Characteristic Terms

Culture

The practice often exhibits a state of stress and of being on a “hamster wheel” of endless work.

The practice often exhibits a state of stress and of being on a “hamster wheel” of endless work.

This practice is often unreceptive to new ideas due to time pressures and may be reluctant to discuss anything outside their day-to-day tasks. Implementing a new method of work is inherently seen as an additional burden, even if it has the potential to make things more efficient. Team members are often burned out, especially on the idea of making any changes or adding anything new to their workload.

Strategies

Practice facilitators can start by acknowledging the current state, demonstrating empathy, and working with the team to identify small steps and early wins. They may not be able to commit to a long-term project or significant change at first. Alter one small piece of a workflow to increase efficiency, which can demonstrate that they can accomplish improvements and it may also free up time that they can leverage into further improvements. For example, if a practice is struggling with a measure such as controlling high blood pressure in hypertensive patients (CMS 165), meet with all the providers to agree on diagnoses and treatment protocols to use for a subset of patients. Having standardized treatment protocols could enable the clinical care teams to train staff on proper blood pressure techniques and when to recheck readings and may help the team schedule follow up appointments for patients. This would lead to higher quality data and actionable reports, which in turn could lead to better patient outcomes. If successful, this could be a catalyst to get a practice interested in data-driven quality improvement. 

Found in Learning Modules:
The practice has an aversion to change, so new solutions are hard to implement.

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.

The practice often has only one person “leading the charge,” and the team disagrees about the importance of quality improvement activities.

The practice often has only one person “leading the charge,” and the team disagrees about the importance of quality improvement activities.

This practice may have a dedicated staff person for quality improvement activities or a clinical champion that spearheads quality improvement work. In many cases, this individual operates in isolation and may distrust getting input from other members of the team. In other instances, it is a staff person who has many other responsibilities and does not have adequate time to dedicate to quality improvement. Frequently, this team is not communicating internally to be fully aware of all the efforts occurring across the various team members and roles within the practice.

Strategies

Practice facilitators should first assess and, if necessary, bolster the commitment of leadership to quality improvement as a team sport. Consider strategies that demonstrate the importance of the work to leadership. For example, complete a Return on Investment worksheet utilizing the practice’s clinical quality measure data and demonstrate how value-based payment  affects the practice financially. If you start working with a team without getting “buy in” from leadership, the work can lose momentum whether you are successful or not. Getting leadership to support the work by providing protected time is critical. Linking improvement efforts to performance incentives can also be an important motivator for the whole team.  
 
The personality and attitudes of the individual in charge of quality improvement are also important. They may not be willing to share responsibility for quality improvement projects because they suspect that other staff are not dedicated to the work of improvement or because they see it as their job to “own” the project(s). If the lead is dismissive of input from other staff, help them understand why it is helpful to spread out the workload and share examples of how other practices have discovered the value of involving representatives from the whole team structure. If this individual is overworked and does not have time to engage in quality improvement, use this as the basis for involving other staff members in the project. Share examples of how other practices share the workload on QI initiatives.
 
Start with a very small project that includes cross-functional teams for the experience of a quick win, which can help staff feel energetic about QI and illustrate the need for a shared QI culture. Use a tool such as the Quality Improvement Change Assessment (QICA) to foster an open discussion on roles and responsibilities across the care team. This can lead to a discussion on how work could be distributed – with staff encouraged to lead ideas in their work areas – cutting down on inefficiencies and creating more effective workflows. Show examples of successful PDSA cycles to help explain that small, easy changes can have a big impact.

Data

The practice does not have the processes or skillset to interpret what the data indicate about their practice.

The practice does not have the processes or skillset to interpret what the data indicate about their practice.

This practice may have rudimentary knowledge of their process and outcome data, but they do not systematically monitor or engage with the data meaningfully or fully understand the existing issues that could affect how the data are interpreted. Based on their earlier work, this practice may already look at data reports regularly or have dashboards for their clinicians, but there are problems understanding the implications.

Strategies

The practice facilitator can help the practice look at the data they currently generate and ask them to explain what it means and how they act upon it. Look at reports for two or three measures that are a shared priority among the staff, and start a conversation about what concrete steps might be taken in areas they want to improve upon. Discuss what would be a reasonable goal for the practice. Encourage staff to tie overall data trends back to individual patients they know and consider how they might be able to support a patient who is not currently meeting a metric. Help the practice interpret their performance by benchmarking their data with other settings using data available from external registries to understand what is being done in locations with similar patient populations, EHRs, and practice delivery models for shared learning.

Found in Learning Modules:
The practice does not have up-to-date patient self-management 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.

The practice has difficulties accessing and/or refreshing data to guide improvement.

The practice has difficulties accessing and/or refreshing data to guide improvement.

The practice has issues capturing and/or systematically updating the data it needs to drive change. Practice staff may have rudimentary knowledge of where their process and outcome data comes from, but they have no ability to routinely refresh or upload information to their EHR so they can understand their data and act upon it. They often lack an in-depth understanding of data sources and definitions, which raises issues involved in its interpretation. Practices frequently underestimate the effort required not only to incorporate the EHR into the practice workflow for patient visits, but also to utilize EHR data to drive improvement. Without effective workflow integration, it is difficult for practice staff to use the EHR for quality improvement due to missing data or data not being captured in the correct templates during the patient visit. It is common for this type of practice to have inaccurate reports, which cannot be effectively used for quality improvement.

