What is an Old-Fashioned Practice?

An Old-Fashioned Practice is one very set in its ways and that has perhaps been in practice for a long time. The practice generally sees its years of practice and experience as more valuable in making decisions about care than adherence to evidence-based guidelines. It is not uncommon that an Old-Fashioned Practice also values relationships with patients over providing evidence-based care, thus things like prescribing six months of an opioid, contrary to updated guidelines, happens in the spirit of making a long-known patient feel comfortable and supported.

Example from a practice facilitator:

This “old-fashioned” practice was a small coastal practice, with four providers and 18 total staff.  Its owner was an older physician who did not agree with current hypertension guidelines. While he didn’t see the value in quality improvement, he knew they had to do better on their quality reporting. At first it was difficult to convince the practice to review the latest evidence-based guidelines and try new workflows. The providers were set in their ways. While they didn’t buy in to the specific measurements in the new guidelines, they did agree on some of the key components of the hypertension guideline and communicated a standard approach for patients with high blood pressure. After completing several small changes and indications of improvements, the providers started to get excited and picked up steam. Now they are a high-functioning practice that champions the importance of quality improvement based on evidence-based care, and their team reports less burnout as well.

Data

The practice does not have up-to-date patient self-management materials.

This practice frequently has outdated or limited (in terms of supply and/or detail) patient self-management materials. Especially for settings that serve a distinct population, the ability to identify evidence-based and culturally relevant materials can be a challenge. Additionally, locating appropriate materials and making them accessible to staff can be very time consuming, and thus, often results in the patient having to rely on their recollection of the conversation they had with clinical staff regarding their appointment.

Strategies

The practice facilitator should listen to the practice staff to understand the patient population and the needs of the surrounding community. Research examples of current and relevant materials, and help the practice test their use with a few patients and patient family members to discover what works best for both. Once patient materials are selected, help the practice determine the best way for them to obtain and store needed quantities in the correct languages and develop relationships with the sources to procure ongoing updates.

As an example, state-run smoking cessation programs will send practices pamphlets with phone numbers and websites patients can contact directly. Help practices connect to appropriate training resources for clinic staff to learn skills such as lifestyle coaching, diabetic education, motivational interviewing, care management, and other proven methods for improving patients’ self-management skills. One benefit of documenting and utilizing available community organizations is that it can help direct patients to local resources such as fitness centers or community centers.

The practice can generate data, but one or more members do not trust that it is correct and therefore discount it.

Although the practice can run queries and generate data reports, they often do not have a full understanding of where the data originates and that causes staff to question whether the data are current or accurate. Additionally, an individual clinician may believe, with or without justification, that the data are wrong for their patient panel. They may believe the data generated underrepresent their actual performance, because of incorrect data definitions or inaccurate data capture.

Strategies

A QI culture depends on the staff trusting that the data are correct. Practice facilitators should start by explaining how the data are generated for the reports that the practice runs and work with practice staff to find clinical measures that are not only timely enough to be actionable, but also the most relevant for their population. Often the practice has had prior experience with reports they found to be incorrect, so they may need to be walked through data summaries to build familiarity and trust in the data. Suggest that a clinical staff member look up a sample of 10 to 20 patients and verify accuracy of information. By teaching practice staff how to validate their data, you can decrease anxiety around reporting and empower staff to look at their data in a meaningful way. Finally, encourage one member of the team to become a “power user” – a local resource for the team who spends some time building expertise and comfort with the practice’s systems. Ideally, this team member can include this work as a part of their job description.

QI Team and Project Management

The practice does not have an established quality improvement team or process.

This practice does not have a defined quality improvement team, and instead may have ad hoc groups for each improvement effort. Given the number of local, state, and federal initiatives that a practice might engage in over time, there could be several initiatives, each with independent clinical quality measures and improvement goals, active at the same time without close communication among them. As a result, few opportunities exist to generate discussions across roles, with team members addressing issues individually as they arise, rather than engaging in a team-based approach. If team meetings do occur sporadically, they are often dominated by one or two individuals with many of the team members going unheard, or used for items such as vacation schedules instead of the work of improvement.

