Practice Facilitators’ and Leaders’ Perspectives on a Facilitated Quality Improvement Program

Dear Dr. Mold, Thank you for your interest in our study, and we appreciate your perspectives. The practice leaders received a $50 gift card as a token of our appreciation for their participation in the 30-minute interviews. The practice leaders interviewed were physicians (47%), clinic managers (18%), nurses (29%) and a nurse practitioner (6%).

Indeed, EvidenceNow was a push project, though optional for all participants. The ABCS measures included in the study are used in national quality incentive programs, which may help generate some alignment between the goals of the project and the goals of the practices. However, the amount of money at stake may be too small to offset the time and effort required for small practices to undertake large-scale improvement efforts in the absence of significant payment reform, as you note.

Competing interests: None declared

This small study by McHugh and her colleagues makes important observations. As part of Agency for Healthcare Research and Quality (AHRQ) EvidenceNOW grant, her team in Illinois compared the attitudes of clinic leaders with those of practice facilitators re: the EvidenceNOW quality improvement program to assist small to medium sized primary care practices adopt evidence-based cardiovascular disease prevention guidelines.

Their finding that each group had divergent interests and measures of success are important. Where practice leaders valued being able to set their own schedule for facilitation and their ability to choose from the menu of improvement options, facilitators valued more a quicker pace of intervention. The text reveals many of the reasons for this discrepancy. Available time to meet with facilitators and to introduce interventions, for example was critical. Many practices had very little time to spend on this outside-driven effort while facilitators had a research job to accomplish.

These observations are particularly meaningful to our EvidenceNOW Southwest group in New Mexico for we've introduced a university-employed, community-based participant (a Health Extension Agent) into the facilitation team. That member helps to remind us that our relationships with the 52 practices in New Mexico is long term, far beyond the life of a particular grant and so while a contracted facilitator may leave after the prescribed intervention, the relationship with place-based facilitators is both on-going and the quality of that relationship must be protected.

Because the time limit allowed for the intervention was quite short, the authors report that facilitators recognized the value of introducing quality improvements that were "simple, targeted...rather than larger, [and] comprehensive." I would go further and add that community-engaged investigators must adopt a "demand-side" approach (i.e. what does the practice really need?) rather than a "supply-side" approach (i.e. here's what we want to give them).

Competing interests: None declared