Developing And Running A Primary Care Practice .
Developing and Runninga Primary Care PracticeFacilitation Program:A How-to GuideAgency for Healthcare Research and QualityAdvancing Excellence in Health Care www.ahrq.gov
AHRQ is the lead Federal agency charged with supporting research designed to improvethe quality of health care, reduce its cost, address patient safety and medical errors, andbroaden access to essential services. AHQR sponsors and conducts research that providesevidence-based information on health care outcomes; quality; and cost, use, and access.The information helps health care decisionmakers—patients and clinicians, health systemleaders, and policymakers—make more informed decisions and improve the qualityof health care services.
Developing and Running a Primary Care PracticeFacilitation Program: A How-to GuideAgency for Healthcare Research and Quality540 Gaither RoadRockville, MD 20850www.ahrq.govAuthors:Lyndee Knox, LA NetErin Fries Taylor, Mathematica Policy ResearchKristin Geonnotti, Mathematica Policy ResearchRachel Machta, Mathematica Policy ResearchJung Kim, Mathematica Policy ResearchJessica Nysenbaum, Mathematica Policy ResearchMichael Parchman, Agency for Healthcare Research & QualityAHRQ Publication No. 12-0011December 2011
This report is based on research conducted by Mathematica Policy Research under contract withthe Agency for Healthcare Research and Quality (AHRQ), Rockville, MD, U.S. Department ofHealth and Human Services (Contract No. HHSA290200900019I).The findings and conclusions in this document are those of the author(s), who are responsible forits content and do not necessarily represent the views of AHRQ. No statement in this reportshould be construed as an official position of AHRQ or of the U.S. Department of Health andHuman Services. This document is in the public domain and may be used and reprinted withoutpermission except those copyrighted materials that are clearly noted in the document. Furtherreproduction of those copyrighted materials is prohibited without the specific permission ofcopyright holders.Suggested Citation: Knox L, Taylor EF, Geonnotti K, Machta R, Kim J, Nysenbaum J,Parchman, M. Developing and Running a Primary Care Practice Facilitation Program: A How-toGuide (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO5.) AHRQ Publication No. 12-0011. Rockville, MD: Agency for Healthcare Research andQuality. December 2011.
AcknowledgmentsThis guide was a collaborative effort of many individuals. The Agency for HealthcareResearch and Quality (AHRQ), in coordination with Lyndee Knox of LA Net (who served as thefacilitator) and Mathematica Policy Research, convened an expert working group (listed below)to develop the guide. Through a series of telephone meetings, group members providedinformation and insights from their own experiences in developing and running PF programs andshared numerous tools and resources. The willingness of working group members to share theirexpertise and lend their time was critical to the development of this guide.Our colleagues at AHRQ—including Drs. David Meyers and Janice Genevro—providedvaluable direction, guidance, and feedback throughout this guide’s development. We are gratefulto those who reviewed the manual and provided thoughtful comments and suggestions,including: Sajid Ahmed, HITEC-LA; Chet Fox, M.D., Upstate New York Practice BasedResearch Network; Vanesscia John, M.S.W, M.P.A., California Primary Care Association;Vanessa Nguyen, M.P.H., LA Net; Richard Seidman, M.D., L.A. Care Health Plan; MartinSerota, M.D., AltaMed Health Services; Kimbra Wells Metz, M.H.A., Washington Academy ofFamily Physicians; and Diana Traje, M.P.H. LA Net. Marsha Gold and Eugene Rich atMathematica provided a thoughtful peer review, Molly and Jim Cameron provided superbediting, and Felita Buckner offered excellent secretarial support. Debbie Peikes suppliedvaluable high-level guidance in her role as director of the large set of tasks under which thiswork was supported.iii
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ContributorsCarolyn Allshouse, Family Voices of MinnesotaCheryl Aspy, Ph.D., University of Oklahoma Health Sciences CenterThomas Bodenheimer, M.D., M.P.H., San Francisco General HospitalBonni Brownlee, M.H.A., Qualis HealthCaroline Carter, M.S., L.S.W., Center for Health Care Research & Policy, MetroHealth Medical CenterKatie Coleman, M.S.P.H., Group Health CooperativeAllen Dietrich, M.D., Dartmouth Medical SchoolDarren A. DeWalt, M.D., M.P.H, University of North Carolina School of MedicinePerry Dickinson, M.D., University of ColoradoElizabeth Foley, M.B.A., Medical Care DevelopmentBrenda Fraser, M.Sc., Quality Improvement and Innovation PartnershipAllyson Gottsman, Health TeamWorksJoanne Gutowsky, Michigan Primary Care Consortium (MPCC)William Hogg, M.D., Department of Family Medicine, University of OttawaCraig Jones, M.D., Vermont Blueprint for HealthAnn Lefebvre, M.S.W., CPHQ, NC AHEC Program at University of North Carolina at Chapel HillClare Liddy, M.D., Department of Family Medicine, University of OttawaJeanne McAllister, B.S.N., M.S., M.H.A., Center for Medical Home ImprovementMarly McMillen, M.B.A., The Dochterman GroupGail McNutt, M.D., Department of Veterans AffairsJames Mold, M.D., University of Oklahoma College of MedicineRegina Neal, Primary Care Development CorporationAmanda Parsons, M.D., M.B.A., New York City Department of Health & Mental HygieneJoan Pernice, R.N.C., M.S., Massachusetts League of Community Health CentersDiane Powers, M.A., University of WashingtonMary Ruhe, R.N., M.P.H., Case Western Reserve UniversityConstance S. Sixta, Ph.D., R.N., M.B.A., Sixta Consulting Inc.Jenney Samuelson, Vermont Blueprint for HealthLisa Watkins, Vermont Blueprint for Healthv
