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.