Strategies

Practice facilitators can increase the practice’s understanding of how data flows through the EHR system and the basics behind clinical quality measurement reporting and metric definitions. Help guide practices to create a patient population list, which can be produced in most certified EHRs that support clinical quality measures reporting. Help staff produce patient lists from the metrics such as “patients not compliant” or “numerator misses.” Encourage them to start small - look up about five patients on the list to see if they are appropriately placed on the list and identify gaps in the data capture or gaps in patient care.  If necessary, help the practice engage with external registries such as PRIME to have greater capacity to monitor and identify patients and care gaps. If possible, it is also helpful to connect practices that have similar patient populations, EHRs, and practice delivery models for shared learning.

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

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.

The practice successfully generates data but does not know how to use it to drive improvement.

The practice successfully generates data but does not know how to use it to drive improvement.

This practice may already look at data reports regularly or have dashboards for their clinicians. Because they have access to data and share it internally, they may feel like they are doing everything they can/need to do. In some cases, they might receive support from an external agency for generating reports or gap lists, but they do not have a framework in place to act on those reports. They may not be using benchmarks, goals, or comparisons to national benchmarks to drive improvement.

Strategies

The practice facilitator can identify measures of care that reflect a shared priority among the staff and start a conversation about what actionable steps might be taken in areas where they want to improve. Start small and help them set attainable goals. Focus on aspects of quality improvement from their daily activities, as it is easier to identify how the data can be used to drive improvement. Once they have success at not only generating, but also interpreting reports, help them build up to larger population-scale tests. Using data visualization tools like The Pulse or simple run charts with agreed upon goal lines can be an effective way to engage staff and tie efforts to data trends. For data capture issues and EHR optimization, initiate a redesign session with a staff member representing each part of the workflow. The staff members can identify the current process for data capture and design the improved process while referencing the EHR user guide. The user guide will help them understand the EHR’s capabilities to ensure all care steps are being performed and that corresponding data capture is being done correctly.  Finally, educate the team on the Model For Improvement (MFI) and Plan-Do-Study-Act (PDSA) cycle framework to guide improvement work.  Demonstrate this quick powerful tool for accelerating improvement by helping the team complete a PDSA form and get them set up to run their first test of change. Testing the new workflow for optimal data capture can be a good way to apply a PDSA cycle to an active project and determine if the change is an improvement that can be adapted, adopted, or abandoned. 

Incorporation of Evidence

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

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.
 
The practice is aware of current guidelines but does not alter their standard practices, either because they don’t believe new guidelines are better than their existing practices or because they lack a systematic approach to implementing new guidelines.

The practice is aware of current guidelines but does not alter their standard practices, either because they don’t believe new guidelines are better than their existing practices or because they lack a systematic approach to implementing new guidelines.

Providers feel they prioritize the “art of medicine,” an approach where each provider practices according to their own training and experience. Often an influential clinician acts as a naysayer, leading the disagreement with clinical evidence introduced by a practice facilitator. This can be very uncomfortable for the rest of the team and the providers who agree with the evidence and would like to uniformly modify their care practices in accordance with current best practices.

Strategies

If an individual provider does not agree with the clinical evidence behind a specific measure, the practice facilitator should acknowledge this and talk with them about the parts with which they do agree. Academic detailing or using a tool such as the QICA (add footnote) to stimulate a conversation about the practice’s current quality improvement efforts and data reporting capabilities are additional ways to mitigate a naysayer’s resistance. Unearth and deal with this kind of resistance as early as possible. This is especially important if the naysayer is an informal opinion leader within the practice—that may mean the measure may not match the clinical care pathway, and quality improvement efforts may need to be measured manually or may not be possible in that setting.
 
If the practice agrees that guidelines are important but the problem is the lack of a structured way to incorporate new guidelines as they become known, help the practice to plan how this could be institutionalized. Concerns about the need to continuously improve, and questions about tracking adoption of evidence-based guidelines through quality improvement measures need to be addressed. It is important to promote a culture of openness and learning by encouraging dialogue and debate between clinicians. Well-facilitated conversations addressing operational issues or other reservations may not only yield a better solution for the current topic, but a new standardized approach they can utilize for all guidelines. 

QI Team and Project Management

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

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.  
 
Found in Learning Modules:
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.

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.

The practice is already working on some limited, quality improvement strategies, but needs a push to go outside their comfort zone and take on more difficult practice transformation.

The practice is already working on some limited, quality improvement strategies, but needs a push to go outside their comfort zone and take on more difficult practice transformation.

This practice will have thought about quality improvement often and yet may be doing the minimum work required to meet reporting standards for an external agency. They already have a structure in place to do quality improvement, and are less likely to want to think about changing that structure. This team will be quick to explain that they are already addressing topics effectively, rather than being open to change discussions.

Strategies

The practice facilitator can introduce the practice to new strategies and the theories behind them to help expand their view of what is possible. Start with what they are currently doing and explain the benefits of a more robust and expansive quality improvement framework, which could help them understand the reason behind proposed changes to increase QI capacity. It is important to start small and remember that there are many ways to reach the practice through education, activities, and tools that will help them implement change. Consider facilitating a few teams in workflow redesign for a particular process, which can help to involve more staff in generating ideas to test in PDSAs. Introduce an innovative workflow or resource from a peer practice, which can often spark curiosity and interest in innovation.

Found in Learning Modules:

Self-Management Support Materials

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