Influences of peer facilitation in general practice – a qualitative study

Influences of peer facilitation in general practice – a qualitative study Background: Practice facilitation is increasingly used to support guideline implementation and practice development in primary care and there is a need to explore how this implementation approach works in real-life settings. We focus on a facilitation intervention from the perspective of the visited practices to gain a more detailed understanding of how peer facilitation influenced practices and how they valued the facilitation. Methods: The facilitation intervention was conducted in general practice in the Capital Region of Denmark with the purpose of supporting the implementation of chronic disease management programmes. We carried out a qualitative study, where we observed 30 facilitation visits in 13 practice settings and interviewed the visited practices after their first and last visits. We then performed a thematic analysis. Results: Most of the respondents reported that facilitation visits had increased their knowledge and skills as well as their motivation and confidence to change. These positive influences were ascribed to a) the facilitation approach b) the credibility and know-how associated with the facilitators’ being peers c) the recurring visits providing protected time and invoking a sense of commitment. Despite these positive influences, both the facilitation and the change process were impeded by several challenges, e.g. competing priorities, heavy workload, problems with information technology and in some cases inadequate facilitation. Conclusion: Practice facilitation is a multifaceted, interactive approach that may affect participants in several ways. It is important to attune the expectations of all the involved actors through elaborate discussions of needs, capabilities, wishes, and approaches, and to adapt facilitation interventions according to an analysis of influential contextual conditions and change opportunities. Keywords: Facilitation, Facilitators, Outreach visits, Primary care, Qualitative study, General practice Background [1]. However, there is considerable heterogeneity between Various strategies are used to support guideline implemen- the included studies and generally, there is no clear and tation and practice development in primary care, e.g. regu- consistent operational definition of facilitation. Hence, spe- lations, financial incentives, and information dissemination. cific facilitation interventions vary considerably in their A more active and increasingly widespread strategy is prac- form and content. The literature portrays facilitators as tice facilitation [1–8]. This is a multifaceted intervention, having multiple roles and performing multiple activities [3, where an external person (most often a health care profes- 6, 8, 9]. Among these are audit and feedback, consensus sional) visits the practice and supports a process of change building, plan-do-study-act circles, provision of advice and [1, 7]. A systematic review and meta-analysis concluded education, cross-pollination of good ideas and support of that practice facilitation has “a moderately robust effect on internal discussions, and critical reflection. Recent contri- evidence-based guideline adoption within primary care” butions have emphasised the importance of tailoring facili- tation to the specific needs and circumstances of the * Correspondence: tina.due@sund.ku.dk targeted practices [1, 10, 11]. The Research Unit for General Practice and Section of General Practice, Given the increasing popularity of facilitation, the Department of Public Health, University of Copenhagen, Copenhagen, flexibility of the concept, and the heterogeneity Denmark Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Due et al. BMC Family Practice (2018) 19:75 Page 2 of 9 among interventions labelled as facilitation, there is Chronic disease management programmes based on a need to explore how facilitation is actually per- the Chronic Care Model [16, 17] have been developed in formed in real-life settings, how it affects practices, all five regions of Denmark [18]. The programmes out- and how participants experience it. From January line evidence based treatment and a systematic approach 2011 to December 2012, the Capital Region of to chronic care with division of tasks between GPs, hos- Denmark carried out a facilitation intervention to pitals and municipalities. They describe the GP’s role as support the implementation of chronic disease man- coordinator of care and outline a systematic proactive agement programmes for type-2-diabetes and chronic approach with population based patient registration, an- obstructive pulmonary disease (COPD) in general nual chronic disease check-ups, and stratification of pa- practice. The intervention relied on general practi- tients into three levels by risk of complications and tioners (GPs) as facilitators. In two previous studies, complexity and state of the disease [19, 20]. we explored how facilitation was enacted in this Diverse initiatives have been initiated to support the intervention and the effectiveness of the intervention implementation of the chronic disease management [12, 13]. First, based on observations and interviews programmes and to improve chronic care manage- with facilitators we found that facilitation was ment. The facilitation intervention in this study was enacted through four major roles: the teacher (know- one of these initiatives and it was developed and im- ledge dissemination), the super user (hands-on plemented by the Capital Region of Denmark. The knowledge dissemination on the practice’scomputer overall aim of the intervention was to support the system), the peer (facilitators conveying their experi- implementation of chronic disease management pro- ences and information about their own practice or- grammes for type-2-diabetes and COPD in general ganisation), and the process manager (selection of practice. Fourteen GPs were hired as facilitators. topics, tasks, and status reporting at subsequent These differed concerning age, gender and practice visits). We also found that the facilitators rarely enacted a type. They all went through an educational more coaching based approach to encourage internal re- programme focused on the content of the disease flection and discussion during the visits [13]. Second, our management programmes and related tools, and on randomised controlled trial on the intervention’s effective- how to be a facilitator. All practices in the region