Effective Facilitator Strategies for Supporting Primary Care Practice Change: A Mixed Methods Study

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.

Trial registration: ClinicalTrials.gov NCT02560428.

Keywords: capacity building; implementation facilitation; large-scale initiative; organizational change; organizational innovation; practice facilitation; quality improvement.

Figure 1.

Numbers of facilitators and practices. ABS = aspirin use for high-risk patients; CPCQ = Change Process Capability Questionnaire. Notes: Numbers of practices that improved on the CPCQ score and on the aspirin, blood pressure, and smoking measures are not mutually exclusive and add up to more than the total number of practices with high change capacity or low change capacity. ^a More effective: ≥75% of facilitator’s practices had improved CPCQ scores and/or ABS performance; less effective: <50% of facilitator’s practices had improved CPCQ scores and/or ABS performance. A total of 53 facilitators with 740 practices were neither more nor less effective, and were excluded from effectiveness analyses. ^b Assessed from baseline CPCQ score, dichotomized at the median value as high (score ≥11) or low (score <11).

Figure 2.

Distribution of mean change in ABS composite measure between more and less effective facilitators, stratified by practice baseline change capacity and baseline performance. ABS = aspirin use, blood pressure control, smoking cessation counseling. CPCQ = Change Process Capability Questionnaire. Notes: Plots show absolute changes in percentages, so the magnitude of the difference is small, but across the baseline characteristics, practices with more effective facilitators tended to have higher changes in the ABS composite measure. ^a Assessed from baseline CPCQ score, dichotomized at the median value as high (score ≥11) or low (score <11). ^b Assessed from percentage of patients meeting composite ABS outcome at baseline, dichotomized at the median value as high (≥65%) or low (<65%). ^c More effective: ≥75% of facilitator’s practices had improved CPCQ scores and/or ABS performance; less effective: <50% of facilitator’s practices had improved CPCQ scores and/or ABS performance.