Neuroscience from Emory University.

KEY MESSAGE

Research and quality improvement can not only co-exist, but with thoughtful planning and execution it’s possible for each to contribute to the other.

Rural Oregonians are disproportionately impacted by cardiovascular disease, but practice coaching offers unique support.

 

(Photo above L-R: Practice manager Keli Christman, ORPRN practice coach Angela Combe, and ORPRN founder LJ Fagnan at Winding Waters Clinic in Enterprise, OR, Dec 2018, pop. 1,950.)

*****

By Michael Parchman, MD, MPH, Senior Investigator, MacColl Center for Health Care Innovation and Healthy Hearts Northwest Principal Investigator.

L.J. Fagnan and I have much in common: We’re both licensed family physicians, we’ve both practiced medicine in rural areas, and we both serve as scientific investigators on Healthy Hearts Northwest, a multi-year research project to help patients reduce their risk of developing cardiovascular disease.

With support from the Agency for Healthcare Research and Quality’s EvidenceNOW initiative, our Healthy Hearts Northwest project aims to increase the quality improvement capacity of primary care practices through the use of practice coaches.

An early study goal was recruiting 250 clinics throughout Washington, Idaho, and Oregon, including many clinics located in rural areas. Enrollment for big studies like this always involves significant outreach, and these days recruitment is often accomplished via web or phone from a centralized location. Our project design included face-to-face interactions between our team and participants over a 15-month period, which hinged on us building interpersonal trust. So we began building those relationships by doing mostly in-person enrollment and logged many miles driving backroads and highways getting to the practitioners we wanted to reach.

L.J. founded the Oregon Practice-Based Research Network (ORPRN) in 2002. We partnered with ORPRN because we knew that the strong relationships his organization has forged would help us reach our recruitment goal. But we were excited to collaborate with him for another reason: Rural health care practices face unique challenges. No one knows rural practice like ORPRN, and we knew that the Healthy Hearts Northwest approach would offer unique support. We were eager to test our approach in rural areas.

I asked L.J. questions about Healthy Hearts Northwest in the context of practicing rural medicine — and here’s what he said.

Can you describe a typical rural practice and the challenges they face?

Those who choose to practice medicine in rural areas are special people. Rural physicians attend to clinic, take care of hospital patients, handle emergencies and trauma, deliver babies, and care for citizens in the nursing home. Rural clinicians want to be integrated into their communities in this way.

Rural, or “frontier,” is defined by less than six people per square mile, so that often means more cows than people. Frontier providers try to address the social determinants of health (housing issues, food insecurity, and transportation) along with everything else.

Generally, rural communities can be characterized as having small populations, lacking large health systems and centralized resources, and with a high degree of poverty. Because rural practices don’t turn anyone away at the door, they are the safety net with over 50% of the patients insured by Medicaid (25%) and Medicare (25%). One in five Oregonians lives in a rural area. With our population at 4.14 million, almost 20% of Oregonians live in rural settings.

Why is practice-based research in rural areas important?

The bulk of medical research studies happen in academic medical centers, but less than 2% of patients receive care at these centers. Research is about truth, but the truths found in academic medical centers might not actually be true.

Practice-based research collects data from real people in the real world, often living in underserved areas. As researchers, we have a responsibility to make life better for practitioners and the patients they serve. Casting a wider net, using data from a variety of practices and geographies, gets us closer to a generalizable truth.

Why was Healthy Hearts Northwest a good fit for ORPRN?

Central to Healthy Hearts Northwest is the use of practice coaching, which has its roots in the agricultural extension agent movement of the 1930s. We have a great team of practice coaches (PERCs, or Practice Enhancement Regional Coordinators) working directly within health systems and fifteen Coordinated Care Organizations (CCOs) throughout Oregon.

Our PERCs made monthly site visits to all enrolled Healthy Hearts Northwest clinics over a 15-month period (and sometimes longer.) We were excited to bring our PERC model into frontier medicine because cardiovascular disease affects rural Oregonians disproportionately. Approximately 40% of rural adults have hypertension and 15% have cardiovascular disease as opposed to 27% and 7% in urban areas. This means that there is a greater percentage of potentially excess deaths from cardiovascular disease in rural areas as opposed to metropolitan areas.

Healthy Hearts Northwest is teaching practices how to fish, as opposed to giving them fish. Rural practitioners like this because they like to be self-sufficient. We’ve given them tools that they can apply to other conditions, like depression and diabetes. In turn, practices teach the health services research community how to adapt the tools to the real world.

Many of the Oregon practices have told me that Healthy Hearts Northwest has made an indelible mark on them.

Practices that join ORPRN agree to provide data for your research studies, like Healthy Hearts Northwest. Does ORPRN offer them anything in exchange?

The benefits go both ways. By joining the network, smaller and independent Oregon practices know that they’re contributing to building an evidence base that can lead to better care for rural communities. Participating clinics are eligible for invaluable support from our PERCS navigating today’s shifting health care landscape. Our technical assistance ranges from in-person practice coach help setting up a new EHR to developing innovative ways to compile reporting data to writing federal grants.