ness showed mixed results. There was no difference be- were offered up to three visits of 1 h each. Visits tween the allocation groups for the primary outcome were free of charge and the practices were compen- (change in the number of annual chronic disease check- sated for lost income. The central principle of the ups), but differences in some of the secondary outcomes intervention was that the practices’ own interests and (a higher reported use of ICPC diagnosis coding for type 2 choice of topics should drive the change process and diabetes, stratification for COPD and a faster initial sign- that the facilitators therefore should tailor their activ- up rate for the Data Capture Module - a software program ities to address the particular situation and needs of for patient overview) [12]. With the present study, we sup- each practice. Thus, the intervention relied on the plement our previous results by focusing on facilitation idea of a continuum of facilitator roles. The informa- from the recipients’ (i.e. general practice) perspective to tion material sent to the practices suggested relevant gain a more detailed understanding of how peer facilita- themes for the visits such as workflow procedures tion influenced practices and how they valued the facilita- and division of tasks for chronic disease management, tion. We also identify several factors, which inhibited the leadership and organisation, collaboration with muni- facilitation process. cipalities and hospitals, the role of the GP as coordin- ator of care, and IT solutions for improved overview Methods and systematisation, primarily the Data Capture Mod- Setting and intervention ule (DCM). The DCM was a software program which The Danish health care system is primarily tax fi- automatically collected patient data from the GPs’ nanced and offers free-of-charge access to general electronic health record system and provided individ- practice and public hospital services. The GP serves ual and population based patient overview and data as the primary care provider and gatekeeper for pa- for quality improvement [21]. Shortly after the initi- tients’ referral to specialists and hospitals. They are ation of the facilitation intervention, sign-up to the private entrepreneurs, but mainly financed through DCM became mandatory and all practices were re- the tax financed health care reimbursement scheme. quired to sign up no later than the 1st of April 2013. The service provision of general practice is regu- The intervention has been described in more detail lated via the collective agreement between the Da- elsewhere [13]. As researchers, our role was to study nish Regions and the Organisation of General the intervention and we were not involved in either Practitioners [14, 15]. the design or the implementation of the intervention. Due et al. BMC Family Practice (2018) 19:75 Page 3 of 9 Methods recordings we also obtained information about task We chose an explorative approach for both data collec- completion, the process between the visits, and potential tion and analysis. Practices were strategically sampled challenges. [22], to ensure variation in geography, size, current level of development in areas relevant to the disease manage- Results ment programmes (assessed by initial questionnaires), Prior to the visits, most practices only had a vague no- and the associated facilitator. We observed 30 facilita- tion of what to expect from facilitation, and their under- tion visits in 13 practice settings. Extensive notes were standing of the intervention was generally limited. Also written and the visits were audio recorded. Further, the the practices did not appear to experience a strong need first author conducted group interviews in the 13 prac- for change. The dominant reasons for participating in tice settings after their first and their last visit (4 of the the intervention was to get help with the DCM (because 13 facilitator visits were joint visits where collaborating it became mandatory), or because the visits were seen as practices where present; hence, a total of 18 practices an occasion to get started with developing more system- were represented). The group interviews lasted approxi- atic procedures for chronic care check-ups. A few prac- mately 1 h, and we strived to include all GPs and staff tices had merely signed-up because a colleague had who had been present at the facilitation visits. Table 1 mentioned the intervention. Most of the observed prac- presents an overview of the data material. As shown, the tices chose the DCM as their main topic while two prac- data collection was not complete in all practice settings. tices focused mainly on developing new chronic care We audio recorded the interviews, transcribed them ver- procedures for diabetes and COPD (i.e. written descrip- batim, and analysed them using thematic analysis [23]. tions of the workflow in the practice for a given disease, We used the software program NVivo in the coding and e.g. division of labour between GPs and nurses and theme constructing process for the interviews. We amount and content of systematic check-ups). The grouped codes in themes and sub-themes and then re- topics of the visits are described in Table 1. lated the themes to each other and to the entire data At the first visits, the practices decided on the topics material, thus refining and connecting them. The obser- of the visits. However, there was no introductory dia- vations were primarily used to qualify the interview logue about the practices’ expectations or preferred fa- guides, but from the observation notes and audio cilitation approach and a limited clarification of their Table 1 Participating practices and data material “X” = Observed visits. “-” = Not observed visits or not interviewed. Shaded areas are not conducted visit Due et al. BMC Family Practice (2018) 19:75 Page 4 of 9 existing level of knowledge within the chosen topic. Dur- attention towards some of the addressed issues, e.g. ing the visits, the facilitators mainly engaged in various annual chronic disease check-ups and the webpage forms of knowledge dissemination, practical support and for municipal chronic care activities. However, some process management. Although the intervention design practices did not express any tangible changes and also comprised a more coaching based approach to sup- some reported limited or no impact from the visits. port internal discussions and reflections (e.g. about exist- ing and future procedures) this approach was not enacted Knowledge and skills during the