Extension programs provide a range of services to support quality improvement (QI) in primary care practices, including programs designed specifically to support the practices engaged for specific QI projects and the broader network of practices. In this chapter, we offer information and examples that extension programs can use to understand the needs and interests of primary care practices, select a range of QI support services to provide, and train staff to provide this support.
Select and Tailor QI Services
To determine which QI support services your program will provide, it will be essential to have a good understanding of the existing QI capacity and needs of the primary practices in your state.
You can start to build this understanding from discussions with healthcare leaders, clinicians, and patient organizations in the state, as described in Understand the Needs and Interests of Primary Care Practices in chapter 2. In addition, many of your partners, such as QI organizations, state Medicaid agencies, and the state department of health, could have deep knowledge about the QI needs throughout the state and be able to advise you.
Once you have recruited practices to participate in your extension program, you can collect information from them that you can use to tailor your QI services and materials to best meet their specific interests and needs. Past Agency for Healthcare Research and Quality (AHRQ) grantees have found that using this type of “demand-driven,” rather than “supply-driven,” approach is critical for engaging practices.30
Needs assessment surveys are an effective method to collect information across a broad network of practices as well as with a smaller set of practices participating in a QI project. The Heart Healthy Ohio cooperative conducted two such surveys:
- A survey with team leaders (PDF, 99 KB) at the primary care practices participating in its QI project, to collect clinic-level characteristics including current strategies to improve cardiovascular preventive care, staffing, ownership, participation in other programs, and patient demographics
- A survey with team members (PDF, 619 KB) at the participating clinics, to identify practice concerns and assess team member burnout at the participating clinics
You can use more direct and more in-depth strategies in addition to surveys to collect information from a smaller group of practices. This can include individual practice engagement and feedback sessions and co-designing activities to involve practices in the tailoring of QI services. For example:
- Practice engagement. Alabama Cardiovascular Cooperative compiled a list of evidence-based QI services from various sources including AHRQ’s Primary Care Practice Facilitation Curriculum and the Centers for Disease Control and Prevention’s . A practice facilitator then worked with each practice to identify opportunities for improvement and recommended QI services based on the practice’s interests, motivations, current strengths and weaknesses, and existing capacity. Tennessee Heart Health Network had participating practices select which of three QI projects to implement after the practice had worked closely with a practice facilitator for about a month.
- Co-design. Heart Healthy Ohio engaged in an in-depth co-design process with four practices before rolling out QI services to a larger set of practices. First, practice facilitators conducted baseline needs assessments (with practice observations and interviews) to identify issues with implementation of evidence-based recommendations and team functioning. Then a working group was formed, including staff and patient representatives from each of the co-design practices, practice facilitators, and cooperative leadership. Next the working group discussed the identified problems, brainstormed changes they could make, and selected QI services to develop into a prototype. Finally, the co-design practices piloted the prototype using (PDSA methodology to evaluate and refine the QI project until it was ready to be rolled out across other participating practices.
Develop QI Support Services and Mechanisms for Delivery 
Each extension program might select a somewhat different set of QI support services and activities to offer. The tables below provide an overview of these services, both for broad statewide networks of practices (Table 4) and for practices engaged in active QI projects (Table 5). The tables include illustrative examples from the EvidenceNOW: Building State Capacity cooperatives. In addition, AHRQ has developed a suite of practice facilitation materials to support primary care QI activities, which are available on its website. This includes the following:
- A searchable repository of curated QI tools and resources (EvidenceNOW Tools for Change).
- A practice facilitation curriculum and training modules.
- A handbook (PDF, 6 MB) for health information technology advisors and practice facilitators for obtaining and using data for practice improvement.
Support for Practices in a Broad Network
As described in Table 4 below, extension programs can offer shared learning opportunities and virtual communities of practice to practices throughout a state or region.
Table 4. Quality Improvement Support for Practices in a Broad Network
| Type of Support | Description | Examples |
|---|---|---|
QI Information and Materials
| Materials designed to share information about QI strategies or relevant clinical topics. This includes standalone materials as well as full toolkits that can be used for implementation. Materials are often distributed through the following channels:
| Healthy Hearts for Michigan curated a library of tools, educational resources, and materials reviewed or created by partners including the American Medical Association, the American Heart Association, the American College of Cardiology, and the Million Hearts® campaign and shared through a public website. Heart Healthy Ohio Initiative developed an focused on its heart health QI project. Tennessee Heart Health Network developed focused on health coaching, pharmacist-physician collaboration, and heart health messaging. |
Education and Training
| QI content developed and presented to educate and train practice staff. This content can include Continuing Medical Education credits and is often delivered through:
| Heart Healthy Ohio Initiative hosted monthly for its QI network, available through its website. Tennessee Heart Health Network held regularly scheduled webinars open to all practice partners in its broad QI network. |
| Shared Learning | Opportunities for participating practices to come together (in person or virtually) to learn from one another; build peer support and community; and share strategies, challenges, and lessons learned for QI implementation. Formats include:
| Alabama Cardiovascular Cooperative developed a virtual community of practice to offer opportunities for participating clinicians to learn best practices focused on heart health evidence-based practices. Among other sharing opportunities, participants can read success stories submitted by peer providers and identify local resources for their patients. |
QI = quality improvement.
