Leif Solberg, MD, Dissemination Team Lead for ESCALATES, spoke with Lyndee Knox, PhD, founder of L.A.Net, a primary care practice based research and resource network, about the qualities of a successful practice facilitator. In Part 2 of the interview, Lyndee talks about how to be an effective practice facilitator.
Lyndee: In 2000, I started a primary care, practice-based research network with AHRQ and HRSA when I was a professor in the Family Medicine Department at USC. Over time, our emphasis began to shift from original research to translation of best evidence into practice. We focused on learning how to best develop practice facilitators. That project led to building a curriculum for training practice facilitators and then developing a toolkit for AHRQ on how to start and run a practice facilitation program.
Lyndee: I think there are four main elements to great practice facilitation. The first is what everybody talks about — the sparkle factor — being comfortable engaging and working with people. That’s the one thing I found that we can’t train. I’ve also realized that sparkle looks different in different people. I have one facilitator right now who’s very effective and I wouldn’t consider him “sparkly” personality wise, but he’s just very good at connecting with people, following through, getting things done. He has the ability to connect, while maintaining some objectivity, so that he’s not caught up in some of the human dynamics within that practice.
The second is great project management skills. One of the most important contributions that I make as a facilitator is my ability to keep people on track and moving forward in a way that is acceptable to busy clinicians. A knowledge of the online tools and software, like Smartsheet, that can make project management easier to track is also very useful especially when you are a practice facilitator managing a panel of practices.
Third, is being comfortable with data — at least, a clear understanding of numerators and denominators, how to interpret that information and draw some initial hypotheses and conclusions for the different measures that practice might be working with. Then, how such data links to financial drivers, especially for the smaller practices. I’ve found it’s very hard in the independent practices to get traction unless you can actually trace needed changes back to some kind of financial driver for them.
For example, in some of the independent practices we work with, they receive incentive pay from their network — such as $25 for every PHQ-9 (instrument for measuring depression severity) and $30 for a urinary incontinence assessment. It’s being able to leverage that incentive to motivate changes that may lead to bigger improvements like better management of diabetes. It’s that awareness by the facilitator that no matter how much we are motivated to do good things for our patients, when you get right down to it, it’s very difficult to create sustainable change unless there’s some kind of monetary driver behind it, either through increased revenue or cost savings from improved efficiencies. Another related driver in the non-fee-for-service context would be the quality metrics and how that leads to enrollment gains for that site. That’s a big incentive for these practices, so facilitators need a firm understanding of these drivers so they can be thoughtful about them, and help map the changes to them when possible.
And finally, the ability to gently but persistently insist that the practice adopt and use a systematic QI process, like the Model for Improvement and its PDSA (Plan Do Study Act) Cycles. Some clinicians roll their eyes at this, but I have found the PDSA cycle to be an enormously useful tool mainly for keeping QI teams from running off the rails. It creates structure, and a level of rigor when you’re trying to test a change. The other big value is it prevents a practice from attempting too big of a change too fast, which is where I’ve seen most QI projects fail. Taking on too much too fast and then it just falls apart. Either you can’t execute it or you haven’t had a chance to think it through well enough to make sure it’s something that’s going to work. You go to scale too fast and then it fails because it’s not a good design. Or you abandon the effort because it becomes too overwhelming, or folks charge off in all directions at once.
Those are the four things I absolutely want from a facilitator.
Lyndee: Well yes, to me, this is kind of a given but I also don’t see lack of experience in primary care environments as a deal breaker. A good facilitator can learn what they need to know spending a month shadowing other facilitators or clinicians and staff in a clinical setting. And a good practice facilitator can provide effective project management support, pull together and present performance data, and teach QI teams useful processes like PDSA cycles for example, without deep experience in primary care settings. This said, ideally, the folks we hire are familiar with primary care and have worked in settings similar to the ones they will be supporting — for example, Federally Qualified Health Centers, independent practices, vs. a practice in a large integrated health system. Ideally I hope our facilitators are familiar with key workflows in primary care practices — Tom Bodenheimer outlined a set of 22 workflows – and if they aren’t relevant, one of the first things I will ask them to do is to go observe these workflows to get to know them. For example, one practice we were helping wanted to work on advanced care planning, which I was not an expert on, but I did know about their type of health system and that their physicians did not have time to spend on that topic during a visit. So, given my system knowledge, I was able to help them find an intervention that would work within their constraints. You want to choose an intervention that isn’t too elegant or complicated, so that you are setting them up for success.
The sparkle factor — being comfortable engaging and working with people. That’s the one thing I found that we can’t train. I’ve also realized that sparkle looks different in different people.
Lyndee: I do look for someone who’s had experience in a primary care environment or, at the very least, three to four years in a healthcare setting. Some facilitators I’m currently hiring are coming out of a Quality Assurance department in a hospital. Another one was managing the ER physicians in a hospital. This comes back to what you were just asking about; through this work, they have context. They understand what the constraints are in those environments.
They don’t have to be clinicians. Often I find that clinical background can be a barrier because they’re already set in what they think can or cannot work, and that can interfere with their ability to really facilitate a team. Not that it’s a deal breaker, it’s just that they need a little extra training in terms of leaving their own clinical experience at the door — at least some of it.