observed visits. Still, the majority of the re- The facilitators provided factual knowledge about Inter- spondents were pleased with the visits and did not wish national Classification of Primary Care (ICPC) diagnosis for this sort of facilitation approach. Several respondents coding of individual consultations in the electronic pa- appreciated the knowledge and inspiration offered by the tient records, the content of chronic disease check-ups, facilitators, and some did not envisage that there was suffi- the DCM, and websites on professional guidelines and cient time at the visits for more elaborate discussions municipal chronic care services to which GPs can refer about their practice organisation. Nevertheless, two prac- patients. This was either done by presentations, by tices were quite dissatisfied with the visits because they showing demo versions of the DCM, by demonstrating had mainly expected the facilitators to engage the partici- relevant websites, or by hands-on guidance in the prac- pants in an inspirational discussion about what changes tices’ electronic patient record systems [9]. Prior to the were needed and how to implement them. Instead, they visits, most practices had not used the DCM. Some had experienced the facilitators taking an educative stance not yet installed it and some had not managed to set up which did not involve asking the participants reflective the programme to generate accurate data. Further, they questions and which lacked a focus on implementation: rarely diagnosis-coded individual consultations and they had little knowledge (and made little use of) the various it is not what a facilitator is supposed to do. When websites introduced by the facilitators. On this back- [the facilitator] is sitting on the side-line if you [the ground, the practices experienced that the facilitation practice] are sitting and talking in the group, it is pri- visits increased their knowledge and awareness both marily making sure you do not lose focus, but also pro- of new tools and how to use them, and of errors in viding ideas in the process, saying… So that was what the set-up of the DCM. Some respondents stated that I had expected more of, more on the side-line, and the knowledge provided by the facilitators ensured a then that we as a practice had tried to talk about how faster implementation process due to knowledge being we would organise this. (GP, Practice 12) more easily accessible, and others perceived the knowledge, especially about the correct set-up of the One of these practices described that they rarely set time DCM, as being essential for progress, because they aside for discussions about practice development. There- would not have figured it out themselves: fore, they had hoped that the visits would have focused more on supporting their internal discussions and devel- We found out that we did not do it, that the computer opment processes, but they related that if a temporary was not set up properly... it turned out that the nurses’ doctor in training had not single-handedly taken upon computer was not set up to register the diagnosis- her the task of making new procedures, they would not coding, which we had done through half a year. have accomplished much. In the other practice, the GPs (Nurse, Practice 7) were so disappointed with the facilitation style (being too educative and not enabling internal discussions) that Respondents generally described the content of the they declined more visits. visits as relevant, because they had chosen the topics Across the observed practices, profound changes in themselves, and because these topics were closely related direct patient care were generally not initialised after to their daily practice and specific challenges (experi- the facilitation visits, but there were several examples enced prior to and in-between visits). The respondents of practices having initiated changes in some areas. also found that conducting the facilitation meetings in Several practices increased their use of diagnosis cod- the practice constituted a beneficial frame for knowledge ing and some installed and signed-up for the DCM, provision. Contrary to lectures in larger settings, the fa- corrected the system set-up, and improved their data cilitation visits focused on them, there were no disturb- registration. However, none came as far as using the ing questions from other practices, and they felt safe DCM data for quality improvement. Two practices asking questions and revealing their weak points. Like- formulated new chronic care procedures, and one of wise, some appreciated that joint meetings in the prac- them had begun to implement it after the last visit. tice increased the likelihood of the knowledge being Additionally, a few practices expressed increased applied, and relieved the GPs from spending time Due et al. BMC Family Practice (2018) 19:75 Page 5 of 9 conveying it to the staff. However, other GPs preferred So a small action card. How to do it… because we meetings without the staff so that the meetings focused cannot remember it now, right. (GP, Practice 13) on the needs of the GPs. Regarding patient related data for quality improve- ment, the practices generally did not review their own Motivation and confidence to change data prior to or in between the visits. However, practices According to most respondents the facilitation visits in- that looked at such data during the visits valued this ex- creased their motivation and confidence to change. They perience. For them, the facilitation visits improved their experienced the process of change as demystified and appreciation of the relevance of patient data, helped more manageable because the facilitators showed that them to identify problems, gave them an opportunity to the DCM was easier to use than they had assumed, and consider data (which they could not usually find time the facilitators’ descriptions of their own chronic care for), and reinforced them to improve the registrations procedures gave them something to build upon: even more. A few practices also improved their skills in using their information systems due to the hands-on ap- It might seem a bit less unmanageable and hopefully a proach. The practices were generally satisfied with the little less time consuming than I feared it would be. technical knowledge of the facilitator. Nevertheless, (GP, Practice 5) some facilitators lacked knowledge about the specific IT systems used by the practice (there are 11 IT systems in And Danish general practice), and several times they asked practices to