Strategies

Practice facilitators can convey the roles and responsibilities of a high-functioning quality improvement team, and can educate the practice on what that could look like and the benefits to be found in a  structured approaches. Explain the advantages of a quality improvement team and how it functions, which can remove anxiety about workload. Sharing examples of organizational structures, sample agendas from meetings that have worked well, and successful approaches from similar practices. As they engage in a project, lead a workflow mapping activity  to show them which roles they need to include when forming their team. Help structure a well-functioning quality improvement team with a quality improvement lead, physician champion, reporting/IT representative, nursing staff, and other staff relative to priority initiatives. 
 
Celebrate the team’s early successes!  Highlight how the work is improving patient care, which is essential to clinical staff. If a team is still resistant to regular meetings, or practice leadership doesn’t see the value in protecting staff time for quality improvement monitoring, help them see an example of the return on investment during a quick successful intervention even outside of the main project. This can be very effective to sustaining the team and realizing the value added by this work, even though it will take staff time.
 
Help the practice find an improvement model, such as the Institute for Healthcare Improvement (IHI’s) Model for Improvement, with which they are comfortable. Coach them on how to use this model to identify positive changes and track their effectiveness. Encourage the practice to be consistent in their quality improvement approach, guiding them in selecting a manageable set of  improvement initiatives with clear goals, timelines, and staff time and resources. Many practices are finding success with the IHI Model for Improvement project approach using AIM statements (What are we trying to accomplish), and structuring Plan Do Study Act (PDSA) cycles with Specific, Measurable, Attainable, Realistic, and Timely (SMART) goals and project timelines. 
 
Emphasize the importance of getting ancillary staff who touch the process involved in the quality improvement project, such as billers, front desk, and nursing staff; the best ideas come from the people who are doing the work. This will help them with the issue at hand and will also reinforce that quality improvement teams and process testing should involve the entire practice.
 
If nothing you share resonates with the practice, keep offering options and discussing successful examples of practices until they find something that works for them. Ask them to complete a PDSA worksheet together with you, using a change that they have already made in the past or something that they want to change in the present. Help the team understand improvement science. Communicate that PDSAs that do not show improvement are just as important as those that do and will be implemented. Convey that practices often stick with changes that have added no value, consuming additional staff time and resources, because of a lack of rigor in how improvements are tested and implemented.  
 

The practice lacks a systematic way of identifying issues quickly or anticipating bottlenecks, and instead treats problems on a case-by-case basis as they erupt.

This practice addresses issues as they arise rather than establishing systems to monitor activities to quickly identify and address inefficiencies or prevent emerging issues before they arise. The practice team may identify issues and create ideas on how to solve these issues, but it is often ad-hoc and unsustainable. After a problem is addressed and the crisis passed, there is no opportunity to learn from the situation or apply solutions to other areas proactively. 

Strategies

A practice facilitator can start by teaching this practice why they should monitor the progress of changes over time. Encourage the team to involve all team members that impact a process so that causes are well understood and unintended consequences from the changes are avoided or mitigated. Help them to sustain the change and to not go back to the old workflow after they stop giving it their focus. Use their example of a past quality improvement project as a way to get buy-in from practice staff since it is an example they can directly relate to. Explain that follow-up on these improvements does not have to be intrusive or overbearing. Help them create a mechanism for quality assurance and for follow-up on identified issues that can be applied uniformly across the entire staff and that does not single people out in a negative way. Basing performance off measurable data points is a great way to do this, because there is a shared framework that can be used to define success and monitor counter measures (Steven’s “Supporting people to quit smoking can have an enormous, lasting impact from” H2N blog). Using the PDSA worksheet in conjunction with encouraging the practice to view its own data can be an effective tool with this practice.

Incorporation of Evidence

Clinicians and staff may not be aware of the most recent evidence-based care guidelines.

The practice’s clinical teams rarely discuss treatment protocols or share their personal approaches, so each team functions as an island, without opportunities to learn from each other or share new evidence. These practices tend to have either very high turnover in clinicians or be the domain of a solo practitioner who relies on their personal experience and training, which may have taken place some time ago. Practices that are more geographically isolated, such as in rural settings, may not have processes in place to identify and share the latest evidence-based care, and may also have fewer opportunities to interact and learn from other community practitioners.

Strategies

In many cases, sharing the latest evidence-based guidelines for discussion with the practice’s quality improvement team, including the clinician(s), starts the development of an “organizational” care pathway that includes steps to stay current with new findings. While what is implemented may not exactly match the latest evidence-based guidelines due to local adaptation and staffing considerations, it can result in progress toward that goal as well as set an expectation to stay current.  This may also facilitate moving towards standardizing care within the practice’s walls, applying processes such as standing orders, initiating a path towards team-based care, and applying a uniform understanding of the general care pathway.  
 