Network members tell us that ORPRN has played an important role in collegial support, practice improvement and stability for many of them in rural and remote areas of the state. They feel engaged in a network-wide dialogue about merging the varying accomplishments that we’ve had through the years into a coherent and sustainable vision for Oregon’s future.

You do a lot of driving! You try to visit each ORPRN practice in-person every year. Why is this important?

It’s hard to recruit busy practitioners for studies, but there’s no substitute for doing it in person. Recruitment needs to be a give and take. We make practices aware of opportunities while also finding out what challenges they face. Rural practices are increasingly expected to report data and quality metrics, so I tried to find out what each was doing with that. For Healthy Hearts Northwest, I’d explain that we’d be looking to get data to reduce stroke and heart attacks, and that we think primary care is the right place to institute this. I’d tell them I thought it might work with their practice. You can’t do that by email. You have to show up, make “home visits.”

Also, I visit practices because I get inspired by them. I see how providers are caring for their community, and come away thinking, “Medicine’s a good job, and we do really good things for people.”

What preliminary discoveries has Healthy Hearts Northwest made about rural versus urban Oregon medical practices?

We found that rural Oregon practices were more likely to sign up for Healthy Hearts Northwest than urban practices. One in four rural practices approached for our project signed up as opposed to one in ten urban practices. Oregon rural practices were also more likely to complete the study. The urban dropout rate was 29% as compared to a rural dropout rate of 15%.

The rural practices loved in-person visits from Healthy Hearts Northwest. It was more of a sales job with urban practices.

What’s on the horizon for rural medicine?

We have yet to make rural practice a place that attracts medical students and other health professionals. We need a training program that trains local people to fill roles in rural medicine. New physicians leave medical school with huge debts, and they shouldn’t have to sacrifice income to work in frontier areas. And we need to identify and promote a business model for a patient-centered and community-centered primary care practice — and ensure that it’s sustainable.

It used to be that education was the number one employer in rural settings, but now it’s health care. And if no providers want to or are able to sustain life in a rural community, there’s much more at stake than losing health care; the whole community may die.

I think the isolation of the rural landscape has driven you to do your work. Can you talk about loneliness?

I grew up in and am drawn to rural areas, which is typical of folks working in rural medicine. I started my own family medicine career working in Alaska with native Americans. My daughter was born in a native village. When you’re in rural practice, you make do with what you have, and you learn to solve problems on your own. It’s what we know and love.

And it’s hard work out there. Doing what we love comes with a cost and responsibility. At any given day in a rural practice, a life might be at stake. Providers wonder, “Does someone have my back?”

That loneliness of wondering if I had any support has been a motivator for me, and what’s led me to seek out other people. Voices from Left of the Dial is a paper I co-wrote about the reasons practitioners get involved in such difficult work. The conclusion we ended with is that practice-based research is the antidote to loneliness.

*****

Michael Parchman, MD, MPH
Dr. Parchman is Senior Investigator at the MacColl Center for Health Care Innovation, which he joined in 2012. His research focuses largely on improving chronic illness care in primary care clinics by approaching them as complex adaptive systems. A family medicine physician, Dr. Parchman previously served the Agency for Healthcare Research and Quality as the director of Practice-Based Research Network Initiative and senior advisor for primary care.

 

KEY MESSAGE:
Rural health care practices face unique challenges in addition to the increased quality data reporting currently required of all health care providers.  These include lack of resources and access to centralized support, as well as shouldering an increased burden of responsibility for all members of their communities.  Networking and joining forces with fellow rural practitioners can ease the stress and loneliness that often accompany life as a frontier provider.

Coaches face a dilemma when practices in a QI project stop communicating. 

By Tara Kline and Steven Brantley, 2018

Ghosting, in case you’ve never experienced it, is having someone you believe cares about you (a friend or someone you’re dating) disappear suddenly without explanation. It’s not a new human behavior but it has become more and more common as people favor online and digital communication over face-to-face interaction.

Practices, too, can disappear suddenly in a quality improvement initiative like Healthy Hearts Northwest – sometimes resurfacing months later, sometimes dropping out entirely. During the course of our project, our coaches followed a regular telephone and email outreach regime, but as you can imagine, for a primary care practice juggling patient, clinic, and project needs can be maddening! As a result, some practices stop responding. This can cause a coach to wonder, “Have I been ghosted??!”

According to one of our coaches, it wasn’t a surprise for some enrolled practices to stop communicating altogether. In these instances, our facilitators continued a robust amount of contacts per month, shifting to lesser intensity after months of silence. Eventually we accepted that some practices might not want to “see” or “hear” from us. Our coaches want what’s best for the practices they work with and in some cases, this meant letting go.

We checked in with two of our coaches to get their take on ghosting. Here’s what they said.

But we’re perfect for each other!
The email came as a surprise. A practice that had been doing very well and fairly advanced in their QI structure wanted to stop participating in our initiative. We’d already met 4-5 times, and we were a perfect match: Healthy Hearts offered practice facilitation, shared collaborative learnings, and technical assistance that overlapped beautifully with their existing projects.

When they emailed to tell me they were too busy for another project, I was surprised. We had been making great progress towards the goals they outlined. However, I knew I needed to respond without damaging our relationship. I thanked them for the opportunity of getting to know and work with them. I told them I was sorry to see them go.

