What is an Overconfident Practice?

An Overconfident Practice is one that believes strategies that worked successfully for one issue previously will work well in all circumstances. They work hard and are dedicated to providing high-quality care, but may be resistant when faced with new tools or methods of improvement. This type of practice can also go into a tailspin when a close examination of their data indicates that their care is not as uniformly high-quality as they thought.

Example from a practice facilitator:

This Overconfident Practice achieved Patient-Centered Medical Home (PCMH) accreditation and believed they were very good with high-quality, preventive care. When we started an cardiovascular improvement effort with and looked at their relevant metrics (“ABCS” or Aspirin use, Blood pressure, Cholesterol and Smoking measures), it was clear there were opportunities for improvements in both the process measures and the outcome measure of controlling high blood pressure. The team was resistant to the idea that they could improve an outcome measure due to the complexity of their patients, and wanted to focus improvement on preventive measures, where they felt like the patient population was easier to work with. Once the providers agreed they wanted to include over-the-counter medications in the medication list in their EHR, they were ready to move on to the topic of whether a patient with CSVD was on aspirin or not. After several months of focused efforts on the cardiovascular patients, the team felt good about the care gaps they closed and their success in decreasing the risk of some long-term patients. All it took was finding out that some patients had not moved forward with recommendations from the provider and simply needed follow-up and clarification of agreed upon goals between the provider and patient. At the same time, the metrics they were using to track cardiovascular patients improved, showing staff that they could make progress with just a little focus on a few areas of change.

Data

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. 

QI Team and Project Management

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.

Incorporation of Evidence

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. 

Culture

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

148

QI Team and Project Management

149

Incorporation of Evidence

150

Culture

152