Supportive Services for Practices in a QI Project
Typically, practices engaged in QI projects will have access to all the activities and materials shared with the broader network of practices (as described in Table 4) as well as additional, more intensive QI supportive services. The services described for active QI projects in Table 5 below include both activities that AHRQ believes to be central to QI support activities—described in the EvidenceNOW Model (and labeled in the table as “Core QI Support Activities”)—and activities that are sometimes included but are less typical (labeled “Additional QI Support Activities”). The extension program can select a different set of services to offer for each QI project it engages in over time, depending on specific goals and needs.
Table 5. QI Supportive Services for Practices in a QI Project
| Type of Support | Description | Examples |
|---|---|---|
| Core QI Support Activities | ||
Practice Facilitation
| Practice facilitators work closely with primary care practices to help build practice capacity to implement the best clinical evidence. Activities include:
| Alabama Cardiovascular Cooperative provided practice facilitators with a protocol that outlined suggested meeting schedules with goals for the number of contacts with practices and data collection each week. The recommended minimum number of contacts was one in-person visit and two phone/video/email contacts per month, although practice facilitators could use their discretion to schedule more meetings based on practice needs. Practice facilitators met weekly with the group leader to summarize activities, report successes, troubleshoot challenges, and strategize next steps. Practice facilitators met biweekly for ongoing training and peer learning opportunities. |
| Expert Consultation (also known as ) | Short-term and intensive education from experts (often clinicians) to provide knowledge on a defined topic to aid with the uptake of evidence-based practices | For the EvidenceNOW: Advancing Heart Health initiative, the Heart of Virginia Healthcare cooperative had several family medicine physicians serve as expert consultants who provided peer-to-peer learning support for the practices engaged in QI activities.31 |
| Optimization of Health IT and Health IT Support | Data experts or practice facilitators with health IT expertise support practices in using their EHRs to support QI. Includes helping practices minimize the burdens of data entry and maximize their ability to generate reports they can use for QI and population health–related activities | Heart Healthy Ohio Initiative provided training in using population health tools for data visualization. One-on-one assistance was also provided to practices needing support for EHR data reporting. Healthy Hearts for Michigan worked with participating clinics to implement a Hiding in Plain Sight protocol, which used existing EHR data to identify patients with potential hypertension but no documented diagnosis. |
| Data Feedback and Benchmarking | Data feedback includes tracking practice performance and improvement on key process and outcome indicators over time through reports or dashboards Benchmarking consists of comparing a practice’s performance on selected outcome measures with accepted standards or with the performance of other practices The data for feedback and benchmarking can come from within the practice (e.g., the EHR, chart audits, registry data) or from external sources (e.g., health information exchanges, claims data, hospital utilization data) | Heart Healthy Ohio Initiative developed an interactive dashboard that allows practices to review summary data on measures and create customizable charts based on selected inclusion criteria (such as race/ethnicity, primary insurance class, and medication intensity). The dashboard compares data across practice sites, using unique ID numbers so practices can identify only their own data. Practice facilitators review these data with the practice team during coaching sessions. Participating practices submit monthly EHR data through a portal using a secure transfer. Healthy Hearts for Michigan developed practice dashboards to report key metrics to participating clinics. Dashboards show trends in clinical quality measure data, comparing results with those of other participating clinics as well as with state and national benchmarks of patients identified via the Hiding in Plain Sight protocol and the number of patients referred to tobacco cessation services. |
| Additional QI Support Activities | ||
Financial Management Guidance
| Guidance for practices to help them achieve sustainable financing for ongoing QI activities | Heart Healthy Ohio Initiative developed resources for practices about how to establish a business case for their QI projects, including this podcast. Tennessee Heart Health Network developed an overview and guidance for using CPT codes for payment for the health coaching sessions that the practices provided. |
Workforce Development
| Opportunities for practice staff to receive training and credentialing related to QI activities | Tennessee Heart Health Network offered free and reduced tuition for staff from participating practices to enable them to participate in online training programs on motivational interviewing, health coaching, and patient navigation. |
Community Connections and Resources
| Assistance connecting practices to community resources to help address the social determinants of health for patients (e.g., assistance with housing, food, utilities, transportation, education) | Heart Healthy Ohio Initiative helped connect practices to community resources within their regions by working with rural health innovation collaboratives to pair patients with community health workers. It also shared information about community resources from local public health departments. |
Patient Engagement
| Support or guidance for practices to help bring the patient perspective into improvement activities | Tennessee Heart Health Network convened regional patient advisory councils where members contributed the patient voice and perspective at every stage of the practice improvement process. Members reviewed resources and toolkits the cooperative developed to provide feedback and insights from the patient perspective. |
CPT®=Current Procedural Terminology. EHR=electronic health record. IT=information technology. QI=quality improvement.
