Table 3.

Intervention participation motivations, adaptations, implementation summary, and outcomes by clinic

Clinic	Motivation for study participation	Implementation Adaptations	Case Summary	Outcome	Study Completion
Clinic A	Health system administrators selected this team to participate in the intervention because they hoped understanding patient engagement would help the team improve their low patient satisfaction scores	20 minutes allotted for QI 101 training	Administrators reported that all team members had been trained in quality improvement QI (or that QI knowledge “comes naturally” as part of scientific training), but researchers found this not to be the case. Team members reported that the expectation they do QI was something being imposed on them from above, and that they were given no actual resources to pursue QI projects. Team members were overwhelmed with their patient care work and with frequent personnel changes. Team members generally equated patient engagement with patient satisfaction and with patient complaints.	The health system made the decision to withdraw all three of its clinics from the study before the team selected a project. Administrators reported that the decision had been based on the fact that the team was too busy and was confused about the aims and process of the study. In addition, the team was disappointed to have been assigned to a condition without coaching.	No
Clinic B	The clinic manager volunteered the clinic because of its emphasis on high patient satisfaction	None	All team members emphasized the small size of the clinic and the closeness this engendered among staff members and between staff and patients. Previous QI experience was highly variable among team members. In general, team members valued QI because they saw it as a way to improve patient experience and health outcomes. When asked to talk about patient engagement, team members emphasized the high quality of their interpersonal relationships with patients.	At the time the health system withdrew from the study, the team had initiated a project focused on distance access to diabetes educators, begun analyzing the problem, and had a preliminary plan for patient engagement. The health system reported that they had considered allowing this clinic to remain in the study, but in the end decided that staffing issues would make continued participation too difficult.	No
Clinic C	Clinic C’s team was selected by a clinic manager, who told the researchers “I have lots of things I want to improve here.”	20 minutes allotted for QI 101 and 30 minutes for patient engagement training	Interviews with team members suggested there was a fair amount of tension between administrators and clinical staff and between different disciplines on the clinical teams. Most team members had little experience with QI and saw it as something that administrators wanted them to do, but that resulted in very little value because there was little focus or follow-through on results. Researchers’ questions about patient engagement prompted answers about the relationships between individual providers and patients. Team members emphasized that they had little time to do anything other than their clinical tasks.	At the time of drop out, the team had not yet chosen a project. At the exit interview, the health system administrators reported that the team was confused and frustrated about the work they were supposed to be doing and lacked the time to continue to participate in the study.	No
Clinic D	Health system administrators chose this clinic because the MD was a QI champion and open to change	A full hour was allocated to QI 101 to allow for questions and several additional health system leaders and clinic staff members were invited and attended	Clinic staff reported that their health system emphasized both quality improvement and population health. QI activities appeared to be driven by individual physicians, who were monetarily incentivized to improve their metrics. In an environment described as “hierarchical,” staff engaged in QI activities only at the direction of the physician(s) with whom they worked. Most staff did not seem to have had prior training in or experience with QI. Questions about patient engagement prompted clinical staff to note “patients in this community aren’t used to being engaged,” which they attributed to their older, rural patients.. In general, while clinic administrators were enthusiastic about patient engagement, which they defined as something like patient activation, members of the team seemed wary, equating it with providing a venue for patient complaints. With the help of the coach, the team decided to focus their QI project on improving workflows around routine patient lab work (i.e., lipid screening). They engaged patients by surveying them about their preferences for the timing of lab work vis-à-vis scheduled appointments. Based on the results of the survey, and their analysis of the issue, clinic staff began asking patients to get their labs done before scheduled appointments. The team tracked screening rates, conducted further patient surveys to assess patient satisfaction with the new system, and also informally assessed provider satisfaction.	All parties liked the new process, and overall clinic lipid screening rates increased from 56% to 64.4%, with the rates of the participating physician team increasing from 62% to 69%. At the conclusion of the six-month intervention, the team was figuring out how to scale up the new workflow to the entire clinic. They were optimistic about engaging patients in other situations where there was disagreement among providers about the best way to institute a change.	Yes
Clinic E	The practice had recently participated in a successful QI project with a consultant and expressed interest in broadening their QI experience, with an eye toward improving patient health.	QI 101 and Patient Engagement training combined into a 1:1 conversation that occurred while the team member had breaks from other clinical duties.	Clinic E was a three-person operation, comprised of a physician and two staff members who each fulfilled multiple roles in the practice. In interviews, clinic staff made it clear that the physician would not be participating in the project, and also that he would limit what they could do as part of the project (e.g., no patient surveys). The clinic staff described having close relationships with practice patients, but expressed skepticism that their patients would be willing or able to participate in QI work. The “team,” which consisted of a single staff member, decided to focus the project on increasing the proportion of clinic patients with advance directives on file. The QI plan did not include a formal patient engagement component; instead, the team member viewed patient engagement as involving patients in making decisions about their own advance directives.	The single staff member made efforts to figure out what needed to be done to encourage patients to complete advance directives, but encountered difficulties getting the information required. Ultimately, the practice decided to drop out of the study, citing recent personnel changes and a resulting lack of time to “[take] on extra projects.”	No
Clinic F	Two teams were selected by the health system administration to participate in this intervention based on these teams’ willingness to participate in QI.	None	Team members described a preventive care emphasis and a scheduling system that allowed them to have longer than average patient appointments. The clinic conducted frequent patient satisfaction surveys, but little was done with the results. Staff without administrative titles reported having little prior QI experience. At the site visit, team members described a new no-show policy that was about to be implemented at the clinic, and expressed a desire to focus their project on the new policy. However, this was viewed as too negative, and by the time the coaching part of the intervention started, the focus had shifted to increasing the number of asthmatic patients with asthma plans in place. The teams began their efforts by running small tests of change on the workflows of two providers. Their plan for patient engagement, beyond a focus on completing asthma action plans as part of office visits, was to invite patients to a lunch and learn at which the asthma plans would be explained and patient feedback solicited. Despite inviting more than 100 patients to the lunch, no one showed up.	By the end of the six-month intervention the teams had exceeded their stated benchmarks for the proportion of the providers’ patients with completed asthma plans—the team physician increased from 20% to 36% (goal for project: 30%) and the second team nurse practitioner increased from 16% to 51% (goal for project: 26%)--and were planning for how to improve numbers across the clinic. Clinic leadership expressed ongoing intent to consider patient engagement in future QI projects.	Yes
Clinic G	A pre-existing team was selected by the clinic manage that was working on issues related to the electronic health record in-basket	None	Team members described many recent organizational and personnel changes and a sense of always being overworked and short on time. A single individual on the team had significant QI training and experience, but this was not shared by the rest of the group. Questions about patient engagement evoked statements about patients’ customer service expectations, and team members had little vision for how patients might be engaged in QI work. During the site visit, team members spoke of their wish to focus their QI project on management of their electronic “in-basket” system. By the time the team had its initial meeting with the coach, however, they had shifted to a focus on vaccination rates.	Before its second scheduled meeting with the coach, the clinic dropped out of the study. A subsequent conversation with the health system administration revealed that the new regional system administrator had not been aware of the project and did not want the clinic to participate. They cited the failure of the researchers to obtain proper permissions from the appropriate chain of command, concerns about sharing confidential corporate information with the researchers (conflating the university with the competing health system affiliated with the university) and a belief that the focus of project did not reflect corporate priorities.	No