Implementation of Quality Improvement Skills by Primary Care Teams

Abstract

Background: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects. Objective: To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams. Design: We obtained qualitative and quantitative information about existing primary care team QI initiatives. Participants: Eleven interdisciplinary primary care teams and 4 facilitators/coaches. Methods: We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators. Results: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress. Conclusions: In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

Introduction

Background Knowledge

Improving care delivery through evidence-based continuous quality improvement (QI) is a key component of the patient-centered medical home (PCMH) model.^1-3 PCMH team members are expected and encouraged to work together to implement improvement initiatives to enhance the quality of care for their patients. In theory, the PCMH model is well suited to QI work because of its emphasis on longitudinal multidisciplinary patient-centered collaborations.^4,5 However, little is still known about QI work within the context of PCMH teams^6,7 despite the recent rapid uptake of the PCMH model by large health care systems such as the Veterans Health Administration (VHA). ⁸ To begin to address this knowledge gap, we initiated an examination of QI work in our local PCMH clinic environment.

Local Context

Our large academic primary care practice converted to a PCMH care model in May 2011. This transformation was part of VHA’s (our clinic’s health care system) large-scale effort to move to the PCMH model (known within VHA as patient-aligned care teams or “PACT”). ⁸ As part of PCMH implementation, clinical staff engagement in QI work was encouraged via several system-wide initiatives, including distribution of nationally developed materials that encouraged team-centered QI activities and discussions of QI-related topics at national PCMH meetings. ⁹ In our local context, a variety of QI training opportunities were offered, including (a) basic training in QI-specific methodology (2 separate 2-hour sessions) and (b) a 2-day Yellow-Belt Lean Six Sigma certification program that covered introduction to QI methodology, identification and incorporation of optimal tools to address clinical quality challenges, and completion of a final written test for certification. ¹⁰

Additionally, consistent with prior work suggesting that formal training in QI may not be sufficient for successful implementation of improvement techniques,^11-13 other QI-specific resources were also provided to staff: at least 2 hours weekly without direct patient care responsibilities, open access to local QI experts, assistance with data gathering, and access to a project coach with Lean Six-Sigma master black belt certification.

Here, we report a case study to better understand how successful resources have been at enabling QI work by PCMH teams. We examine (a) progress of QI work and (b) the barriers and/or facilitators to QI work reported by PCMH teams. We use the Standards for Quality Improvement Reporting Excellence (SQUIRE) framework to report our findings. ¹⁴

Methods

Data Collection and Analysis

In order to understand QI project progress and to identify challenges and facilitators to QI work, we performed unstructured interviews with PCMH team members. Face-to-face discussion occurred with at least one member of each of the clinical teams, and in most cases, multiple members. Consistent with frameworks for understanding factors related to successful implementation (eg, RE-AIM: Reach Effectiveness Adoption Implementation Maintenance; CFIR: Consolidated Framework for advancing Implementation Research),^15,16 these interviews were used in conjunction with documentation (eg, aim statements) gathered from team members to characterize the team QI work and to identify challenges and facilitators to project implementation.

Ethical Issues

Discussions with team members were informal and voluntary. No names are included in the summary of projects, though local identification of specific team projects is possible. To ensure a variety of perspectives, we sought authorship representation on this article to include facility clinical (SA) and quality (BW) leadership, PCMH providers (SS, MKS), and a PCMH nurse case manager (CW).

Setting

Our work focused on the Louis Stokes Cleveland Veterans Affairs Medical Center outpatient primary care clinic site, an inner-city campus with numerous physician and nurse practitioner trainees. Within the clinic, there are 11 PCMH teams, each with a panel of approximately 1000 patients. Each team is composed of a physician or nurse practitioner provider, a registered nurse (RN) care manager, a licensed practical nurse, and a clerical staff member. Other supporting clinical staff (eg, pharmacists, social workers, mental health providers) are readily available in the clinic setting. The standard VHA comprehensive electronic medical record is used for all clinical documentation.

Results

Quality Improvement Implementation Progress: Alignment With QI Standards?