Several months passed, and I emailed them to touch base. I’m really glad I did because they were in crisis mode. Their electronic health record had dropped its analytic component, which completely removed all QI and clinical quality measures reporting capability. I explained how Healthy Hearts was helping clinics in the same predicament, which caused them to re-engage. We helped them with connecting to a registry and using a tool to evaluate their QI for improving outcomes for their cardiovascular patients.

Over time, they realized how teaming up with a collaborative effort and other resources, such as coaches were advantageous to keep them in the current environment, and at the same time, having experts in various areas at their fingertips.

In one of their last messages to me they said that, “Healthy Hearts Northwest wasn’t such a scary project at all.” Maybe you can call me a ghostbuster!
– Tara Kline

It’s not you, it’s me.
We recruited all our Healthy Hearts Northwest practices with the best intentions, yet I saw signs that some were misaligned from the start. It wasn’t a surprise when such clinics dropped.

One of my practices had zero resources with little ability to act on Healthy Hearts Northwest activities. Additionally, in the middle of the project, their CEO had a massive stroke. Their leadership team fell apart, staff were in crisis, and it was a struggle just getting through each day.

We continued to meet monthly despite me doing a variation of “it’s not you, it’s me.” I made space for them to back out, explaining that I didn’t want to take up their time. They saw value in the time we spent together – even though they lacked the resources to do anything– so we kept meeting.

I connected them with another practice that had an interesting structure for staffing, one from which they could learn and take back to their practice. They weren’t able to change their staffing model but they were eager for the information. I regularly shared what other practices were doing, and in some ways, I acted as their counselor.

We continued like this for 18 months, and we were almost at the end of the intervention period. At that point, they hired a new CEO who came from the federally-qualified health center world and had been doing quality improvement (QI) for most of her career. In two months, she and I wrote a charter for a QI committee and compliance credentialing. These committees convened staff members from all three sites and at the same time, added patients.

Seemingly overnight, they switched into high gear and started making big changes. We ended our time together on such a high note! They were one of my most memorable and favorite teams to work with.

Our instinct as coaches is to be unfailingly respectful yet persistent. It’s a bit of a dance, but that’s part of the job. We never know which practice may end up soaring.
–Steven Brantley

*****

Tara Kline, MS is a Qualis Health Practice Coach with expertise in meaningful use, PQRS/Value Based Payment Modifier, HIPAA security risk analysis and mitigation, and the patient-centered medical home. Ms. Kline holds a master’s degree in the field of clinical laboratory science and is a Certified Professional in Health Information Technology, is a Certified HIPAA Professional, Certified Professional in Healthcare Quality, and a Certified Lean Six Sigma Black Belt.

 

Steven Brantley, MPH is an ORPRN Practice Enhancement Research Coordinator.  His interests include the spatial relationship of health determinants, primary care transformation, and improving access to healthcare. Steven received his master’s degree in public health and his bachelor’s degrees in biochemistry and Spanish from Oregon State University.

 

KEY MESSAGE:
Meet practices where they are, understand their limitations, and know it’s not always you. Expect the unexpected.

In both stories, the practice coach was surprised by the unexpected.  One practice made significant progress toward the end, and one seemingly on course both suddenly dropped out – but both practices re-engaged later. The key is maintaining a respectful relationship and cultivating large dose of patience.

There are times when I feel like I’ve seen everything.

By Carolyn Brill, 2018

Carolyn Brill has worked as a practice facilitator in Washington State for about a decade and has been witness to many changes. Still, a few things she encountered on this project surprised her.

One lesson that’s stuck with me from my work with Healthy Hearts NW is that there’s always more to learn in the role of practice facilitator. I know this work, I know the challenges going out to do practice coaching. There are times when I feel like I’ve seen everything. But after ten years in this role I’ve learned not make assumptions about clinics based on their demographics.

When we began recruiting practices for Healthy Hearts NW, our emphasis was mainly on small- to mid-sized clinics. I used to have beliefs around organization size and capacity for quality improvement. For instance, I thought that organizations were likely better situated to be successful at quality improvement because they had more resources.

There are advantages to working with large organizations, certainly, including that they generally are rich in information technology (IT) resources. This is very different from working with, say, an independent practice where a provider who’s seeing patients is also doing the IT work. With larger organizations, the providers don’t normally run data reports. This means the providers are not as administratively burdened as someone who’s running his or her own business.

I worked with a family of clinics owned by one hospital: four clinics, all at different locations, but existing within the same hospital system. Each differed in its readiness for doing QI work, to engage their provider teams directly with their coach, and to learn skills they could take with them past the project’s end.

Lack of contact with frontline providers is a problem
I supported some larger organizations in Healthy Hearts, and found that communications in this environment can be extremely challenging. Practice facilitation works best when it builds on a good relationship and clearly defined roles and responsibilities between the coach and the practice.

In a large system, levels of management might exist between a coach and the providers. This has the unfortunate consequence of the on-the-ground provider team really not having a good grasp of the improvement work because they’re hearing it second- (or third-) hand from management, directors, or the CEO. It reminds me of that game of telephone: by the time the message gets back around to the beginning, it’s completely different than what was originally said.

