Systematic Review and Meta-Analysis of Practice Facilitation Within Primary Care Settings

Thank you very much for the positive feedback on our article on the effectiveness of practice facilitation. The majority of the studies reviewed in our paper described facilitation interventions incorporating a number of change strategies - consensus building, audit and feedback, practice changes, reminder systems, etc. The facilitators were predominantly external to the practice. Our paper includes a supplemental table that describes the tools and strategies most commonly utilized. http://www.annfammed.org/content/suppl/2012/01/09/10.1.63.DC1/Baskerville_Suppl_Table_2.pdf Grimshaw and colleagues have shown that multi-component interventions such as practice facilitation are more successful in improving practice than single component interventions. I agree that a PF is necessary but not sufficient for success. Based on the review it seems that the ability of the PF to work with the practice and incorporate amenable tools and strategies to improve practice performance is key.

Competing interests:   None declared

The Baskerville and colleagues' review provides useful insight into facilitation process and activity within the context of primary care and is an important contribution to the implementation science literature. In our review of the facilitation literature (in nursing) over the past decade, we also discovered that increasingly more attention is being paid to the importance of tailoring facilitation to the local context (Dogherty et al., 2010). In my view, the need for pragmatic, practice-based evaluation research is one of the most important conclusions to the Baskerville review to not only examine the impact of facilitation but also the relationship between contextual characteristics and components of facilitation interventions to understand how the intervention is applied in different settings, and to what effect. This type of research would provide information to help practitioners and organizations better tailor facilitation interventions to specific local settings. Kitson and colleagues (2008) are now suggesting that the most appropriate facilitation method could be best determined using preliminary diagnostic and evaluative measures of both context and the evidence being implemented. The nature of the facilitation intervention is then established based on the particular context, at a specific time and place including the specific actors within the setting. Their group is currently developing and investigating these measures.

Facilitation appears to be a multifaceted and complex intervention and what works in one setting likely may not work across settings or even in the same setting at a different point in time. Tailoring is critical. However, the challenge lies in replicating studies and producing findings which are generalizable when the intervention is specific to the context. Perhaps this lies in determining the core elements of facilitation which can be applied across settings and what components may be adjusted according to the context. As such, I agree with Eric Shaw's suggestion that additional qualitative inquiries, and specifically appreciative inquiry approaches, are needed to develop the evidence base and a greater understanding of these fundamental process elements in other words the "art" of this important, multifaceted intervention.

Dogherty EJ, Harrison MB, Graham ID: Facilitation as a role and process in achieving evidence-based practice in nursing: A focused review of concept and meaning. Worldviews on Evidence-Based Nursing 2010, 7(2):76 -89

Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A: Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges. Implementation Science 2008, 3:1

Competing interests:   None declared

As others have noted, I also greatly appreciate the work put forth by Baskerville et al to provide sound evidence on the value of practice facilitation. What I am challenged with is assimilating this broad take on facilitation with the intricate realities of what facilitation "looks like" practice by practice. There is an art to facilitating practice change and the authors' finding on "tailoring" seems in line with this claim. There is a complex relational dynamic when facilitators work with individuals/teams in practices. Facilitators may be able to incorporate proven tools and draw on resources that can lead to desired organizational changes. But in doing so, the facilitator is faced with and must manage many complex group dynamics. Any attempt to improve how a practice delivers care means that communication structures, patterns of authority and power, motivation for/fear of change, and many other variables will matter for the change process. While efforts to move towards large-scale evaluation studies is warranted, I would emphasize the need for additional qualitative explorations of these complex change dynamics (from these existing studies) so that we have a stronger evidence-base on the art of facilitation.

Competing interests:   None declared

Dr. Baskerville and colleagues provide an important service to practices and health care organizations in their review of the contribution of care facilitators. While it will be no surprise that care facilitation works, the data in Figures 3 and 4 deserve special attention. Not only is the process of facilitation important, so is the right balance of practices served by each facilitator.

Going forward, the issues of when it is best to have a facilitator based within the practice and when a centrally located facilitator can serve multiple practices are important questions to address. It is clear that a 15- or 20-minute office visit several times a year with a clinician is not enough to support behavior change for some patients. The role of the facilitator can provide an important boost to support patient behavior change.

Competing interests:   None declared

Drs. Baskerville, Liddy, and Hogg:

I thoroughly enjoyed reading your article and it will certainly help set the stage for primary care practice facilitation. Adoption of evidenced-based guidelines in primary care settings can to improve the efficiency of practice operations as well as improve overall patient care. Your results that primary care practices are more likely to adopt evidenced-based guidelines through practice facilitation are important for the primary care field as a whole and to practice facilitators in particular. I agree with your point that we need to move away from more testing of the conceptual model and move into large-scale evaluation studies. I think these types of studies that get into the quantitative and qualitative measures of the impact of practice facilitation will be immensely beneficial for primary care practices moving forward. It was an honor to be invited to provide this commentary. Kudos to the whole team!

Joseph Clift, EdD, MS, PMP

Competing interests:   None declared

Dear Zsolt,

Thank you very much for your positive feedback on our systematic review. We both know how difficult it can be getting evidence into practice and our review has demonstrated the overall impact of practice facilitation as a KT strategy for improving quality. As do you, I look forward to practice facilitation being eventually scaled up to a program and distinct profession where we can further evaluate its implementation and effect.

All the best!

N. Bruce Baskerville, MHA, PhD Senior Scientist Propel Centre for Population Health Impact Faculty of Applied Health Sciences University of Waterloo Waterloo, Ontario N2L-3G1 Canada

Competing interests:   None declared

It is indeed gratifying to see evidence that facilitators are associated with a higher likelihood that medical groups will adopt evidence-based interventions. I think it is important to recognize that the facilitator needs to have the tools and support to succeed in the task. In his 2007 Am J Prev Med paper David Ballard describes 11 interventions that Baylor Health Services adopted in their efforts to promote the delivery of evidence-based preventive services. Each intervention improved delivery rates to some extent, and when taken together the results were outstanding. In 2001 Patrick O'Connor reported in Disease Management Health Outcomes their mapping of strategies used to improve care to the Enhanced Primary Care (EPC) model in seven primary care practices. They found that in the majority of successful practices 10 key strategies were used.

It is important to remember that there are many barriers to the delivery of evidence-based practice and that the solution lies in the development of an effective delivery system. While the analysis of Baskerville suggests that a practice facilitatior is beneficial, it is my impression that a practice facilitator (an internal champion) is necessary but not sufficient for success.

Competing interests:   None declared

Dear Bruce,

I am truly thankful for your team's work on this fundamental study. Since our systematic review in 2005, we had many occasions when we needed the kind of evidence you generated, in order to support our message that practice facilitation has been perhaps the most successful primary care practice-based implementation and knowledge/resource dissemination approach so far. I agree that this rigorous study settles the question in favor of practice facilitation, in addition to the estimate of a positive (40%) ROI you have shown when facilitation is properly implemented to improve preventive services delivery (http://www.ncbi.nlm.nih.gov/pubmed/15755330). These results will help further our long-term goal to establish practice facilitation as a distinct profession in the United States.

The practice-based research community appreciates your team's significant contribution to this area!

Zsolt Nagykaldi, PhD University of Oklahoma Health Sciences Center Department of Family and Preventive Medicine

Competing interests:   None declared