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Fiscella KA, Sass E, Sridhar SB, Maguire JA, Lashway K, Wong G, Thien A, Thomas M, Bisognano JD, Rosenberg T, Sanders MR, Johnson BA, Polgreen LA. Team-based home blood pressure monitoring for blood pressure equity a protocol for a stepped wedge cluster randomized trial. Contemp Clin Trials 2023; 134:107332. [PMID: 37722482 PMCID: PMC10725081 DOI: 10.1016/j.cct.2023.107332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/29/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity. METHODS We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration. RESULTS Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity. CONCLUSIONS Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity. REGISTRATION DETAILS www. CLINICALTRIALS gov Identifier: NCT05488795.
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Affiliation(s)
- Kevin A Fiscella
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America.
| | - Emma Sass
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - Soumya B Sridhar
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Jennifer A Maguire
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Katie Lashway
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Geoff Wong
- Nuffield Department of Primary Care, Medical Sciences Division, University of Oxford, United Kingdom
| | - Amy Thien
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Marie Thomas
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - John D Bisognano
- Department of Medicine, Cardiology Division, University of Michigan, 24 Frank Lloyd Wright Dr. Ste 1300, Lobby A, Ann Arbor, MI 48106, United States of America
| | - Tziporah Rosenberg
- Department of Family Medicine, Highland Hospital, University of Rochester Medical Center, 777 S. Clinton Ave, Rochester, NY 14620, United States of America
| | - Mechelle R Sanders
- Department of Family Medicine Research, Highland Hospital, University of Rochester Medical Center, 1381 South Ave, Rochester, NY 14620, United States of America
| | - Brent A Johnson
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 265 Crittenden Blvd, Rochester, NY 14642, United States of America
| | - Linnea A Polgreen
- College of Pharmacy, Iowa University, 340 College of Pharmacy Building, 180 S Grand Ave, Iowa City, IA 5224, United States of America
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Breton M, Gaboury I, Beaulieu C, Deville-Stoetzel N, Martin E. Ten years later: A portrait of the implementation of the advanced access model in Quebec. Healthc Manage Forum 2023; 36:317-321. [PMID: 37326497 PMCID: PMC10446410 DOI: 10.1177/08404704231181676] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Since 2012, implementation of the advanced access model in primary care has been highly recommended across Canada to improve timely access. We present a portrait of the implementation of the advanced access model 10 years after its large-scale implementation across the province of Quebec. In total, 127 clinics participated in the study, with 999 family physicians and 107 nurse practitioners responding to the survey. Results show that opening schedules for appointments over a period of 2 to 4 weeks has largely been implemented. However, reserving consultation time for urgent or semi-urgent conditions was implemented by less than half and planning supply and demand for 20% or more of the upcoming year by fewer than one fifth of respondents. More strategies need to be put in place to react to imbalances when they occur. We demonstrate that strategies based on individual practice change are more often implemented than those requiring changes at the clinic.
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Oshman L, Walton T, Schultz P, Barry R, Speer L. Quality Improvement Capacity in a Department of Family Medicine: A Mixed-Methods Study. PRIMER (LEAWOOD, KAN.) 2023; 7:17. [PMID: 37465834 PMCID: PMC10351432 DOI: 10.22454/primer.2023.889614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background and Objectives Quality improvement capacity is defined as ongoing commitment to sustained quality improvement (QI) and requires knowledge of QI methods and commitment to QI activities from practice leadership and staff. The aim of this project was to identify the major facilitators and barriers to developing quality improvement capacity in a teaching practice of a department of family medicine. Methods We conducted an exploratory, sequential, mixed-methods study, inviting key informants to participate in qualitative interviews and then conducting a survey of faculty, resident physicians, and staff at a community residency teaching practice affiliated with an academic medical center in the Midwest United States. Results Among 12 qualitative key informant interviewees, facilitators of QI capacity included a strong motivation to provide high-quality care and a desire to leverage team-based care in QI interventions. Barriers included competing clinical and educational priorities, lack of faculty expertise in quality and scholarship, and lack of infrastructure to turn QI into scholarship. The survey response rate was 75% (48 of 64 total team members). The most common motivation for participation in QI work was "making a difference" (41, 85%), while the biggest barriers were prioritization of patient care (25, 53%), and teaching (19, 40%). Conclusion This mixed-methods study identified key barriers and facilitators to QI capacity, of which addressing competing priorities, improving QI training, and creating infrastructure for scholarship may improve QI capacity.