Practice Facilitation
Across the range of services provided for a QI project, practice facilitation is a key approach for helping primary care practices implement evidence-based approaches to improve patient outcomes. The EvidenceNOW: Advancing Heart Health initiative found that practice facilitation can:32
- Increase practices’ capacity to implement the best clinical evidence.
- Connect practices to information, resources, and strategies to improve care.
- Help practices overcome electronic health record (EHR) challenges and optimize their EHR for meeting QI goals.
- Help practices harness patient and practice data to identify gaps in care and monitor effects of improvement activities.
- Help mitigate the impact of major disruptions (staff turnover, changing EHRs, clinician loss, etc.) on the practice.
- Link practices to community resources that patients and clinicians can use to support care plans.
The AHRQ website includes valuable resources for practice facilitators along with lessons learned about practice facilitation from the EvidenceNOW: Advancing Heart Health initiative. Among these lessons, evaluators found that effective practice facilitators use a combination of the following strategies (PDF, 544 KB):33
- Cultivating practice motivation by using a flexible, tailored, and open approach.
- Guiding practices through the change process by sharing best practices while empowering practice staff to do the work themselves.
- Addressing resistance to change
- Providing accountability by assigning tasks, establishing target deadline, and tracking progress.
Practice Facilitation Approach, Training, and Oversight
For each QI project, the extension program will determine its approach for providing practice facilitation. This approach includes who will provide the practice facilitation services, how these services could vary by type of practice (e.g., independent versus system affiliated), how frequently practice facilitators will engage each practice, how many visits will be virtual versus in-person, and how much choice practices will have in selecting the QI activities they want to engage in. For details about how to select a practice facilitation approach, go to Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide (PDF, 3 MB; chapter 4).
Primary care extension programs also decide how to train and provide oversight for their practice facilitators. Practice facilitators come with a wide range of experience, training, and styles—regardless of whether the program directly hires them or it partners with an organization that provides their services (refer to Staffing in chapter 2 for more on this topic). The EvidenceNOW cooperatives generally required practice facilitators to have completed a certified training program, have significant work experience, or both. Still, most programs held their own training sessions to ensure that the support provided to practices was consistent.
Across the EvidenceNOW: Advancing Heart Health cooperatives, practice facilitator trainings included a review of general practice facilitation principles, skills, and approaches, as well as training in project-specific content including protocols, tools, and subject matter (e.g., evidence-based practices to improve cardiovascular preventive care).12 These facilitator trainings were typically multiday, in-person events conducted with a mix of didactic modules and role-playing activities. In addition, the EvidenceNOW: Advancing Heart Health cooperatives approached facilitator training as an ongoing process. The initial training event was complemented with regular “booster” trainings, including follow-up meetings (both in-person and virtual) and webinars. Some cooperatives incorporated having less-experienced facilitators observe firsthand how a more-experienced facilitator worked with a practice.
As an example from the EvidenceNOW: Building State Capacity grantees, Healthy Hearts for Michigan held a robust practice facilitator training over 7 weeks, with 2‑hour sessions each week. For the first 5 weeks, the team reviewed the AHRQ Primary Care Practice Facilitator Curriculum. The last 2 weeks went over the project-specific QI services and resources, including discussions with clinical subject matter experts. In addition to this training program, Healthy Hearts for Michigan also provided the following ongoing support:
- A practice facilitator community of practice, which included discussion-based meetings and a listserv to debrief on their experiences working with the participating practices, identify and discuss challenges, and share best practices for implementation
- Weekly “office hours” with clinician leaders to provide opportunities to get advice and input on clinical topics and concerns that arose during implementation
It is also good practice for the lead facilitator to conduct one-on-one “ride-alongs” with each practice facilitator to observe how the facilitator interacts with practice staff and to provide real-time feedback. The lead facilitator should also conduct regular quality checks on practice facilitator reporting to ensure consistency of the services delivered.