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Preface“If we truly believe that primary care is too important to fail, how will we ensure itssuccess?” This is the question that motivated the development of this how-to guide. The deliveryof primary care is complex, to say the least. Changing a complex system like a primary carepractice is fraught with difficulties and challenges, leading to the common analogy ofredesigning an airplane while it’s flying. One of the most promising methods to support primarycare transformation is a practice facilitation model that supports an ongoing, trusting relationshipbetween an external facilitator and a primary care practice. This is not the traditional “parachutein” model of facilitation often seen in the corporate world. Although some of the basicfacilitation skills may be similar, this model is much more aligned with the FederalGovernment’s agricultural cooperative extension system developed in the early 20th century. Theintent of this manual is not to describe how to facilitate change in a primary care practice; rather,its focus is on how to establish and run an effective practice facilitation program. Its intendedaudience is organizations or individuals who will develop and run such a program.This manual draws on the collective experience and knowledge of a remarkable group ofpeople who have been involved in practice facilitation for many years. As a participant on manyof the calls conducted in preparing this work, I found their commitment to the writing of thismanual inspirational. We here at AHRQ express our heartfelt appreciation for their invaluablecontributions. Our thanks to this team for taking on and completing this extremely challengingtask. It is our hope that this manual will be a starting point for many successful practicefacilitation programs, and that the delivery of primary care in the United States truly will betransformed as a result.Michael L. Parchman, M.D., M.P.H.PBRN Initiative Director & Senior Advisor for Primary CareCenter for Primary Care, Prevention, and Clinical PartnershipsAgency for Healthcare Research and Qualityvii
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About This GuideThe contents of this guide were developed from the suggestions and experiences of a panel ofmore than 30 individuals recognized by their peers as possessing expertise in the design andmanagement of practice facilitation programs for primary care transformation. Unless otherwisenoted, the “experts” referred to throughout the guide are the contributors listed on the title pagewho served as members of the working group. While the contributors included many prominentexperts representing a wide range of organizations, we recognize that other practice facilitationexperts and organizations exist whose views are not necessarily reflected here.This guide reflects current practical knowledge and hard-won lessons from the area ofpractice facilitation. Its aim is to provide information for others to draw on, but should not betaken as a final statement on how to develop facilitation programs. This work is intended toassist others so they do not have to reinvent the wheel, while recognizing that other, more refinedapproaches and techniques may evolve over time—particularly as facilitation programs focusincreasingly on transformational efforts in primary care practice.ix
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OverviewWhy Was This Guide Developed?This how-to guide was developed by the Agency for Healthcare Research and Quality tosupport organizations interested in starting a practice facilitation (PF) program for primary caretransformation. The focus on primary care transformation reflects the growing consensus that theU.S. primary care system must be redesigned in fundamental ways so that, in the end, weimprove health and patient experience and lower costs.In this guide, we define PF as a supportive service provided to a primary care practice by atrained individual or team, using a range of quality improvement (QI) and practice improvementapproaches to build the internal capacity of a practice to improve over time. Another aim of PF isto support attainment of both incremental and transformative QI goals, with the ultimate goal ofimproving patient outcomes.What Are the Goals of This Guide?This guide was developed based on information and resources shared by more than30 experts in the field of PF. The guide focuses on designing and administering facilitationprograms, not the content of an actual facilitation intervention. It is designed for use by directorsof facilitation programs, not the facilitators themselves. Its goal is to make the knowledge andexperience of these experts available as a resource for you and your organization as you designand administer your own facilitation program. This manual can also be a resource to directors ofexisting programs who want to enhance their program and intervention models.Who Is This Guide For?This guide is for future and existing directors of facilitation programs to use as they makeimportant decisions about the start-up and administration of their own programs. It can be usefulto any organization interested in developing a facilitation workforce to improve or transformprimary care services. This includes groups such as: State or local departments of health Quality improvement organizations (QIOs) Area health education centers (AHECs) HITECH regional extension centers (RECs) Practice-based research networks (PBRNs) Primary care associations (PCAs) Accountable care organizations (ACOs) Chartered value exchanges (CVE) Large health care systems Insurance companies Anyone else interested in improving the quality of U.S. primary carexi