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Affiliation(s)
- Lauren Oshman
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI | Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Paul Schultz
- Department of Family Medicine, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Robin Barry
- Department of Family Medicine, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Linda Speer
- Department of Family Medicine, The University of Toledo College of Medicine and Life Sciences, Toledo, OH
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Breton M, Gaboury I, Martin E, Green ME, Kiran T, Laberge M, Kaczorowski J, Ivers N, Deville-Stoetzel N, Bordeleau F, Beaulieu C, Descoteaux S. Impact of externally facilitated continuous quality improvement cohorts on Advanced Access to support primary healthcare teams: protocol for a quasi-randomized cluster trial. BMC PRIMARY CARE 2023; 24:97. [PMID: 37038126 PMCID: PMC10088119 DOI: 10.1186/s12875-023-02048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Improving access to primary health care is among top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results. The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes. METHODS Cluster-controlled trial allowing for a comprehensive and rigorous evaluation of the proposed intervention 48 multidisciplinary primary care clinics will be recruited to participate. 24 Clinics from the intervention regions will receive the CQI intervention for 18 months including three activities carried out iteratively until the clinic's improvement objectives are achieved: 1) reflective sessions and problem priorisation; 2) plan-do-study-act cycles; and 3) group mentoring. Clinics located in the control regions will receive an audit-feedback report on access. Complementary qualitative and quantitative data reflecting the quintuple aim will be collected over a period of 36 months. RESULTS This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients' experiences of care. CONCLUSION This mixed-method approach offers a unique opportunity to contribute to the scientific literature on large-scale CQI cohorts to improve AA in primary care teams and to better understand the processes of CQI. TRIAL REGISTRATION Clinical Trials: NCT05715151.
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Affiliation(s)
- Mylaine Breton
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada.
| | - Isabelle Gaboury
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Elisabeth Martin
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | | | - Tara Kiran
- University of Toronto, Toronto, ON, Canada
| | | | | | - Noah Ivers
- University of Toronto, Toronto, ON, Canada
| | - Nadia Deville-Stoetzel
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Francois Bordeleau
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Christine Beaulieu
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Sarah Descoteaux
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
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Baldwin LM, Tuzzio L, Cole AM, Holden E, Powell JA, Parchman ML. Tailoring Implementation Strategies for Cardiovascular Disease Risk Calculator Adoption in Primary Care Clinics. J Am Board Fam Med 2022; 35:1143-1155. [PMID: 36460353 PMCID: PMC10691203 DOI: 10.3122/jabfm.2022.210449r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/19/2022] [Accepted: 02/24/2022] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION When implementing interventions in primary care, tailoring implementation strategies to practice barriers can be effective, but additional work is needed to understand how to best select these strategies. This study sought to identify clinicians' contributions to the process of tailoring implementation strategies to barriers in clinical settings. METHODS We conducted a modified nominal group exercise involving 8 implementation scientists and 26 primary care clinicians in the WWAMI region Practice and Research Network. Each group identified implementation strategies it felt would best address barriers to using a cardiovascular disease (CVD) risk calculator previously identified across 44 primary care clinics from the Healthy Hearts Northwest pragmatic trial (2015 to 2018). These barriers had been mapped beforehand to the Consolidated Framework for Implementation Research (CFIR) domains. We examined similarities and differences in the strategies that 30% or more of each group identified (agreed-on strategies) for each barrier and for barriers in each CFIR domain. We used the results to demonstrate how strategies might be tailored to individual clinics. RESULTS Clinicians selected 23 implementation strategies to address 1 or more of the 13 barriers; implementation scientists selected 35. The 2 groups agreed on at least 1 strategy for barriers in each CFIR domain: Inner Setting, Outer Setting, Intervention Characteristics, Characteristics of Individuals, and Process. Conducting local needs assessment and assessing for readiness/identifying barriers and facilitators were the 2 most common implementation strategies chosen only by clinicians. CONCLUSIONS Clinician stakeholders identified implementation strategies that augmented those chosen by implementation scientists, suggesting that codesign of implementation processes between implementation scientists and clinicians may strengthen the process of tailoring strategies to overcome implementation barriers.