Table 1 presents the key findings related to team QI work. Overall, despite available resources, little progress consistent with QI standards was reported. All eleven PCMH teams in our primary care clinic are represented (100% sample). Each team identified a focus for a team project. The first 2 projects listed in Table 1 did not identify an intervention as a starting point; thus 9 of the 11 projects (82%) demonstrated a choice of project focus consistent with QI work standards. In the 18-month follow-up period, none of the teams developed a formal aim statement for their project. Eight of the 11 teams (73%) developed any type of project plan beyond the initial team discussion. Of the 4 teams that implemented a change (last 4 rows of Table 1, representing 36% of the 11 projects), 2 of the initiatives are still in place, both sustained by the same nurse care manager, though no assessment of the impact of the change has taken place. None of the teams completed assessment of change impact or reported any further changes they had made as a result of project assessment.

Table 1.

Summary of Patient-Centered Medical Home (PCMH) Team Projects and Assessment of Alignment with Quality Improvement (QI) Standards.

Team	Intended Project Focus	Information Provided by Team Member(s) Regarding QI Project Progress	Alignment With QI Work Standards?
1	Identify patients who do not receive their primary care from VA to evaluate impact on performance measures	• Added a structured question to provider note • A team member reviews data monthly • No changes to practice have been made	Starting point was not an intervention/improvement; need to think about change concepts
2	Identify components of best practices for PCMH RN	• Met with several RN Care Managers • Unable to identify specific area for focus • Did not continue working on project	Starting point was not an intervention/improvement; need to think about change concepts
3	Improve the check-in process	• Felt too many variables were involved • Couldn’t identify a target for improvement • Stopped working on project	Too broad, need to narrow focus by developing SMART aim statement
4	Improve A1c control in team patients	• Nurse to contact patients with poor control • Time limitations made project sporadic • Stopped working on project and are focusing on new national program to implement “Personalized Health Plan,” hope this will address quality concern	Need to narrow focus by developing SMART aim statement; not team based
5	Increase immunizations for diphtheria, tetanus, and pertussis	• Didn’t have time to work on project due to competing demands	Realistic project focus, but lack supporting data to indicate this is a quality concern
6	Improve hypertension management	• Nurse to contact patients with poor control • Not able to implement due to competing clinical demands • Stopped working on project and are focusing on new national program to implement “Personalized Health Plan,” hope that this will address quality concern	Need to narrow focus by developing SMART aim statement; not team based
7	Decrease the number of team patients who are going to the emergency department	• Team was short-staffed for several months (LPN left) • Stopped working on project	Too broad; not team based; limited stakeholder involvement
8	Improve clinic discharge instruction template	• New template introduced • Accessed informatics/data resource person • Provider left practice, no other providers use template	Not team based; limited stakeholder involvement
9	Improve prostate-specific antigen (PSA) screening for patients 50-75 years old	• Nurse distributed education material on PSA screening to patient prior to seeing provider • Some data review completed for baseline but required time-intensive manual chart review • Stopped working on project	Jumped to intervention; focused on “how” rather than exploring solutions
10	Increase number of patients with low-density lipoprotein (LDL) at goal	• Nurse used local registry to identify and contact patients not at goal • Accessed informatics/data resource person • Ongoing monthly data reviews • Results have not been evaluated	Jumped to intervention; not team based; person’s behavior changed, not the system
11	Increase number of patients with hemoglobin A1c less than 8%	• Nurse used local registry to identify and contact patients not at goal • Accessed informatics/data resource person • Ongoing monthly data reviews • Results have not been evaluated	Jumped to intervention; not team based; person’s behavior changed, not the system

Implementation Challenges and Facilitators

Table 2 summarizes themes identified from interviews related to challenges to and facilitators of QI work. Although traditionally accepted facilitators (eg, QI training, leadership buy-in) were in place, QI work remained limited suggesting the barriers outweighed the facilitators. For example, only 1 of the 11 teams (9%) met (only once) with an improvement coach despite awareness and availability of this resource.

Table 2.

Summary of Facilitators and Challenges for Patient-Centered Medical Home Team Project Development and Implementation.

