This is Part 2 of Leif Solberg, MD, Dissemination Team Lead for ESCALATES’ conversation with Lyndee Knox, PhD, founding director of L.A. Net, a primary care practice based research and resource network. In Part 1, Lyndee talked about what to look for in hiring practice facilitators and the qualities of a successful facilitator. Now that the facilitator is onboard …
Lyndee: One of the most important things a facilitator can do is ask good questions and then listen well. A team I was working with was stalled coming up with ideas to problem solve an EHR issue. My job was to say, “Have you checked to see how other places are handling this? Have you checked with the vendor to see if they have examples of some of their other clients that maybe have a process that they use?” And the whole room stopped and went, “We didn’t think to do that. Of course, we’ll do that.” That was a very simple intervention, but it changed the entire course of that conversation.
The facilitator needs to be able to do that higher-level system thinking and ask the questions that get the practice thinking in a new way.
The facilitator needs to be able to do that higher-level system thinking and ask the questions that get the practice thinking in a new way. They have to be comfortable asking the practice to think and act in a different way. It’s a weird balance because in some ways, you’re coming in and directing them. But you’re not coming in as an expert in the content. You somewhat own a process and have some authority around that process, but you don’t own the content. And then sometimes you know the answer to a particular problem before your team does, but you can’t tell them. For example, one team wanted to compile a paper packet for advanced care planning, and I knew that it was not going to work the way they hoped, due to past experiences I’ve had. But they didn’t know that and they needed to get there on their own. If I had come in and said “That’s not going to work, let’s find something else,” they might have cooperated, but it would’ve felt imposed rather than them trying it out for themselves. It’s leading them through the process to help them find their solution.
Lyndee: We do two things. We train them on how to do a good kick-off meeting and then also how to balance grassroots needs — with (because there’s always a funder), top down requirements.
Anne Lefevre, a fabulous PF director from North Carolina tells this great story about a clinic from one of her projects who said “We would really like a facilitator to help with an access issue.” The facilitator arrived at the clinic parking lot, and it was full of geese who began to bite her as she got out of her car — the practice staff were peeking out of the door, pointing to them saying “see, this is our access issue.” Instead of saying “I don’t do this,” the facilitator suggested doing a PDSA (Plan Do Study Act) cycle. When researching, they discovered the woman next door to the rural clinic who had been feeding those geese broke her hip and was hospitalized, which meant no one had been feeding the geese. So the geese moved into the parking lot of the clinic. The team did an intervention to get another neighbor to start feeding the geese and the geese moved out of the parking lot.
In the process of doing that, the facilitator was able to teach them some basic principles of quality improvement, the PDSA cycle, and build a relationship with them because she’d come and helped them solve the problem that was really bugging them. Then she was able to segue into what she was funded to do, which was to improve diabetes care.
We equip facilitators with that story, and teach them to ‘go find the geese’ at each practice so they can engage and build a relationship from the ground up, so practices see them as a resource and a solution to real problems that are happening. Then, we balance that with helping the facilitator with their 30-day deliverables with the funder, or 50-day deliverables, and we compile a set list of things that they need to work through with that site. It’s up to the facilitator then to begin to balance those ground up and top down agendas. So they’re really working on two different agendas that eventually, hopefully, merge.
Lyndee: We’ve made a mistake before in being too ‘goose in the parking lot’ focused. We came in with the idea that you just had to do what the practice said and eventually it would all work out. But what we discovered is there are hundreds of good things you can do for a practice, but a pretty limited number of things that are actually going to move the metrics and your outcomes.
What we discovered is there are hundreds of good things you can do for a practice, but a pretty limited number of things that are actually going to move the metrics and your outcomes.
It’s hard to balance because you’ve got to be able to take care of the geese (changes the practice wants), but then you have to make sure that you’re focusing time and effort on those things that we know will make a difference in measures, and those aren’t always the ones that folks are either ready to do or interested in doing. It takes some talent and experience to navigate that. Developing and using a key-driver model to guide the facilitator’s work can really help facilitators balance these two things. The facilitator and his or her director can use the key driver model and its list of change tactics as a way to ensure that the facilitator and the practice are moving forward on the funders’ or projects’ key deliverables and goals, while they are also working on responding to the “geese” projects at the practice. Often times you can even map the “geese” project to that key driver model. It can also be helpful to create encounter note formats that parallel the key driver model and change tactics so that the facilitator (and practices) are constantly checking-in and being reminded of the high yield activities they need to focus on.
Lyndee: Success to me is meeting the outcome metrics, not just the process ones. It’s pretty easy to go through and click the boxes. If it doesn’t ultimately improve the outcome you’re after, then to me it’s not an actual success. It’s a procedural success. Many times we don’t know the correct answer to get that outcome. We know different processes we can try, but sometimes we’re not certain it’s actually going to improve BMI, for example. That one’s almost impossible to move.
I agree with Jim Mold’s school of thought that facilitators should really be permanently attached to a practice or a group of practices. The facilitator might be on maintenance where they only visit the practice every two months and maintain that relationship. But a success for me would be the next time that practice has a challenge or change they’re wanting to make, the first thing they do is say, “Let’s bring in Lyndee so she can help facilitate us through this process.”