contact their IT-providers with questions It was really good to get it [description of facilitators’ and problems they could not handle themselves. Some chronic care procedures], so you did not have to practices would have preferred a facilitator that had ex- reinvent the wheel. (Nurse, Practice 7) perience with their specific IT system, while others did not perceive this as a barrier. Several practices experi- Further, the facilitators’ descriptions of the benefits enced IT challenges such as limited user-friendliness, er- they had gained from making the changes in their rors in setting-up the DCM, and insufficient support own practices as well as the content of their chronic from their IT system providers between the visits. This care procedures inspired the practices by increasing seemed to slow down the implementation process as their sense of the changes being usefulness in daily some practices did not complete tasks or did so at a practice. Most GPs found that it added to the cred- slower pace. ibility of the facilitators that they were peers with At the first visit, the facilitators did not clarify exactly personal experience and knowledge of life in general what the visited practices wanted to focus on within a practice. This meant that the GPs generally perceived given topic or the level of their existing knowledge. Thus, the facilitators’ statements as relevant, trustworthy, although most practices reported that they obtained new and transferable to their own practice: knowledge from the facilitation visits, some of the know- ledge provided was not new to everyone in the practices. I think it is true that a general practitioner will reach While the GPs had generally gained little new knowledge us more easily. We listen because there is a from the presentations on medical and organisational as- professional respect ... We listen more sharply and take pects of chronic care, the practice staff often found this it more seriously … than if it was a nurse… she would knowledge more relevant; not because it directly affected initially have to struggle against whether we could use their own work, but because it improved their under- it for anything. (GP, Practice 2) standing of the GPs’ work. There were also several exam- ples of participants forgetting the knowledge provided The GPs did not perceive the descriptions of the facilita- during the visits and several participants still had ques- tors’ own practice organisation as something to be directly tions about the correct use of the DCM after the last visit. copied, but as a credible source of inspiration. The prac- Some felt that too little time had been spent on some of tices generally did not experience disadvantages from the the topics, that the visits had not been sufficiently struc- facilitators being peers. Some could not see how the facili- tured and requested more written material on both the tators could have other professional backgrounds, while a DCM and the facilitators’ organisation: few did not regard the peer component as crucial for the process. However, one of the previously mentioned dissat- One might have been given a sort of a template. isfied practices felt provoked when the facilitator pre- Because the problem is that you forget it a bit sented them with factual and experience-based knowledge afterwards…what is it you need to remember to because they did not perceive the facilitator as an expert implement it… perhaps one might have needed that. or someone with an outstanding practice but just as a Due et al. BMC Family Practice (2018) 19:75 Page 6 of 9 random GP. Also, while most GPs were motivated by Second, practices reported that the visits supported the visits, some still expressed a feeling of obligation task definition and delegation and increased the sense of toward the DCM and doubted whether they would obligation, agreement, and mutual responsibility because use the system beyond the required registrations: the whole practice attended the visits. However, from the observations it was clear that the clarity and system- Well, it is the obligation that does it, because it is atisation of task definition and delegation varied and oc- something that we have to do. If we had not had to, casionally clear tasks were not explicitly defined. the question is whether we would have done it. That I Third, several practices described how the return of don’t know. (GP, practice 3) the facilitator at subsequent visits came to function as a reminder and deadline during the process. According to Additionally, the technical problems experienced in some respondents this speeded up the change process the process triggered increased frustration with the and ensured the completion of initiated projects that DCM: otherwise might not have been prioritised in a busy working day: Well it is just difficult to mobilise any energy among the doctors, who are to sit and code, if the shit does So you knew, that you had a meeting at this and that not work, excuse my directness. Then I bloody do not date and suddenly, you were a bit more motivated to want to, and again I swear. Then I do not want to sit go in and code and do things…. So the meetings have there and spend my time on something like that. Then another function than just being a meeting, they also it must be left to its own device until it is working. (GP, have the function of keeping you up to scratch. (GP, Practice 1) practice 3) Thus, several practices managed to perform their dele- Internal conditions for change gated tasks and/or to set a deadline for their implemen- Three aspects of the intervention, which did not re- tation before the next visit. Still, most practices rarely late to the specific content of the visits nor to the discussed the tasks or changes in the time between the specific skills and actions of the facilitator, influ- visits and they explained this limited attention to the enced the change process and how the practices change process by referring to the daily time pressure in assessed the intervention. general practice. First, the visits offered an occasion to focus on and initiate changes and provided protected time for this, which was much valued by the respondents, Discussion whoreportedonbusyworkdays wheretimewas Most of the respondents from general practice reported usually not set aside for practice development meet- that facilitation visits had increased their knowledge and ings with both GPs and staff attending. Thus, the skills in relevant areas as well as their awareness of the visits were described as a timeout for