One of the four clinics in the hospital system was very connected to their parent organization’s IT. When I met with that clinic, I met with hospital directors. Their provider champion attended, but in those meetings the agenda never strayed from high-level reporting. Their approach to Healthy Hearts was 100% about how the data were being entered into the E.H.R. It was the only thing they wanted to focus on.

There is a problem with this approach. Data undeniably are a big component of this work: they must be entered correctly into the system so they can be pulled for accurate reporting. However, because this clinic was solely focused on data entry, they didn’t engage or include their frontline teams on clinical quality improvement. They missed opportunities to connect tasks like data pulling with the “a-ha” moments we see during the Plan-Do-Study-Act (PDSA) cycles that demonstrate that learning is happening. They could’ve done so much more.

Are your practices learning anything, or just pulling data?
I’ve seen exceptions. Interestingly, the team and the clinic next door to the one I just described (in the same organization) continuously met with me, the provider champion, and the provider champion’s nurse. We filled out PDSAs, we set an aim, we really dug in on change! They rearranged their reception area to streamline how they intake patients and answer phones. We addressed so many different areas of process improvement and QI, that I felt like they really understood as a team how they could sustain this work.

These two clinics were in the same town, on the same street, even in the same building, but the way I was able to work with them was like night and day. A few characteristics of note:

  • Each clinic was caring for different populations of patients
  • The clinic I was able to work with more closely had fewer providers
  • The clinic I was not able to work closely with took direction from their office manager

At the end of the project I met with the provider champion at the larger clinic, but we’d never worked together directly on QI.

Both of these clinics, in the same system, made improvements. The smaller clinic seemed to really understand from the inside out what QI could do for them. I feel confident that they’re continuing to improve and grow and change. The larger clinic that focused solely on IT also saw improvements with data extraction but I’m not convinced they learned anything to take forward other than how to more efficiently use their E.H.R.

Leveraging the special skills that coaches bring
Bringing in a practice coach and maximizing that opportunity is a culture change for a lot of clinics. It’s about more than the coaching, really. It’s one thing for a coach to meet with clinic staff and say “let’s work together as a team on this” and dig in, versus having the office manager walk into a monthly meeting and say, “Tomorrow we’re going to start doing this.”

One of the talents of a coach is to interact with the teams they’re supporting. Coaches ask good questions. We’re great listeners. We assist with evaluating what’s working and what’s not working. The experience and skills that the coach brings can sometimes get lost in organizations with many layers of management. It’s unlikely that the manager or director are seeing what a coach sees on the front lines. Sometimes teams in larger organizations miss out!

Carolyn Brill, Practice Coach at Qualis Health, has extensive practice facilitation and healthcare information technology experience. She has done builds for both Epic and Allscripts, is certified in Allscripts Enterprise, and has worked with many other EHR vendors. Previously she worked as a consultant supporting practices on meaningful use and clinical measure improvement.

 

KEY MESSAGE: Approach each practice you encounter with curiosity about learning who they are. Assume nothing about how well they might be able to do QI or how many resources they may have. A large organization doesn’t necessarily equate to a large amount of resources with which to do QI well — and vice-verse.

Themes emerged early on that recurred throughout the project

by Ross Howell, 2017

One of the challenges in our Healthy Hearts Northwest work has been accessing reliable, valid data to drive quality improvement on the ABCS (Aspirin-Blood pressure-Cholesterol-Smoking cessation) measures within our enrolled clinics. After recently talking with two of our practice coaches about what they’re seeing out in the field, I noticed themes emerging across Washington and Idaho. Let’s take a deeper dive into these change patterns.

Practice coaching is useful for boosting health IT
H2N has been a great opportunity to push the boundaries of what clinics with limited functioning electronic health records EHR can do with their technology to improve patient care. One coach expressed that before H2N some clinics “never ran reports or could never run reports. They never had, until we started asking.” Particularly challenging for clinics are what one coach called “third tier vendors”—those that sell a relatively inexpensive product accessible to smaller clinics with few resources — but that lack the ability to change their user interface or see how their care helps patients at the population level.

In the end, it takes much more work and costs clinics more time in process change and fixes to report their quality measures or identify care gaps. Much of the time our coaches spent with these clinics was dedicated to collaborative HIT (health information technology) work to improve system capacity. They also worked with clinics on making sense of the data they received. This was especially important for clinics that were reviewing data for the first time, as the numbers they saw often didn’t match the quality of care that they knew they were delivering

When clinics run a few PDSAs (Plan-Do-Study-Act cycles) and see their quality measures move in the right direction, they get more engaged in the idea of QI. As another coach put it, “the PDSA process has been really effective for demonstrating the value of this work. It’s not just random variation; you can see the improvement as you’re working toward the goal.”

Choosing a ‘good’ EHR isn’t the whole answer
In several clinics that our coaches worked with, the HIT challenges were as much as result of user knowledge gaps as system capabilities. Our coaches described several instances where reports we needed were accessible, but the clinic contact either had never received training or those reports had not been activated in the user interface. The coaches were able to support the clinics in accessing tech assistance or requesting the activation of reports through their vendor. Some clinics have robust, highly functional EHRs with strong reporting capabilities and easily modified templates or user interfaces, in some cases custom-built for the practice.