In many cases, updating the EHR clinical decision support rules or flags to support the care team in their care pathway may be helpful.  In the case of improving cardiovascular risk factors, for instance, if the adopted organizational guideline of blood pressure is out of control for anything above 140 systolic/90 diastolic, a flag can be created in the EHR to highlight a BP reading of 140/90 as “High”.  This would alert the staff responsible for taking the BP, allowing to add a process for a repeat BP after 15 minutes to verify the BP is truly elevated.  Flags can also be set to aid in a diagnosis of hypertension.  Helping the nursing staff utilize reporting capabilities may help identify patients into a population, such as hypertensive or diabetic, allowing ease of monitoring with subsequent follow-up as needed.   
 
A key step for practice facilitators for this type of practice is to bring literature on the most recent evidence-based guidelines.  Help the practice leverage their EHR’s ability to review patients that are not meeting target goals and look at the possible care gaps to identify opportunities for process improvement.  Share ideas of how other practices have utilized clinical decision support rules and various processes to close care gaps at the time of the patient visit.  Practice facilitators should be supportive of the clinicians’ current care pathway, or guideline, yet encourage them to test the effectiveness of their treatment plans using validated clinical quality measures that are short-term, such as “Controlling High Blood Pressure- CMS165”.  
 
Practice facilitators should be prepared to encourage a team that lacks initiative and empowerment to engage in quality improvement endeavors.  When first starting with these practices, they can take quite a bit time to discuss cultural and role definitions.  This may lead to a cultural shift to allow for the consideration of standardized work to be considered and implemented.
 

Self-Management Support Materials

The practice does not have up-to-date patient self-management materials.

This practice frequently has outdated or limited (in terms of supply and/or detail) patient self-management materials. Especially for settings that serve a distinct population, the ability to identify evidence-based and culturally relevant materials can be a challenge. Additionally, locating appropriate materials and making them accessible to staff can be very time consuming, and thus, often results in the patient having to rely on their recollection of the conversation they had with clinical staff regarding their appointment.

Strategies

The practice facilitator should listen to the practice staff to understand the patient population and the needs of the surrounding community. Research examples of current and relevant materials, and help the practice test their use with a few patients and patient family members to discover what works best for both. Once patient materials are selected, help the practice determine the best way for them to obtain and store needed quantities in the correct languages and develop relationships with the sources to procure ongoing updates.

As an example, state-run smoking cessation programs will send practices pamphlets with phone numbers and websites patients can contact directly. Help practices connect to appropriate training resources for clinic staff to learn skills such as lifestyle coaching, diabetic education, motivational interviewing, care management, and other proven methods for improving patients’ self-management skills. One benefit of documenting and utilizing available community organizations is that it can help direct patients to local resources such as fitness centers or community centers.

Culture

The practice has an aversion to change, so new solutions are hard to implement.

This practice might say things like “We have been doing this for years” or “We already have a workflow in place for that issue.” They may have addressed the problem in the past but lack a structure to ensure they follow up on their work or move on to new goals or approaches. Reluctance by this practice to discuss new ways of working may be tied to their belief that they are already performing quite well, despite indications in their data that there are areas for improvement. In some cases, this overconfident practice can become “straightjacketed” by a need to achieve perfection—only willing to take on new tasks if they can immediately perform them well, and therefore they may be averse to small-scale tests of change.

Strategies

Practice facilitators can run clinical quality measure reports for this practice comparing their performance data against other similar practice data or benchmark data, which can uncover opportunities for improvement. After addressing concerns they have with comparability of the practice or quality of the data, invite them to consider a small test of change, beginning with a simple workflow mapping exercise. After an initial success, people will be more willing to explore new ways. It may also be helpful to expand the number of staff engaged in a topic to get more buy-in. Some practices have used structured trainings followed by staff satisfaction and learning surveys to boost engagement successfully. Overconfidence may occasionally be a coping mechanism for teams reluctant to spend the time or energy examining their processes. Data performance can convince an overconfident practice to establish a quality improvement team and incorporate some of the facilitation strategies.

Data

QI Team and Project Management

Incorporation of Evidence

Self-Management Support Materials

Culture