Supporting Practice Facilitators in a Learning Health Care System

Background

The learning health care system (LHS) envisions the integration of research and care delivery in a manner that rapidly generates and adopts new evidence to improve health care quality and patient experience.^1,2 Efforts to operationalize and evaluate the LHS have identified facilitation as a core construct when describing the implementation support needed to achieve the desired outcomes.^3,4 There is a rich literature documenting the effectiveness of facilitation as a strategy for implementing evidence-based innovations that improve the quality of health care.^5–8 Examples include improving the areas of opioid medication management,⁸ cancer screenings,⁵ and chronic kidney disease management.⁶ Facilitation is enabled by practice facilitators (PFs) who activate implementation of changes that improve care quality.^6,9–11 PFs can have a diversity of backgrounds, including social work, nursing, public health, and others. They help others navigate complex change processes when implementing new evidence into practice by assessing and responding to unique characteristics of both the interventions and the context within which they are being implemented.¹² For the evaluation of LHSs, one proposed measure of the presence of adequate implementation support is a count of PF hours provided for care delivery initiatives.³ As a result, there is a growing interest in understanding how an LHS might prepare and support individuals to be effective in this role with the goal of improving care quality.¹³

Evaluations conducted within studies that use facilitation highlight the need to carefully consider facilitator training and ongoing support.^7,14 Although it is widely recognized that initial training in the principles of effective facilitation is necessary, less is known about how to provide ongoing support to PFs so that they can be effective in their role and advance from novice to expert facilitators.^13,15,16 Sweeney and colleagues evaluated organizational support provided to PFs by seven cooperatives funded by the Agency for Healthcare Research and Quality EvidenceNow initiative. The researchers found the following five common components used to support PFs:

• Mentoring from more experienced PFs

• Peer support

• Support from clinical experts

• Toolkits

• Communication infrastructure to support sharing of resources among PFs

Sweeney et al’s findings are consistent with our experiences conducting a training program for PFs to work within primary care practices to improve opioid medication management.^3–5 This experience, combined with prior experiences of the authors on other PF initiatives to improve quality and outcomes in primary care,^8,17,18 allowed us to reflect on organizational supports and resources necessary for ongoing support of a facilitator to increase their effectiveness. This commentary examines these five critical supports needed for a PF program within an LHS and offers suggested practical actions based on the authors’ experience that an LHS can take to enhance the effectiveness of facilitation as an implementation strategy to improve care quality and outcomes. Examples of how these critical supports were provided for training PFs for an opioid medication management improvement initiative (the Six Building Blocks program) is provided in Table 1.

Table 1:

Strategies used to support Practice Facilitators: Examples from the Six Building Blocks training program

PF Support Component	Strategies Used in the Six BBs Program to Support PFs
Mentoring from more experienced PFs	An experienced Six BBs facilitator met with new facilitators for ad hoc mentorship as needed.
Peer support	An experienced Six BBs facilitator held monthly shared learning meetings to discuss challenges and solutions.
Subject matter expertise	New facilitators identified a clinician at their clinics with experience in opioid medication and chronic pain management. The clinician attended implementation meetings alongside the facilitator to answer clinicians’ questions.
Resources and tools	The Six BBs website (https://familymedicine.uw.edu/improvingopioidcare/) included clinical resources for implementation of the program and resources to support the facilitators.
Support and accountability	The new Six BBs facilitators were asked to report on implementation milestones for their clinics during monthly meetings.

PF, practice facilitator; Six BBs, Six Building Blocks.

Mentoring by More Experienced Practice Facilitators

“…just because of their experience with the curriculum and as facilitators, they know inside and out what the resistance might be related to, if we get stuck or if we're having a challenge.” -PF trainee

Why It Is Important

Although a facilitator may have a sound knowledge of the improvement to be implemented, the recipients, and the plan for making changes, the dynamic nature of making these changes within the context of a health care system can challenge even the most experienced facilitators. For this reason, facilitators often find it helpful to have support and mentorship from a more experienced PF. ⁶ Importantly, this relationship allows for a conversation that helps the facilitator both understand why they are experiencing a challenge and how they might approach it in a new and different manner. ¹⁹

Implications for LHSs

When a diversity of experience is available across PFs within an LHS, the pairing of lessexperienced PFs with more experienced PFs should be considered. When there is a lack of experience or when a skill set needed to facilitate a specific change is not present, consider pairing PFs internal to the LHS with a more experienced facilitator in another setting, such as an academic institution or another health care system. It may also be important to identify a facilitator external to the LHS who has experience with improving care for a clinical topic area such as cancer screening, cardiovascular risk reduction, or de-prescribing of harmful medications.

Peer Support and Processes That Make It Possible

“…subject matter experts were bringing the practice facilitators together. So I think that was important for relationship building, which leads to ultimate success in a lot of programs.” -PF trainee

Why It Is Important

In addition to mentorship from a more experienced facilitator, the social and emotional support provided by peers is important. ⁶ There is a risk that a lone facilitator within an LHS organization may become overwhelmed with the complex process of implementing changes in the way care is provided. Organizations committed to rapidly translating evidence into improved patient care need to carefully consider the infrastructure needed for a facilitator to succeed, including peer support.