In other cases, EHRs are built by a third-party vendor that hosts their system remotely. In these clinics, both coaches stressed the importance of leadership engagement: “without leadership plugged into the project, it’s very difficult to make progress. Even if you have a clinic team trying to improve, they just go in circles without leadership engagement.” Where we can overcome institutional or analytical barriers to accessing reports and implementing short change cycles, our coaches see improvement and positivity.

Size has an impact
In smaller practices it can be easier to get the leaders to commit time and resources to Healthy Hearts NW. In large clinic groups the leadership may have many competing initiatives, of which Healthy Hearts is just one. At a certain size of organization, the administrative coordination involved in QI tends to make it difficult to innovate on the level of small clinical teams. For administrators trying to implement standard, reliable processes clinic- or organization-wide, small team-based innovation and change cycles can appear to be threatening deviations from their plan.

Despite having extensive HIT resources to support QI work, some clinics have layers of administration and bureaucracy slowing innovation and change. These tend to be large delivery systems, often associated with hospitals, with large QI departments including analysts and administrators. Our coaches have also seen that first-tier EHRs don’t guarantee access to high quality reports, especially for the smaller QI teams. This is especially the case where the EHR is purchased through a vendor that may require additional fees to produce the reports or connect to a third-party registry – costs that a smaller practice can’t bear.

FQHCs have a head start
One coach was careful to distinguish between private practice clinics and those that operate under federal rules and funding systems—such as federally-qualified health centers (FQHCs) or tribal clinics. Among the latter, QI methods have been in use for many years due to reporting requirements associated with their funding sources. Such clinics may have been running PDSA cycles or implementing changes for some time. Our Healthy Hearts NW coaches did less basic training in QI methodology and used their visits to improve the QI processes already in place. In the words of the coach, these clinics “have had different approaches to QI—but when we looked at what they were doing we saw that there were refinements we could make.”

Clinics want to change
It’s been an uphill battle to get our clinics the data they need to change for the better, but both coaches expressed optimism for the future: “With MACRA coming on, even small practices are starting to understand that this isn’t sending data out to a black hole but about improving the population health of their patients”. Practices are increasingly “not seeing it as just about patient responsibility” but are moving toward understanding that they are part of a “synergistic relationship between healthcare and the population at large.

It’s a huge shift of change to understanding why QI is important and why HIT is valuable for finding the care gaps in your patients.” The other coach expressed that he’s seen “a lot more involvement and improvement than expected–clinics want the change. They’re overwhelmed but starting to get rolling. They see the writing on the wall—and are implementing HIT improvements to prepare.”

*****

Ross Howell provided the Qualis Health Healthy Hearts NW practice facilitator team with a coordinative backbone of organizational support, meeting facilitation, and information management.  Prior to joining Qualis Health he served as a teaching assistant for undergraduate courses in the University of Washington School of Public Health and a research assistant at the Northwest Center for Public Health Practice.

I feel privileged to work with these providers

by Steven Brantley and Beth Sommers, 2016

Portland metro area
One of the independent, physician-owned practices I work with in the Portland-metro area has been focusing on identifying patients who use tobacco products and assessing their readiness to quit. This team developed a structured form, called the Tobacco Free Readiness Assessment (TFRA), to gather patient details around tobacco use and patient’s interest in becoming tobacco-free as a means to target cessation conversations and intervention activities based on patients’ self-identified stage of change readiness.

The TFRA gathers information from patients on their perceived barriers and motivations to becoming tobacco-free, gauges their awareness of resources available to help them quit, and asks whether patients are interested in receiving active support in becoming tobacco-free.

After administering the TFRA, dummy codes are used to enter these data into the clinic’s electronic medical record (EMR) so that they could measure their progress. Family Medical Group Northeast created data sets to enable tracking of individual and population changes over time. They became interested in following patients who’ve quit using tobacco so they also assigned a dummy code to the “I have quit” stage. Additionally, they created codes to delineate non-tobacco users and to chart when the TFRA is administered. The TFRA data displays in the clinic’s EMR health maintenance section.

Over six months, this practice has fully implemented a Tobacco-Free Readiness Assessment workflow across the practice, and continues with a wide spectrum of other smoking cessation activities. I’m so proud of the progress they made in such a short time!
– Beth Sommers

Southern Oregon
One of the primary care clinics I work with in southern Oregon has taken a slightly different approach with smoking cessation. To get started, clinical champions researched the epidemiology and impact of tobacco use in their population, city, county, and state, and presented their findings to the entire staff. They created a 10-question survey to assess staff interest in quality improvement, retention of tobacco information, and to collect ideas to improve their smoking cessation campaign.

The clinic’s quality improvement (QI) team was already screening champions: they were monitoring about 99% of their patients for tobacco use. Their opportunity was to increase their rate of counselling to patients, either via the physician or medical assistant. They worked with their IT department to develop an EMR baseline performance measure and began tracking the percentage of patients that screened positive for tobacco use and that were offered counseling. After 3 months, this counseling metric increased from 12% to 70%. After another 2 months and a steady increase in counseling offerings, they dedicated members of the QI team to continue reporting on tobacco cessation activities.