development need for change and their belief that change was possible that accentuated the focus on the chosen topics: and manageable. They also described having carried out tasks that otherwise would not have been completed, It also just helps quite a lot by creating a focus, and they pointed to various features of the intervention because we devote an hour to it and sit here all of us that helped to generate these influences. Nevertheless, together. Instead of in our busy workdays, where we the impact of the facilitation visits mostly concerned in- just quickly went in and looked, and had set aside half tentions to change (or initial changes) rather than actual an hour and then were fifteen minutes late and just changes in chronic care management, and the study got to look at something. Then this gives it much focus. identified several factors which impeded the change (GP in training, Practice 2) process. Below we discuss these results using the theor- etical model of behavior change proposed by Michie et However, sometimes the observed visits were de- al. [24], the COM-B model. According to the COM-B layed and sometimes people were absent or left dur- model, the three critical prerequisites for behavior ing the meeting. Thus, while most respondents – change are: Capability (knowledge and skills required for practical reasons – appreciated having the facili- for change), Opportunity (enabling environmental re- tator meetings in the clinic, some mentioned that sources), and Motivation [24]. Applying the COM-B this also increased the risk of interruptions and de- model to our results, the various enablers and inhibitors lays since patients were waiting before, during, or of change in the facilitation intervention and its context after the visits. may be characterized and understood as follows: Due et al. BMC Family Practice (2018) 19:75 Page 7 of 9 1. Motivation: The visits generally increased the recurring visits. Still, the intervention did not participants’ desire and confidence to make provide additional resources (time or money) for changes. Most of the GPs found it important that the change process in between visits where most of the facilitators were peers, because this helped to the work was supposed to take place. This lack of establish the credibility of the facilitators and to influence of the participants’ opportunities for increase the GPs’ perceptions of manageability and change seem critical for understanding the limited usefulness. This resembles the value that has often amount of actual changes in chronic care been ascribed to opinion leaders as change agents management generated by the intervention. Thus, [25]. In both cases, much of the influence of the contextual conditions inhibited the opportunities of change agent is linked to the legitimacy and the participants in several ways: First, the visits credibility gained by having worked under similar were sometimes delayed or interrupted due to conditions. The participants’ motivation to change urgencies in the clinic; second, the technical was also augmented by the recurrent visits which problems with the DCM wasted precious time; and served as deadlines for the completion of the third, some practices found it difficult to prioritize agreed-upon tasks. This sometimes appeared to be change efforts in between visits due to busy work more influential for generating engagement and schedules. commitment than the specific content of the facili- tation visits. Further, the DCM being mandatory Previous studies have found that GPs appreciate fa- often motivated the practices to focus on this cilitation visits for some of the same reasons as iden- change area. However, the motivation of some par- tified in this study, i.e. due to the contributions of ticipants was negatively affected during the process the facilitators (motivating; giving advice and guidance due to the technical problems with the DCM. Fur- in relation to specific problems; and helping with data ther, the practices had diverse understandings and mining and data correction) as well as the facilitation expectations in relation to the facilitation visits, and frames (offering protected time from the demands of in some cases where these expectations were not dailyworklifeand supporting afocus on change fulfilled, motivation dropped. through recurrent visits) [6, 27–31]. Meanwhile sev- 2. Capability: The capabilities of the participants eral of the points mentioned above illustrate how improved when the facilitators addressed the contextual conditions may affect a facilitation process experienced challenges of the participants and negatively, and similar impeding conditions (compet- engaged in a hands-on approach to knowledge dis- ing priorities, heavy workload and problems with in- semination. The facilitators also helped some partic- formation technology) have been identified in other ipants to focus their change efforts and define studies [6, 28, 32, 33]. Since facilitation interventions specific tasks in practices with limited traditions for always support change within a given context it is im- engaging in structured improvement processes. Yet, portant to consider how the context will enable or in some cases tasks were not made specific enough weaken the capabilities, motivations and opportunities to promote change, and further some of the know- of the participants and how to deal with these influ- ledge provided by the facilitators was redundant, in- ences when preparing the intervention – either by adequate, or forgotten. This latter problem with attempting to affect the context or by providing add- insufficient tailoring (which also concerned the mo- itional support as part of the intervention. tivational dimension, cf. above) suggests that a more Berta et al. [34]havearguedthatthe promise of fa- thorough dialogue about current knowledge and cilitation lies in its potential to stimulate higher-order preferred facilitation approach should have been learning in organizations, and not just in supporting initiated as the first step in the process. Such an ap- single-loop learning defined as corrective actions that proach could have optimized the perceived rele- “focus exclusively on improving efficiency of existing vance of the knowledge provision and the style of routines or processes” [34]. In contrast, double-loop facilitation and thereby increased the impact of the learning occurs when organizations question the “ini- visits on both capability and motivation. A study by tial goals, assumptions, and values that led to a par- Watkins et