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

Megan McHugh; Tiffany Brown; David T. Liss; Theresa L. Walunas; Stephen D. Persell

doi:10.1370/afm.2197

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Table 1

Characteristics of Participating Practices and All Wave 2 Practices (n = 33)

Characteristic	Interviewee (n=17)	All Wave 2 Practices
Clinicians in practice
Mean (SD), No.	2.82 (2.2)	2.3 (0.8)
Median (range), No.	3.0 (1–10)	2.0 (1–10)
Part of larger organization, No, %	5 (29)	7 (21)
State
Indiana, No. (%)	6 (35)	12 (36)
Illinois, No. (%)	8 (47)	17 (51)
Wisconsin, No. (%)	3 (18)	4 (12)
H3 quality improvement encounters
Mean (SD), No.	6.4 (2.9)	6.4 (3.0)
Median (range), No.	6.0 (0–13)	6.0 (0–14)

H3 = Healthy Hearts in the Heartland.

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Table 2

Summary of Key Themes From Interviews, by Respondent Type and Consolidated Framework for Implementation Research Domain

CFIR Domain	Practice Leaders	Practice Facilitators
Intervention design	H3 was a valuable program that provided practices with skilled practice facilitators and access to new resources. H3’s educational resources were of high quality H3’s focus on the ABCS was highly attractive, because many quality-based incentive programs include ABCS measures. A minority of respondents, however, questioned the validity of the ABCS measures A shortcoming of H3 was its limited support for improving patient adherence H3 offers little added value for very advanced practices (eg, practices that excel on the ABCS measures) and very high-need practices (eg, practices with a large number of homeless patients).	H3 was a valuable program that provided needed resources to offices with limited quality improvement capacity. The educational resources were of high quality H3’s focus on the ABCS helped practice facilitators recruit practices to the program H3’s internal structure was supportive for practice facilitators, including communication channels that permitted shared learning, and access to internal medicine physicians who provided guidance and clinical expertise regarding the ABCS measures Practice facilitators’ dual responsibility of conducting quality improvement work and collecting ABCS data required for the H3 evaluation was burdensome and time consuming Despite extensive training before the launch of H3, practice facilitators reported substantial learning on the job.
Quality improvement process	A strength of H3 is that it is tailored to each practice, based on the practice’s needs and capacity to change H3 was a relatively low priority for the practices The easiest H3 interventions to implement were EHR documentation changes, connecting patients to state-run smoking quit lines, and providing guidance to nurses and medical assistants on best practices for blood pressure measurement	H3’s reliance on practice leaders to determine the frequency of visits and interventions to implement led to a lower dose of the H3 intervention than expected H3 was a relatively low priority for the practices The easiest H3 interventions to implement were EHR documentation support and other interventions that did not alter the way that physicians delivered care
Internal environment	Lack of clinician time and staff turnover were considerable barriers to H3 implementation A capable, easy-to-use EHR platform and well-functioning team approach to care were enablers to H3 implementation H3 was a good fit for most practices	Lack of clinician time and staff turnover were considerable barriers to H3 implementation Limited engagement in H3 by clinicians from many practices compromised the fit of the program for many practices

ABCS = aspirin use, blood pressure control, cholesterol management, smoking cessation; CFIR = consolidated framework for implementation research; EHR = electronic health record; H3 = Healthy Hearts in the Heartland.