Table 4.

Lessons learned and examples by implementation stage

Implementation Stage	Lesson Learned	Example
Recruitment	Recruiting practice participants across multiple organizational settings takes a long time	Recruitment for this project started in March 2016 and was not completed until October 2017. The research team aimed to recruit 9 practices yet only 7 practices were recruited.
	Recruitment was most successful when there was a preexisting relationship or via a warm handoff introduction from a known entity	All participating clinics had a prior relationship either with the research team or the QI consulting organization
	It is important to understand the relationship between practices and the recruitment partner	Successful recruitment came from the organization that had a positive relationship with the clinics and the clinics trusted their recommendation to participate in the intervention.
	There is a need to understand motivations for participation at multiple levels (system leadership, clinic leadership, and grass roots team members)	The clinic teams that participated ranged in motivation. Some clinic teams were volunteered by the health system to become more patient centered and to fix patient satisfaction scores and others teams thought it would make their day to day lives easier and would help with their workflow.
	Stakeholders at multiple levels need to clearly understand the intervention	One clinic dropped out because of misalignment with the overall health system goals. Other clinic teams dropped out due to leadership not understanding the importance of QI and other outcomes.
Implementation	Adapting the intervention to meet clinic’s time pressures was unsuccessful	Clinics that dropped out of the intervention received 20 minute of QI 101. One tried to fit education in while doing other clinical duties. These team expressed confusion about the intervention and had difficulty choosing their own projects. The clinics that received the full trainings were better equipped to take on their projects.
	Teams found it challenging to identify their own quality improvement projects	Clinic teams were used to being told what outcomes or projects to work on from the overarching organization and didn’t have the processes or skills in place to choose their own projects.
	If teams did not understand the intervention, they had to back track and choose new projects	Clinic teams did not understand the difference between patient activation and patient engagement. Projects were changed last minute to accommodate the patient engagement component.
	Academics and real world practices had different beliefs about the importance and meaning of engaging patient in quality improvement work	Patient engagement wasn’t an organizational goal and therefore teams didn’t have an expectation or motivation to include patient engagement in their QI projects.
	Academics trying to engage with systems that are potential competitors to their own health system may face suspicion	The research team was asked to sign a non-disclosure agreement since their university owned a competing medical system.
	Smaller sized project teams with a clear champion were most successful	The two successful clinics formed workgroups of 3–4 people that met on a regular basis. They would then relay their progress back to the bigger clinic team