While the team as a whole moved on to other issues as their primary focus, smoking cessation is discussed it at every QI meeting. They’re constantly developing new ideas to address the remainder of their care gap. Smoking cessation is just one piece in the overall structure of our initiative, but supporting people to quit smoking can have an enormous, lasting impact. It’s a privilege to work with a group of providers that’s doing such great work for the people in their communities.
-Steven Brantley

*****

Beth Sommers, MPH is a Practice Enhancement Research Coordinator at the Oregon Rural Practice-based Research Network (ORPRN).  Her interests include social determinants of health, health policy, primary care transformation, and quality improvement. Beth received her master’s degree in public health from Portland State University, and her bachelor’s degree in physical anthropology from Oregon State University.

Steven Brantley, MPH is also an ORPRN Practice Enhancement Research Coordinator.  His interests include the spatial relationship of health determinants, primary care transformation, and improving access to healthcare. Steven received his master’s degree in public health and his bachelor’s degrees in biochemistry and Spanish from Oregon State University.

Life as a practice coach

by Cullen Conway, 2017

I’m a Practice Enhancement Research Coordinator (practice coach) with the Oregon Rural Practice-based Research Network (ORPRN) Healthy Hearts Northwest project.  A core component of our initiative is the dissemination of the latest evidence-based research via practice facilitators that are coaching clinical teams on improvement projects and better use of their health information technology data.

I started my work with clinics in November of 2015. I’m assigned to about 20 practices in the Willamette Valley and on the Oregon coast. I live in Portland, and from there traveled to each of my clinics for an initial in-person visit to get acquainted, go over program basics, talk about their goals, and complete a data assessment. After that first meeting, I visit each clinic monthly. Initially, I alternated between in-person trips and video conference calls, but I realized that the face-to-face meetings were more enjoyable and effective so I’ve begun doing all visits in-person.

Out in the field there’s a wide range of capacity to do quality improvement (QI) work. For most clinics, during the second visit we looked at their data and did early brainstorming on PDSAs (plan-do-study-act cycles.) The PDSAs usually didn’t start until the third visit, but some practices are already in the swing of doing them. For instance, when I returned for the second visit to one of my clinics, they pulled out 3 or 4 PDSAs they’d run since my first visit. They learned from each experiment and created the next from that so this practice was involved from the start in the iterative learning cycles that I think PDSAs are really meant to be.

“A-ha” moments with the clinics are the most gratifying 
One clinic was questioning their aspirin levels and why they weren’t meeting the Healthy Hearts measure. The numbers they were generating were disappointing them. Together we dug into this, figured out what was happening, and that they were actually doing well. Taking the time to do this gave them the confidence to move towards addressing the blood pressure (BP) measure. Once we’ve been able to help pull data and define the patient population – especially the high risk population – I’ve heard pleased comments about being able to view their patient panel this way, and generating alternative ways of allocating resources.

Frustration around electronic health record (EHR) software is common across clinics. With many EHR products, providers have great difficulty trying to pull data at a population level.

“We want the EHR to get population-level data that we can’t get”
I’ve heard this from providers and practice managers many times: “It’d be much easier for us clinically to just have paper charts”. Providers have invested time and money into new technology for this type of data use, but the systems don’t readily deliver this functionality.

Uncertainty around addressing data theoretically or conceptually can cause anxiety. If a clinic sees it’s performing 55% on the blood pressure measure but can’t see the patient denominator it can be really frustrating. Part of what I do is go into clinics’ EHRs with my teams, create patient reports so they can see the patients who aren’t meeting the measure, and come up with ideas on how to help reach their goal. Pulling data then shifts from a burdensome administrative requirement to information that applies to daily practice — and actually helps patients.

Sharing what works
One of my most effective tools as a facilitator in this project is sharing what’s been working in one practice with another. When I go into a clinic, and ask them where they want to start, they may say “We’re interested in blood pressure” – and I say, “Ok these are a couple of things I’ve seen done” or “I’ve seen a lot of teams focus on outreach”, etc. Sharing those stories is a good way to get the QI wheels turning in peoples’ minds. If people hear that it’s been working in other clinic settings it holds a lot more weight than if it was just me saying, “Let’s try this.” With the other coaches at ORPRN, we support each other by telling these stories to each other – what we’re seeing in our clinics – and so there’s a form of cross-pollination happening on many levels.

Sharing stories is not just about the positive – the things that’ve worked – but the struggles and frustrations that are common across the board. So I find myself often saying “You’re not alone. Let’s see where we can start”. It’s such a powerful message.

*****

Cullen Conway, MPH is a Practice Enhancement Research Coordinator at the Oregon Rural Practice-based Research Network.  His interests include social determinants of health, social justice, and working to reduce health disparities among underserved demographics. Cullen received his master’s degree in Public Health from Columbia University, and his bachelor’s degree in psychology from Lewis and Clark College.

My team asked me to step into a role I knew I was qualified for, but had no real-world experience doing. 

by Caitlin Dickinson, 2018

I’m a project manager with Healthy Hearts Northwest, based within Portland’s Oregon Rural Practice-based Research Network (ORPRN). I’d like to share with you what happened when I headed out into the field as a Healthy Hearts NW coach with zero on-the-ground experience.

