Deepening the practice transformation bench

I remember feeling giddy and celebrating together.

by Angela Combe, 2018

One of the small, single-physician rural clinics I was assigned to in Healthy Hearts Northwest (H2N) stands out in my mind due to the incredible progress made during the time I worked with them. Dr. Emma Boone’s Oregon clinic (a provider pseudonym) was in the process of working towards patient-centered medical home (PCMH) status when they joined H2N. They enrolled in the program with the goal of improving efficiency and processes, as well as learning to maximize their electronic health record software.

Dr. Boone’s practice and its surrounding community have been experiencing steady population growth and need additional providers, but recruiting and training medical professionals has been historically difficult in this region. Dr. Boone’s office was receiving 5-6 new patient calls daily to request care, but she didn’t have the capacity to take on so many new patients. This was another driving reason they sought coaching assistance.

The office manager was extremely engaged
In complete alignment with Dr. Boone, the clinic had a focused and driven practice manager who was invested in the health and type of care delivered in the clinic. I’d say most of the push to improve originated with the office manager, who was trying to forge a path, learn and grow, and implement best practices in the clinic. To ensure everyone was working to the top of their skills and licensure, the two medical assistants (MAs) and the office manager at Dr. Boone’s practice became CMAs (certified medical assistants) during H2N so the clinic had three medical assistants to fill care gaps. They were extraordinarily supportive of one another, and the roles that each played in providing care to their patients.

No prior experience in quality improvement
This group had never done any quality improvement (QI) work prior to H2N, and had very little infrastructure support. Though essentially starting with nothing, they were completely open to change. Of the Pacific Northwest clinics I worked with, I’d say only 25% were motivated to the extent of this clinic. Roughly speaking, 25% are completely disengaged, with the remaining 50% sort of muddling along doing their best.

A big part of coaching in the H2N project was introducing and creating Plan-Do-Study-Act (PDSA) cycles, a classic QI activity. Although our project provided printed instructions, I planned at least one visit for an in-depth discussion about PDSAs with each of my practices. It can take months for a clinic to get the hang of PDSAs – and some never quite understand how to do them, or the value they bring.

Jaw-dropping progress
I’ll never forget the day I showed up at Dr. Boone’s clinic, discussion agenda items in hand, for the first meeting about PDSA cycles. Nothing could have prepared me for what I encountered: the front desk staff had taken on PDSAs with the support of the entire team, and had already completed their first one. They even had results to share, such as what they learned and next action steps. They were so excited to show me what they’d done.

I think my mouth might have dropped open in shock. My plan for that visit was blown! I remember feeling giddy and happy, and celebrating that moment together. Not all days in a coach’s life are like that one, but I hold onto that memory.

Meaningful and exiting to watch this unfold
This is a perfect example of the ways a coach is uniquely qualified to support a practice: by recognizing progress and celebrating success. Their success with PDSAs continued, as the whole team took responsibility for conducting them. There was no single person responsible for QI – they alternated leading each cycle. The team’s enthusiasm kept them going, and it was so meaningful and exciting to watch it unfold. This was a practice that truly transformed.

Such an outcome is the reason I do this work, and seeing success happen before our very eyes is exactly what coaches hope for.  Isn’t this true in so many areas of life, not just health care practice coaching? When working to make changes, it’s great to have someone who really understands to cheer us on. The positive energy just flows, and helps keep us moving towards our goals.


Angela Combe, MS is a Practice Enhancement Research Coordinator for the Oregon Rural Practice-based Research Network serving the Healthy Hearts NW Eastern Oregon region. She holds a Master of Science in Community Health Education and a Bachelor’s of Science degree in Nutrition/Dietetics, both from the University of New Mexico. Prior to joining ORPRN, Ms. Combe worked as Faculty for the Extension Services of Oregon State University and Washington State University.