Implications for LHSs

Facilitators can be internal or external to an LHS. Some LHSs may have the resources to build their own cadre of internal facilitators as part of their quality improvement program and can create peer support internally. If the LHS is not able to hire and develop a team of internal facilitators who can provide peer support to one another, then it might be important to enable a lone internal facilitator to obtain peer support from one or more external facilitators. In addition, as discussed by Sweeney and colleagues, creating a communication platform that allows facilitators to communicate with each other rapidly and efficiently might be a practical way to enhance peer support. ¹³

Subject Matter Expertise (Both Clinical and Health Information Technology)

“I think with Dr. [name] and Dr. [name] coming down and having that clinical expertise was helpful for them to feel more comfortable.” -PF trainee

Why It Is Important

Although a facilitator may have a sound understanding of the innovation being implemented and the evidence supporting it, they may need the support of clinical subject matter experts to command the respect of the recipients who are being asked to make a change. For example, the facilitator may be challenged by those who work in clinical settings about the evidence for why a change is needed. If the facilitator is unable to respond based on clinical experience, it may undermine their efforts to provide support for implementing a change in how care is provided. ⁷

Implications for Learning Health Systems

Identify a clinical topic expert who is a respected opinion leader, either internal or external to the LHS, who can be a resource for a PF to call on when needed. In addition, it may be helpful for both the clinical expert and the facilitator to both meet with the team(s) that will be implementing a change or improvement at the launch of the initiative. This can be accomplished by pairing a clinical expert with one facilitator or with a cadre of facilitators who are working on an improvement initiative. In addition, expertise in other areas such as health information technology or billing and finance may be needed and should be made available for a facilitator to call upon when needed.

Resources and Tools

“There were so many times I was like ‘[H]ey, check out this website, a lot of information is on there and it’s so informative, it’s really awesome, really helpful, answers a lot of the questions you might have.’” -PF trainee

Why It Is Important

As previously mentioned, PFs are not always knowledgeable about a clinical topic and may have questions from members of the health care team that they are unable to answer. They might be uncertain about practical next steps they can take to support care teams in making complex changes in the care they provide to their patients, or they may have members of the care team request a resource such as a patient handout or a clinical workflow. Providing PFs with a toolkit of practical resources and information that they can quickly turn to for help during their daily work might be invaluable. ¹³

Implications for Learning Health Systems

Before launching an improvement initiative led by PFs, anticipate requests for clinical information, tools, and resources, and gather them from other sources or develop draft versions of them internally. Ask clinical experts for background materials such as evidence for the intervention being implemented, and summarize these into short one-page briefs with bullets that are easy to understand. Consider the sequence in which the need for these resources or tools might arise. First, develop those needed early in the work, and then continue to gather tools and resources throughout the project and organize them in an easy-to-access fashion for use by the PFs. Bring requests for other clinical resources, such as templates for visit notes or after-visit summaries, back to the PF team or clinical expert, and identify them as needed.

Support and Accountability

“I felt accountable to you all as a training team but not necessarily to my own [clinic] organization. And I didn't have any collegial connections.” -PF trainee

Why It Is Important

PFs often experience pushback or resistance to the changes they are attempting to facilitate, and they sometimes feel isolated or alone in their efforts. Having a PF/quality improvement (QI) team to which they are expected to report back about both their progress and their challenges creates a level of accountability and motivation that is helpful in their iterative efforts to respond to challenges and overcoming resistance. ^6,7

Implications for Learning Health Systems

Provide a timeline and proposed milestones for PFs, with an individual or team to whom they can report. Create psychological safety for these reporting relationships so that PFs can be open and honest about what they are seeing and experiencing in their work. Modify the timeline and milestones as needed, and anticipate that flexibility will be needed, as clinical sites are unique in their resources, personalities, and prior experience with making changes. Ask PFs to monitor the progress of each of their assigned clinical sites and discuss each site in PF/QI team meetings. Providing PFs with practical resources and reporting tools or other systems for monitoring progress at each site may help with these efforts to maintain accountability.

Conclusions

Learning health care systems are based on the concept of organizational learning, which requires executive leadership support for the allocation of resources and support. ²⁰ Executive leaders who are committed to the rapid translation of new knowledge into clinical care using facilitation should assess whether they have the resources and systems in place to provide ongoing support to PFs as a component of their implementation capacity. These resources and systems include establishing mentoring relationships, fostering peer support, providing subject matter expertise, acquiring or creating tools and resources, and creating processes for reporting and accountability. Planning for and strategically recruiting resources to establish and grow this organizational infrastructure as an LHS should be a deliberate process and should include the input of PFs. The potential for a high return on investment is considerable given evidence of the effectiveness of facilitation as a strategy for implementing new knowledge and innovations into diverse health care settings.