al. likewise discussed the importance of ticular workplace process” and this type of learning an introductory talk about objectives and rules of may “manifest as significant adaptive changes to engagement [26]. workplace behaviours and routines and to goals, as- 3. Opportunity: The opportunities of the participants sumptions, and underlying values”.Furthermore, for discussing and engaging in change were to some triple-loop learning is reflective “learning about learn- extent enhanced by the formal frames of the ing” where learners “focus on learning that improves intervention providing protected time at three their learning processes, in addition to adaptive Due et al. BMC Family Practice (2018) 19:75 Page 8 of 9 learning that improves production processes and opti- of facilitation are dependent on the content of the inter- mizes behaviours” [34]. However, in our study it ap- vention as well as the institutional context and the the peared that the learning which emerged from the facilitators’ skills and professional background. Since fa- facilitation visits only corresponded to single loop cilitation interventions vary in their purpose and content learning. Thus, the participants mostly focused on and since they always take place in a specific context this concrete practical changes and they did not seem to put certain limits on transferability. However, as de- obtain tools to ensure future improved learning pro- scribed in the discussion, some of the ways that the cesses, or to challenge their existing values, objectives, practices were affected by facilitation in this study and or ways of working. While it is possible that a greater some of the influential contextual conditions have also ‘dose’ of the coaching approach (encouraging prac- been identified in other studies and should therefore be tices to engage in more internal reflections and dis- considered in future facilitation projects. cussions of current practices) delivered over an extended period of time might have generated the Conclusion kinds of higher order learning described by Bertha et In this study of practice facilitation in a real-life setting, al., this cannot be determined on the basis of our most of the participants from general practice experi- data. Nonetheless, the study also demonstrated that enced that facilitation had increased their knowledge in support on the level of single-loop learning was cru- some areas of chronic care and changed their percep- cial for the improvement process in the practices, and tions of the relevance and manageability of making hence the importance of single-loop learning should changes in these areas. Several elements of the interven- also be considered in future interventions. tion influenced the process positively such as the flexi- bility of the intervention (allowing participants to choose Strengths and limitations among several different topics), the provision of pro- Using interviews with participants as well as observa- tected meeting time, the legitimacy and know-how of tions of facilitation visits is a strength of this study. Al- the peer facilitators, the focus on defining and delegating though rarely used in facilitation studies, observations tasks, and the commitment associated with the deadlines provide a more nuanced picture of the facilitation set by recurrent visits. Despite the overall positive as- process when combined with the practices’ reported ex- sessments of the participants, a number of internal and periences. Thus, the observations made it possible to ex- external factors impeded the facilitation process. Some plore less idealized versions of the facilitation process of these challenges may be alleviated by a thorough ini- and to pose more nuanced and critical questions to the tial discussion of the needs, capabilities, and wishes of practices. It is also a strength that data was collected the involved practices; by employing facilitators with di- prospectively while the intervention was carried out verse skills so that the different needs and starting points since this reduced recollection bias among the partici- may be optimally matched by the individual facilitators; pants and made it possible to explore the entire process. and by adapting the intervention according to an ana- Potential limitations are that not all practices were inter- lysis of influential contextual conditions and change viewed twice and that the group interviews (where GPs opportunities. and staff were interviewed together) might have inclined Abbreviations staff not to state conflicting opinions and made GPs COPD: Chronic obstructive pulmonary disease; DCM: Data capture module; more careful about criticizing the peer facilitator. Still, GP: General practitioner; ICPC: International classification of primary care we deemed it important to give room for dialogue about Acknowledgments a common experience between the various participants. Our thanks go to the practices for participating in the study and the funding Using qualitative methods, we generated detailed know- bodies for funding the study. ledge on how practices can be influenced by facilitation, Funding connecting intervention activities and their impact, and The study was funded by The Danish Research Foundation for General uncovering types of influences, e.g. the sense of deadline, Practice, The Health Foundation, and the Research Foundation for Primary Care in the Capital Region of Denmark. These funding bodies played no role which likely would not have been identified with other in the design of the study, the collection, analysis, and interpretation of data methods. On the other hand, we do not know to what or in writing the manuscript. extend these findings apply to all the practices in the Availability of data and materials intervention, and the described impacts are not quanti- The anonymised audio files and transcribed interviews from the current tative or standardized and therefore less comparable. study are available from the corresponding author on reasonable request. However, a quantitative RCT based assessment of the Authors’ contributions intervention impact is previously reported [12]. TDD designed the study, collected the data, analysed and interpreted the Regarding the transferability of the findings beyond data, and drafted the manuscript. MBK participated in the interpretation of the specific setting both the enactment and the impact the data and the drafting of the manuscript. FBW Participated in the Due et al. BMC Family Practice (2018) 19:75 Page 9 of 9 interpretation of the data and the drafting of the manuscript. TT supervised 16. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for the study, and participated in the design of the study, the interpretation of patients with chronic illness. JAMA. 2002;288(14):1775–9. the data, and the drafting of the manuscript. All authors read and approved 17. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for the final manuscript. patients with chronic illness: the chronic care model, part 2. JAMA. 2002; 288(15):1909–14. Ethics approval and consent to participate 18. Forløbsprogrammer for kronisk sygdom - Generisk model og According to Danish law a qualitative study like this one does not require forløbsprogram for diabetes [Disease management programmes - generic ethical approval by the research ethics committee or written consent by the model and Disease management programmes for Type 2 Diabetes]. participants [35]. All participants were promised anonymity and Copenhagen: The Danish Health and Medicines Authority; 2008. confidentiality. 19. Forløbsprogram for Type 2 Diabetes - Hospitaler, almen praksis og kommunerne i Region Hovedstaden [Disease management programme For Competing interests Type 2 Diabetes - Hospitals, general practice and municipalities in the The authors declare that they have no competing interests. Capital Region of Denmark]. Hilleroed; 2009. 20. Forløbsprogram for KOL - Hospitaler, almen praksis og kommunerne i Region Hovedstaden [Disease management programme for COPD - Publisher’sNote Hospitals, general practice and municipalities in the Capital Region of Springer Nature remains neutral with regard to jurisdictional claims in Denmark]. Hilleroed; 2009. published maps and institutional affiliations. 21. Schroll H, Christensen RD, Thomsen JL, Andersen M, Friborg S, Sondergaard J. The danish model for improvement of diabetes care in general practice: Author details impact of automated collection and feedback of patient data. Int J Family The Research Unit for General Practice and Section of General Practice, Med. 2012;2012:208123. Department of Public Health, University of Copenhagen, Copenhagen, 22. Patton M. Qualitative Research & Evaluation Methods. 3rd ed. United States Denmark. Research Unit for General Practice, Institute of Public Health, of America: Sage publication; 2002. University of Southern Denmark, Odense, Denmark. 23. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Received: 22 January 2018 Accepted: 2 May 2018 24. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. References 25. Locock L, Dopson S, Chambers D, Gabbay J. Understanding the role of opinion 1. 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Organization and financing of the Danish health care system. Health Policy. 2002;59(2):107–18. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

Influences of peer facilitation in general practice – a qualitative study

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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Practice facilitation is increasingly used to support guideline implementation and practice development in primary care and there is a need to explore how this implementation approach works in real-life settings. We focus on a facilitation intervention from the perspective of the visited practices to gain a more detailed understanding of how peer facilitation influenced practices and how they valued the facilitation. Methods: The facilitation intervention was conducted in general practice in the Capital Region of Denmark with the purpose of supporting the implementation of chronic disease management programmes. We carried out a qualitative study, where we observed 30 facilitation visits in 13 practice settings and interviewed the visited practices after their first and last visits. We then performed a thematic analysis. Results: Most of the respondents reported that facilitation visits had increased their knowledge and skills as well as their motivation and confidence to change. These positive influences were ascribed to a) the facilitation approach b) the credibility and know-how associated with the facilitators’ being peers c) the recurring visits providing protected time and invoking a sense of commitment. Despite these positive influences, both the facilitation and the change process were impeded by several challenges, e.g. competing priorities, heavy workload, problems with information technology and in some cases inadequate facilitation. Conclusion: Practice facilitation is a multifaceted, interactive approach that may affect participants in several ways. It is important to attune the expectations of all the involved actors through elaborate discussions of needs, capabilities, wishes, and approaches, and to adapt facilitation interventions according to an analysis of influential contextual conditions and change opportunities. Keywords: Facilitation, Facilitators, Outreach visits, Primary care, Qualitative study, General practice Background [1]. However, there is considerable heterogeneity between Various strategies are used to support guideline implemen- the included studies and generally, there is no clear and tation and practice development in primary care, e.g. regu- consistent operational definition of facilitation. Hence, spe- lations, financial incentives, and information dissemination. cific facilitation interventions vary considerably in their A more active and increasingly widespread strategy is prac- form and content. The literature portrays facilitators as tice facilitation [1–8]. This is a multifaceted intervention, having multiple roles and performing multiple activities [3, where an external person (most often a health care profes- 6, 8, 9]. Among these are audit and feedback, consensus sional) visits the practice and supports a process of change building, plan-do-study-act circles, provision of advice and [1, 7]. A systematic review and meta-analysis concluded education, cross-pollination of good ideas and support of that practice facilitation has “a moderately robust effect on internal discussions, and critical reflection. Recent contri- evidence-based guideline adoption within primary care” butions have emphasised the importance of tailoring facili- tation to the specific needs and circumstances of the * Correspondence: tina.due@sund.ku.dk targeted practices [1, 10, 11]. The Research Unit for General Practice and Section of General Practice, Given the increasing popularity of facilitation, the Department of Public Health, University of Copenhagen, Copenhagen, flexibility of the concept, and the heterogeneity