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Affiliation(s)
- Laura-Mae Baldwin
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Leah Tuzzio
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Allison M Cole
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Erika Holden
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Jennifer A Powell
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
| | - Michael L Parchman
- From Department of Family Medicine, University of Washington, Seattle, WA (L-MB, AMC); Kaiser Permanente Washington Health Research Institute, Seattle, WA (LT, EH, MLP); Powell and Associates, LLC, Asheville NC (JAP)
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Sweeney SM, Baron A, Hall JD, Ezekiel-Herrera D, Springer R, Ward RL, Marino M, Balasubramanian BA, Cohen DJ. Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study. Ann Fam Med 2022; 20:414-422. [PMID: 36228060 PMCID: PMC9512557 DOI: 10.1370/afm.2847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 03/16/2022] [Accepted: 05/04/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Practice facilitation is an evidence-informed implementation strategy to support quality improvement (QI) and aid practices in aligning with best evidence. Few studies, particularly of this size and scope, identify strategies that contribute to facilitator effectiveness. METHODS We conducted a sequential mixed methods study, analyzing data from EvidenceNOW, a large-scale QI initiative. Seven regional cooperatives employed 162 facilitators to work with 1,630 small or medium-sized primary care practices. Main analyses were based on facilitators who worked with at least 4 practices. Facilitators were defined as more effective if at least 75% of their practices improved on at least 1 outcome measure-aspirin use, blood pressure control, smoking cessation counseling (ABS), or practice change capacity, measured using Change Process Capability Questionnaire-from baseline to follow-up. Facilitators were defined as less effective if less than 50% of their practices improved on these outcomes. Using an immersion crystallization and comparative approach, we analyzed observational and interview data to identify strategies associated with more effective facilitators. RESULTS Practices working with more effective facilitators had a 3.6% greater change in the mean percentage of patients meeting the composite ABS measure compared with practices working with less effective facilitators (P <.001). More effective facilitators cultivated motivation by tailoring QI work and addressing resistance, guided practices to think critically, and provided accountability to support change, using these strategies in combination. They were able to describe their work in detail. In contrast, less effective facilitators seldom used these strategies and described their work in general terms. Facilitator background, experience, and work on documentation did not differentiate between more and less effective facilitators. CONCLUSIONS Facilitation strategies that differentiate more and less effective facilitators have implications for enhancing facilitator development and training, and can assist all facilitators to more effectively support practice changes.
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Affiliation(s)
- Shannon M Sweeney
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Andrea Baron
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jennifer D Hall
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Rachel Springer
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Rikki L Ward
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Dallas, Texas
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Science, UTHealth School of Public Health, Dallas, Texas
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
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Coleman KF, Krakauer C, Anderson M, Michaels L, Dorr DA, Fagnan LJ, Hsu C, Parchman ML. Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices. Ann Fam Med 2021; 19:499-506. [PMID: 34750124 PMCID: PMC8575517 DOI: 10.1370/afm.2733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 02/08/2021] [Accepted: 03/22/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance. RESULTS Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA. CONCLUSION Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.
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Affiliation(s)
- Katie F Coleman
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Melissa Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - LeAnn Michaels
- Oregon Rural Practice Research Network, Oregon Health & Science University, Portland, Oregon
| | - David A Dorr
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Lyle J Fagnan
- Oregon Rural Practice Research Network, Oregon Health & Science University, Portland, Oregon
| | - Clarissa Hsu
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Michael L Parchman
- Center for Accelerating Care Transformation (previously MacColl Center), Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Gaboury I, Breton M, Perreault K, Bordeleau F, Descôteaux S, Maillet L, Hudon C, Couturier Y, Duhoux A, Vachon B, Cossette B, Rodrigues I, Poitras ME, Loignon C, Vasiliadis HM. Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services. BMC Health Serv Res 2021; 21:812. [PMID: 34388996 PMCID: PMC8361639 DOI: 10.1186/s12913-021-06839-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/30/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.
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Affiliation(s)
- Isabelle Gaboury
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada.
| | - Mylaine Breton
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Kathy Perreault
- GMF-U Saint-Jean-sur-Richelieu, Saint-Jean-sur-Richelieu, Canada
| | - François Bordeleau
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Sarah Descôteaux
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Lara Maillet
- École Nationale d'Administration Publique, Montreal, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Yves Couturier
- School of social work, Faculty of letters and social sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montreal, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Benoit Cossette
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Isabel Rodrigues
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Marie-Eve Poitras
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Christine Loignon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Helen-Maria Vasiliadis
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
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Place Matters: Closing the Gap on Rural Primary Care Quality Improvement Capacity-the Healthy Hearts Northwest Study. J Am Board Fam Med 2021; 34:753-761. [PMID: 34312268 PMCID: PMC8935997 DOI: 10.3122/jabfm.2021.04.210011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 11/08/2022] Open
Abstract
CONTEXT To compare rural independent and health system primary care practices with urban practices to external practice facilitation support in terms of recruitment, readiness, engagement, retention, and change in quality improvement (QI) capacity and quality metric performance. METHODS The setting consisted of 135 small or medium-sized primary care practices participating in the Healthy Hearts Northwest quality improvement initiative. The practices were stratified by geography, rural or urban, and by ownership (independent [physician-owned] or system-owned [health/hospital system]). The quality improvement capacity assessment (QICA) survey tool was used to measure QI at baseline and after 12 months of practice facilitation. Changes in 3 clinical quality measures (CQMs)-appropriate aspirin use, blood pressure (BP) control, and tobacco use screening and cessation-were measured at baseline in 2015 and follow-up in 2017. RESULTS Rural practices were more likely to enroll in the study, with 1 out of 3.5 rural recruited practices enrolled, compared with 1 out of 7 urban practices enrolled. Rural independent practices had the lowest QI capacity at baseline, making the largest gain in establishing a regular QI process involving cross-functional teams. Rural independent practices made the greatest improvement in meeting the BP control CQM, from 55.5% to 66.1% (P ≤ .001) and the smoking cessation metric, from 72.3% to 86.7% (P ≤ .001). CONCLUSIONS Investing practice facilitation and sustained QI strategies in rural independent practices, where the need is high and resources are low, will yield benefits that outweigh centrally prescribed models.