Great opportunity exists in emerging fields like ours 
Practice coaching is still a wide-open field: no standards exist for the title of practice facilitator. Even these two nouns (coach, facilitator) are sometimes interchangeable, sometimes not. Whether coach or facilitator, working in this capacity isn’t like being a registered nurse, or a licensed massage therapist, or an attorney. There’s no national or state accrediting body, there is no one-size-fits-all definition of a practice coach or facilitator. If you do an internet search for employment as a health care practice coach, you’ll find that many aspects of this profession vary between job postings.

I began working as a project manager at ORPRN in 2015 after earning my Master’s in Public Health and working in OHSU’s OB/GYN department for four years. ORPRN’s mission is to improve the health of rural Oregonians by promoting knowledge transfer between communities and clinicians. Being involved in work that reflects community health values, priorities, and needs with like-minded colleagues is a dream come true for me.

When ORPRN embarked on Healthy Hearts NW, I supervised our team of practice coaches (Practice Enhancement Research Coordinators, or PERCs.) I managed project operations, and my curriculum development perspective served me well in that role. I was intimately involved in the design of the visits and the program. I attended the PERC trainings and had in-depth knowledge of the coaching day-to-day activities.

Staffing changes often necessitate switching roles
Multi-year initiatives like Healthy Hearts NW often undergo staffing changes, and ours was no different. When we lost one of our coaches more than halfway through, Healthy Hearts NW pulled me in as a coach to finish out the project. Because I was thoroughly familiar with the role and the work being done by our coaches themselves, it made sense to step in.

Here’s the thing, though: I’d never actually gone out in the field. I was nervous! Changing gears and becoming a coach meant that I’d inherit clinics that had begun the project with someone else, and were well on their way with their project work.

H2N created a powerful tool in the Quality Improvement Change Assessment, or the QICA. It’s a survey completed by staff and clinicians that assesses their current quality improvement (QI) capabilities and describes aspirational QI capabilities. It is used by the coach to guide them in supporting their practice on their journey to improving patient care. In Healthy Hearts W, our coaches work with their clinics to complete the QICA twice: once at the beginning of their work together, and then again approximately a year later to measure progress.

One of the practices I inherited is a great example of why I love the QICA. The practice took very good care of their patients and had an extremely hard-working team, but they lacked a unified approach for QI – the major focus of Healthy Hearts NW. My colleague had completed the first 10 visits with this clinic. She’d already administered the QICA with the practice at her very first visit with them, and again at the 10th visit. It was at that point that I stepped in, acting as their coach for the last five visits.

Having the QICA to rely on made all the difference
When I started working with the clinic, I had 10 months’ worth of extremely detailed notes and all of this theory swirling around my head, but I needed to zero in on something. I used the QICA, and as a new coach it saved me. I find this really reassuring as a new practice coach! Everyone on the clinic team fills out the QICA, not just the physicians. Although I appreciated having access to the first coach’s documentation, I didn’t have to sort through it all and rely on that. I had a well-rounded self-report from the team I’d be working with to guide my efforts.

I decided to focus in on a priority as determined by the QICA data, versus input from individual providers. The activities the clinic chose to work on with me arose from what they’d been learning from their data. Data began to drive the action, not self-selected provider interests.

This shift had a huge impact on team functioning! The Medical Assistants (MAs) became much more involved in rolling out QI activities. They seemed happier in their jobs and started speaking up in meetings.

My successes as a practice facilitator in the end stages of our project directly result from the solid foundation built by the coaches that came before me, and the timely administration of an effective measurement tool. This team wouldn’t have gotten where they ended up without these two factors. This clinic’s fabulous providers were doing well before Healthy Hearts NW, but they turned an important corner. They now embrace a data-driven, team-based approach to improving the way they run their practice. I feel so fortunate to have witnessed this, and to have been part of their journey.

*****

Caitlin Dickinson, MPH serves as project manager for ORPRN’s Healthy Hearts Northwest project. Prior to joining ORPRN, she worked for OHSU’s department of OB/GYN and coordinated career development (K12) programs and research projects focused on evidence-based medicine, comparative effectiveness, patient safety, and improving teamwork and leadership among healthcare personnel. Caitlin holds a Bachelor’s degree in biology and chemistry from the University of Denver and a Master of Public Health degree from Oregon State University.


KEY MESSAGE:  Here are two important aspects of real life as a practice facilitator. First is the guiding structure, or curriculum, to inform the work.  In our case it’s the QICA tool, which measures seven change concepts and allows for input from everyone in the practice.   These high-leverage changes expand and build quality improvement capacity in an objective manner.  The QICA also provides the information coaches need to tailor their approaches to individual practices.  On this journey, it helps to have a road map!

Persistence pays off

by Marion David Stipe, 2018

The Port Smithson Family Clinic of the Martin General Hospital Family Clinics is a rural practice nestled on the banks of a large river in Washington State. When Healthy Hearts NW Practice Coach David Stipe began working with Martin General clinics, he discovered that Port Smithson, the smallest in the family, had experienced significant provider and clinic manager turnover. Although it initially seemed that this clinic could have given up, they didn’t. It turned out that its slow start was just the beginning. David Stipe describes their journey.

