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.

Welcoming diverse points of view is powerful – and smart

by Cullen Conway, MPH, 2018

One of the clinics I worked with during Healthy Hearts is a federally-qualified health center (FQHC) on the northern Oregon coast. Like other FQHCs, it mostly cares for patients who are middle-aged and/or underserved.

When I started meeting with the clinic as their practice facilitator, they already had a clinical quality manager on staff and were meeting regularly to discuss typical topics like metrics and workflows. They had been in conversation about their blood pressure metric, but were struggling to find improvement.

Things started to brighten when the clinic came up with the idea to improve BP processes by engaging the people who took BP readings: their medical assistants (MAs.) The first step in doing this was to carve out time for the MAs to gather in a room so that they could brainstorm solutions. What was interesting to me, and I think very astute, was that the administrators and providers excluded themselves from the process.

The MAs were excited to take this on! They generated fifteen ideas to address, voted to distill down the top three, and used these as the basis for their Healthy Hearts PDSAs (“Plan-Do-Study-Act cycle”.) The MAs created great, effective workflows that were well-liked across the team.

The clinic’s initial improvement approach was what we call “top-down”: only high-level administrators and providers were at the discussion table.  They learned that by limiting the quality improvement conversations to only those in senior leadership positions, they missed hearing directly from care team members that perform the processes they were trying to fix. Blood pressure improvement started with the higher-ups trying to figure a way to do it better, but the medical assistants ended up being the problem-solvers.

Over the course of the project, the clinic bolstered their QI committee to include multidisciplinary staff, patients, and community members. One of their big takeaways from the PDSAs was that incorporating more voices, rather than deferring to a single authority, often led to the most effective protocols and designs.

For example, a team member described to me how community members helped the practice think outside of their clinical box. The clinic knew it needed to improve their BMI metric. They discovered that many of their elderly patients did not want to take off their shoes to step onto the scale. As they were discussing workflow ideas for this metric in a QI committee meeting, a community member raised his hand and asked, “Well, do you have a shoehorn near the scale?” Voila! Two shoehorns were installed near their scale and the BMI metric shifted for the better. Having the community member perspective allowed them to identify basic and practical solutions that they were missing on their own.

This FQHC continued their impressive and inspiring work throughout Healthy Hearts. Most of their good work initiated from their ideas and occurred during time when I was not with them, but I was with them in spirit to support and cheer them on.

I am so happy to share these examples of what can happen when a practice makes a habit of taking an inclusive approach to thinking through problems that impact an entire clinic. More voices at the table can be effective – and smart.

*****

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.

 

KEY MESSAGE: A practice facilitator often creates an opportunity for others in the clinic to feel safe and speak up. This can change the nature of the conversation within an organization, which creates buy-in with bottom-up rather than top-down ideas.

I feel privileged to work with these providers

by 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 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 ORPR). 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-based Practice 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!

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.