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Allen CG, Cotter MM, Smith RA, Watson L. Successes and challenges of implementing a lung cancer screening program in federally qualified health centers: a qualitative analysis using the Consolidated Framework for Implementation Research. Transl Behav Med 2021; 11:1088-1098. [PMID: 33289828 PMCID: PMC8248958 DOI: 10.1093/tbm/ibaa121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In recent years, studies have shown that low-dose computed tomography (LDCT) is a safe and effective way to screen high-risk adults for lung cancer. Despite this, uptake remains low, especially in limited-resource settings. The American Cancer Society (ACS) partnered with two federally qualified health centers and accredited screening facilities on a 2 year pilot project to implement an LDCT screening program. Both sites attempted to develop a referral program and care coordination practices to move patients through the screening continuum and identify critical facilitators and barriers to implementation. Evaluators conducted key informant interviews (N = 46) with clinical and administrative staff, as well as regional ACS staff during annual site visits. The Consolidated Framework for Implementation Research guided our analysis of factors associated with effective implementation and improved screening outcomes. One study site established a sustainable lung screening program, while the other struggled to overcome significant implementation barriers. Increased time spent with patients, disruption to normal workflows, and Medicaid reimbursement policies presented challenges at both sites. Supportive, engaged leaders and knowledgeable champions who provided clear implementation guidance improved staff engagement and were able to train, guide, and motivate staff throughout the intervention. A slow, stepwise implementation process allowed one site's project champions to pilot test new processes and resolve issues before scaling up. This pilot study provides critical insights into the necessary resources and steps for successful lung cancer screening program implementation in underserved settings. Future efforts can build upon these findings and identify and address possible facilitators and barriers to screening program implementation.
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Affiliation(s)
- Caitlin G Allen
- Department of Behavioral Science and Health Education,
Rollins School of Public Health, Emory University, Atlanta, GA,
USA
| | - Megan M Cotter
- Population Sciences Department, American Cancer Society,
Inc., Atlanta, GA, USA
| | - Robert A Smith
- Prevention and Early Detection Team, American Cancer
Society, Inc., Atlanta, GA, USA
| | - Lesley Watson
- Strategy and Analytics Team, American Cancer Society
Cancer Action Network, Inc., Washington, DC, USA
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11
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Schuttner L, Coleman K, Ralston J, Parchman M. The role of organizational learning and resilience for change in building quality improvement capacity in primary care. Health Care Manage Rev 2021; 46:E1-E7. [PMID: 33630509 PMCID: PMC7541444 DOI: 10.1097/hmr.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. PURPOSE The aim of the study was to examine the association of AR and development of QI capacity. METHODOLOGY One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. RESULTS Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. CONCLUSIONS Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. PRACTICE IMPLICATIONS Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.
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12
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Nguyen AM, Cuthel AM, Rogers ES, Van Devanter N, Pham-Singer H, Shih S, Berry CA, Shelley DR. Attributes of High-Performing Small Practices in a Guideline Implementation: A Multiple-Case Study. J Prim Care Community Health 2020; 11:2150132720984411. [PMID: 33356790 PMCID: PMC7768565 DOI: 10.1177/2150132720984411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. Methods A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. Results Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. Conclusions These attributes may be important determinants of high performance, indicating not only a small practice’s capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.
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Affiliation(s)
| | | | | | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Sarah Shih
- New York City Department of Health and Mental Hygiene, New York, NY, USA
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13
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Parchman ML, Anderson ML, Dorr DA, Fagnan LJ, O'Meara ES, Tuzzio L, Penfold RB, Cook AJ, Hummel J, Conway C, Cholan R, Baldwin LM. A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care. Ann Fam Med 2019; 17:S40-S49. [PMID: 31405875 PMCID: PMC6827661 DOI: 10.1370/afm.2407] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/06/2018] [Accepted: 01/09/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.
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Affiliation(s)
- Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Melissa L Anderson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - David A Dorr
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Lyle J Fagnan
- Oregon Rural Practice Research Network, Oregon Health & Sciences University, Port-land, Oregon
| | - Ellen S O'Meara
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | | | - Cullen Conway
- Oregon Rural Practice Research Network, Oregon Health & Sciences University, Port-land, Oregon
| | - Raja Cholan
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Laura-Mae Baldwin
- Department of Family Medicine, Institute of Translational Health Sciences, University of Washington, Seattle, Washington
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