My work with this group of four clinics began, per usual, with scheduling a project kick-off meeting with each. The purpose of this first meeting is to complete the Quality Improvement Change Assessment (QICA), an instrument introducing team members to the high-leverage changes guiding the project’s technical assistance approach as well as assesses the practice’s current capabilities. Although kick-off meetings are intended for all staff, just two Port Smithson people attended.  At the start of the meeting, I looked around the large room and with just the clinic manager and one provider staring back at me.  I asked when the rest of the team would be joining, and was told they had too much work to do that day, and would not be attending.  So, I went ahead with the meeting.

Is it the end of the road?
The next month I prepared for the second of the fifteen months of technical assistance support for Port Smithson.  After that uneventful and awkward first meeting and before their second H2N visit, the clinic contacted me to tell me they would be dropping out of the project altogether.  The clinic gave many reasons for withdrawing, and with each reason, I generated a “we can do this” response.  My messages didn’t work, and it seemed like the end of the road.

Soon after that conversation with Port Smithson, I met with another Martin General Hospital clinic and to my surprise, the provider champion broached the subject of Port Smithson with me.   By the end of our conversation, I was told to expect a call from Port Smithson confirming that they’d re-engage with Healthy Hearts NW and all staff would attend meetings.  That call came, and I scheduled a follow-up meeting.  But, just prior to the meeting, the clinic manager and provider announced to me that they would be retiring.  Once again it seemed like my efforts were failing and Port Smithson was going to let the H2N opportunity pass them by.

Or just the beginning?
Here’s where it gets interesting:  what should have been the end of the Healthy Hearts NW (and transformation) journey for Port Smithson ended up being only their beginning.  I witnessed a turnaround that was truly amazing.  The clinic’s two medical assistants (MAs) and front desk staff took over the project work and were engaged from the start. They quickly started working on the tobacco measure: They created a spreadsheet of patients who reported smoking to determine how many were referred to the Washington State Tobacco Quit Line, and by doing so, designed their first Plan-Do-Study-Act (PDSA) cycle.  They were eager to try out new changes in their workflow to better facilitate patient rooming and improve communications with providers.  Before the first meeting was over, the staff discussed the necessary changes, drawn up the new workflow, and made a small-scale testing plan with me.  Port Smithson repeated this process for all four Healthy Hearts measures.

Reversing initial resistance
Additionally, as part of the project’s mission to provide opportunities for shared learning between clinics, staff from Port Smithson travelled to St. Paul’s Family Medicine Clinic in northern Washington for a site visit. Our site visit had its intended impact, which was to demonstrate how to translate proven quality improvement changes from one practice into another, similar clinic setting.  I saw Christmas morning at our next meeting!  The faces of the MAs were glowing and animated, full of curiosity, each describing and demonstrating the work and knowledge they took away from their visit to St. Paul’s. The outstanding dedication of those MAs, supported by my patience and persistence, helped this clinic reverse its initial resistance.

The Port Smithson team continued to discuss and test what worked for them and what didn’t. They bubbled with ideas of changes, and I felt a sense of reward working with and guiding them through the next year and a half.  Despite provider changes in the clinic, their ABCS numbers still improved. They ordered ASA, statin, and smoking posters from the Centers for Disease Control. They located a state-generated blood pressure poster and developed brochures for all ABCS measures.

I soon became aware my coaching was less and less necessary.  The only support the clinic requested from me was to help locate information for them to make their own brochures. For me, Port Smithson is such a great example of success!

Spreading changes across multiple clinics
While working on Healthy Hearts NW, the Port Smithson team implemented a change that was adapted by all four Martin General locations.  Their electronic health record (EHR) software was not designed to readily supply necessities for patient exams, so the team added white boards to every exam room with that information.  This freed up more time for the providers to spend with patients, face-to-face.  If a patient’s initial blood pressure was elevated, they followed the 5-minute protocol and re-took the patient’s blood pressure. If it was still elevated, they marked blood pressure in red on the white board. Today, all four Martin General Hospital clinics have implemented the white boards in all patient rooms.   This innovation not only improved patient-provider communications, but the white boards served to visualize this clinical quality measure information.

Leadership takes note of improvement
As Port Smithson continued to progress, their work was recognized by hospital leadership and the team felt excited to know they were making a difference in their patients’ lives.

Port Smithson is special to me.  I am confident this group has the knowledge and skills for sustainability. They started this work with so many excuses, but a combination of new staff and engagement turned things around completely.  I’ve shared this story with other primary care clinics whose teams believed they couldn’t afford the time or resources to improve, just like Port Smithson.

*****

Marion David Stipe, RRT, Practice Coach at Qualis Health, has worked in health care for more than 30 years. He began his career as a registered respiratory therapist and has 20 years of healthcare IT experience. He is proficient in several EHR systems including Epic, Greenway Medical and MedHost, as well as an expert with implementations and workflow. Additionally, he has deep experience in meaningful use, EHR improvements related to workflow, optimization and reporting. Mr. Stipe has previously been certified in Epic Ambulatory and MyChart modules.

 

KEY MESSAGE: This story shows the resilience of a small practice getting unstuck early in the improvement journey. It also describes the power of learning and collaboration across clinics. Finally, it highlights specific ways an engaged clinic team can improve upon clinical quality measures. This practice didn’t drop out: instead, it graduated from Healthy Hearts with flying colors!