Facilitators Identified in Team Interviews and Resources Provided by Facility	Challenges Identified in Team Member Interviews
System project champion	Staff turnover/changes
Team members identified and working as a clinical team with shared goals	Competing programs or priorities (eg, of the 3 teams who did not develop a project plan, 2 teams (teams 5 and 6) identified competing clinical demands as a reason that they were unable to proceed); incomplete team
Informatics/data resource person available, knowledgeable, and helpful	No clear sense of focus (eg, team 3 stated that, despite initial enthusiasm, they were unable to identify a focus for improvement), aim or measures
User-friendly information technology resources	Not linked to performance assessment
Knowledge of quality improvement methodology/tools	Unable to translate tools provided into doable projects
Allocated time	No overlapping time for meeting as a team; competing demands create differential use of allocated project time; separate activity from “job tasks”
Leadership support	No clear sense of added value

Discussion

Summary

Despite leadership support, formal education sessions, dedicated nonclinical time, and availability of QI coaches, none of the teams completed a single plan–do–study–act cycle. Our findings underscore recent suggestions in the literature that time and educational resources may not be sufficient for frontline teams to engage in QI work.^17,18 Based on the feedback from the 11 teams and our observations of the process, we developed a cause–effect diagram (Figure 1) to organize the factors identified in Table 2 structuring the “effect” as the desired outcome: Successful PCMH QI Project. Our goal was to enable action plans to improve the quality and quantity of QI projects in the PCMH teams.

Figure 1.

Cause–effect diagram of barriers and facilitators of patient-centered medical home (PCMH) quality improvement (QI) work.

Relation to Other Evidence

The upper half of the Figure 1, “Basic Foundation,” outlines traditionally acknowledged factors (“causes”) of successful QI work that are well established in the literature, for example, get leadership support and buy-in, choose relevant projects^5,18 and are consistent with the facilitators identified by our teams. These factors and their subcomponents may provide a necessary foundation for QI work but were not sufficient to propel progress in our clinical environment.

The lower half of Figure 1, “Moving Beyond Basics,” summarizes the novel factors and their subcomponents we identified through this evaluation initiative: Structuring Resources, PCMH Team Development (or “PCMH Maturity”) and System Alignment. The “Moving Beyond Basics” factors align conceptually with the established factors; however, potentially unique nuances are identified in the subcomponents. Further investigation will be necessary to determine the relative importance of these factors and their subcomponents to QI work within the PCMH model and to develop strategies to address them.

Interpretation and Next Steps

Specifically, development of strategies to address the “Moving Beyond Basics” factors and subcomponents may be important to achieving the transformative potential of the PCMH model to facilitate successful QI work. Based on our findings and examination of the existing literature, below we provide some preliminary strategies that may be helpful to translate the 3 identified factors into actionable next steps:

1. Structuring resources—ensuring that teams do not have competing demands or that time allotment is done in a way to make it conducive for teams to work together. Strategies for implementation may include asking the team to identify a set meeting time each week, facilitating scheduling so that all team members can attend, providing space for the meeting, and requesting routine documentation of the results of the team meeting.

2. PCMH team development—recognizing the importance of establishing a PCMH teams’ ability to work together, including meeting staffing requirements, before engaging in QI initiatives. This component acknowledges that expectation of QI activities may be counterproductive when teams are struggling with meeting the basic needs of their panel of patients due to staffing deficiencies. Management may be able to assist by providing teams with a timeline of expectations (eg, “WHEN the LPN position is filled, THEN we will plan on beginning our QI meetings . . .”).

3. System alignment—aligning PCMH QI work transparently with other performance metrics for a clinic or facility. Although addressing this factor at a minimum will require assistance from local quality management/regulatory groups, this would ideally be guided by policy changes at the broader level. For example, development of metrics to evaluate for the presence of QI work in general may be one strategy.

Limitations

This work represents a single-site case study. However, our clinic setting is similar to other large academic primary care practices. In addition, we have 2 years’ experience with integrating the PCMH care model into practice, which provides suggestions for other efforts to enable QI work to become part of routine daily clinic practice, an important consideration as this practice transformation continues to spread throughout primary care.

Conclusions

Successful QI work in the PCMH model may require more than formal education, dedicated time, and leadership support. We offer areas of further investigation and suggestions that may ultimately facilitate the goal of sustainable integration of QI into daily practices of primary care teams.