How to Use This GuideAs a resource to directors of facilitation programs, this guide can be read cover to cover as anintroductory text on creating a facilitation program, or to dip into for specialized content in aspecific area. Through the tools and links provided in the document, the guide also can serve as ajumping-off point for accessing other resources on facilitation. The following table lists some ofthe topics covered in the guide’s eight chapters.ChapterSelected Key Topics1Background and existingevidence for practicefacilitation History and current state of PFEvidence supporting PF’s effectivenessPF in the context of the current policy environment andexisting QI activities2Creating the administrativefoundation for your practicefacilitation program Selecting an organizational home for your PF programForming an advisory boardDefining your mission and primary goalsStaffing3Funding your practicefacilitation program Creating a business plan for your programIdentifying potential sources of fundingTypical PF program budgetsMarketing your program to funders4Developing your practicefacilitation approach Creating a key driver modelIdentifying your PF teamStages and key activitiesDefining facilitator roles and core activities5Hiring your practicefacilitators Core competencies needed by facilitatorsDeciding who to hireStaffing models6Training your practicefacilitators Assessing and leveraging existing training resourcesCreating a curriculumSelecting your educational approach and strategiesSelecting your trainer and training team7Supervising and supportingyour practice facilitators Selecting a supervisor for your facilitatorsDeciding on individual versus group supervisionProviding supervision in-person or by distance technologySuggestions for creating a learning community8Evaluating the quality andoutcomes of your practicefacilitation program Creating an internal QI programIdentifying metrics for use in your QI processEvaluating the outcomesIdentifying data sources9Conclusions and next steps Share relevant resources and tools with othersLearn more at www.pcmh.ahrq.govxii
At the end of the guide, you’ll find an appendix of helpful tools and resources (Appendix B).It includes a wide variety of aids, such as: Frameworks for improving primary care/chronic care Theoretical models of change Links to other facilitation manuals and related tools Tools for assessing a practice’s readiness to change Tools for involving patients and families Practice facilitator job descriptions Curricula and coaching resources Measurement tools Selected articles and presentationsxiii
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ContentsCHAPTER 1. PRACTICE FACILITATION FOR PRIMARY CARE TRANSFORMATION:BACKGROUND AND EXISTING EVIDENCE .1What Practice Facilitation Is and Does .1A Brief History of Practice Facilitation .3Evidence Supporting PF as a Resource for Practice Improvement .4Practice Facilitation as a Resource for Primary Care Redesign and Transformation . 5Practice Facilitation in the National Health Care Context .6CHAPTER 2. CREATING THE ADMINISTRATIVE FOUNDATION FOR YOUR PRACTICEFACILITATION PROGRAM .9Select an Organizational Home for Your Program .9Form an Advisory Board for Your Program .10Define Your Program’s Mission and Goals .13Frameworks to Guide You in Identifying Program Goals.14Staff Your PF Program .17Determine IT Resource Needs of Your Program .19Determine the Physical Space Needs of Your Program .20Checklist for Developing a PF Program’s Administrative Infrastructure. 21Practical Resources.21CHAPTER 3. FUNDING YOUR PRACTICE FACILITATION PROGRAM. 23Create a Business Plan for Your Program .23Develop a Plan for Funding Your Program .24Potential Funders for PF Programs .25Typical Program Costs and Budgets .28Market Your Program to Funders .31Checklist for Funding and Marketing Your PF Program .32Practical Resources.32CHAPTER 4. DEVELOPING YOUR PRACTICE FACILITATION APPROACH . 33Create a Key-Driver Model for Your PF Intervention .33Incorporate a Variety of QI Approaches in Your PF Intervention . 36Decide Whether You Will Use a Team or Individual Approach to PF and Form Your PFTeam .39Outline the Specific Stages of Your PF Intervention and Key Activities That Will TakePlace During Each Stage.45Decide on the Dose and Delivery Schedule .51Decide Whether You Will Provide Services Onsite or From a Distance . 54Determine the Ratio of Facilitators to Practices .55Define the Facilitator’s Role and Core Activities .57Common Activities of Facilitators in a Practice .58Determine the Criteria You Will Use for Selecting Practices for Your Intervention . 60Checklist for Developing Your PF Approach .61Practical Resources.62xv
CHAPTER 5. HIRING YOUR PRACTICE FACILITATORS .63Core Competencies Needed by Practice Facilitators .63Decide Who You Will Hire as Facilitators.66Select a Staffing Model for Your Facilitators .67Checklist for Developing Your Facilitator Workforce .69Practical Resources.69CHAPTER 6. TRAINING YOUR PRACTICE FACILITATORS.71Assess Resources in Your Organization That Can Be Used to Support Training forYour Facilitators .71Decide Whether You Will Provide Training In-House or by Outsourcing . 72Select the Location of the Training: In Person or Online .72Create
intent of this manual is not to describe how to facilitate change in a primary care practice; rather, . 30 experts in the field of PF. The guide focuses on designing and administering facilitation programs, not the content of an actual facilitation intervention. It is designed for use by directors
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Parchman, M. Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO 5.) AHRQ Publication No. 12-0011. Rockville, MD: Agency for Healthcare Research and Quality. December 2011.
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