Denmark Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Due et al. BMC Family Practice (2018) 19:75 Page 2 of 9 among interventions labelled as facilitation, there is Chronic disease management programmes based on a need to explore how facilitation is actually per- the Chronic Care Model [16, 17] have been developed in formed in real-life settings, how it affects practices, all five regions of Denmark [18]. The programmes out- and how participants experience it. From January line evidence based treatment and a systematic approach 2011 to December 2012, the Capital Region of to chronic care with division of tasks between GPs, hos- Denmark carried out a facilitation intervention to pitals and municipalities. They describe the GP’s role as support the implementation of chronic disease man- coordinator of care and outline a systematic proactive agement programmes for type-2-diabetes and chronic approach with population based patient registration, an- obstructive pulmonary disease (COPD) in general nual chronic disease check-ups, and stratification of pa- practice. The intervention relied on general practi- tients into three levels by risk of complications and tioners (GPs) as facilitators. In two previous studies, complexity and state of the disease [19, 20]. we explored how facilitation was enacted in this Diverse initiatives have been initiated to support the intervention and the effectiveness of the intervention implementation of the chronic disease management [12, 13]. First, based on observations and interviews programmes and to improve chronic care manage- with facilitators we found that facilitation was ment. The facilitation intervention in this study was enacted through four major roles: the teacher (know- one of these initiatives and it was developed and im- ledge dissemination), the super user (hands-on plemented by the Capital Region of Denmark. The knowledge dissemination on the practice’scomputer overall aim of the intervention was to support the system), the peer (facilitators conveying their experi- implementation of chronic disease management pro- ences and information about their own practice or- grammes for type-2-diabetes and COPD in general ganisation), and the process manager (selection of practice. Fourteen GPs were hired as facilitators. topics, tasks, and status reporting at subsequent These differed concerning age, gender and practice visits). We also found that the facilitators rarely enacted a type. They all went through an educational more coaching based approach to encourage internal re- programme focused on the content of the disease flection and discussion during the visits [13]. Second, our management programmes and related tools, and on randomised controlled trial on the intervention’s effective- how to be a facilitator. All practices in the region ness showed mixed results. There was no difference be- were offered up to three visits of 1 h each. Visits tween the allocation groups for the primary outcome were free of charge and the practices were compen- (change in the number of annual chronic disease check- sated for lost income. The central principle of the ups), but differences in some of the secondary outcomes intervention was that the practices’ own interests and (a higher reported use of ICPC diagnosis coding for type 2 choice of topics should drive the change process and diabetes, stratification for COPD and a faster initial sign- that the facilitators therefore should tailor their activ- up rate for the Data Capture Module - a software program ities to address the particular situation and needs of for patient overview) [12]. With the present study, we sup- each practice. Thus, the intervention relied on the plement our previous results by focusing on facilitation idea of a continuum of facilitator roles. The informa- from the recipients’ (i.e. general practice) perspective to tion material sent to the practices suggested relevant gain a more detailed understanding of how peer facilita- themes for the visits such as workflow procedures tion influenced practices and how they valued the facilita- and division of tasks for chronic disease management, tion. We also identify several factors, which inhibited the leadership and organisation, collaboration with muni- facilitation process. cipalities and hospitals, the role of the GP as coordin- ator of care, and IT solutions for improved overview Methods and systematisation, primarily the Data Capture Mod- Setting and intervention ule (DCM). The DCM was a software program which The Danish health care system is primarily tax fi- automatically collected patient data from the GPs’ nanced and offers free-of-charge access to general electronic health record system and provided individ- practice and public hospital services. The GP serves ual and population based patient overview and data as the primary care provider and gatekeeper for pa- for quality improvement [21]. Shortly after the initi- tients’ referral to specialists and hospitals. They are ation of the facilitation intervention, sign-up to the private entrepreneurs, but mainly financed through DCM became mandatory and all practices were re- the tax financed health care reimbursement scheme. quired to sign up no later than the 1st of April 2013. The service provision of general practice is regu- The intervention has been described in more detail lated via the collective agreement between the Da- elsewhere [13]. As researchers, our role was to study nish Regions and the Organisation of General the intervention and we were not involved in either Practitioners [14, 15]. the design or the implementation of the intervention. Due et al. BMC Family Practice (2018) 19:75 Page 3 of 9 Methods recordings we also obtained information about task We chose an explorative approach for both data collec- completion, the process between the visits, and potential tion and analysis. Practices were strategically sampled challenges. [22], to ensure variation in geography, size, current level of development in areas relevant to the disease manage- Results ment programmes (assessed by initial questionnaires), Prior to the visits, most practices only had a vague no- and the associated facilitator. We observed 30 facilita- tion of what to expect from facilitation, and their under- tion visits in 13 practice settings. Extensive notes were standing of the intervention was generally limited. Also written and the visits were audio recorded. Further, the the practices did not appear to experience a strong need first author conducted group interviews in the 13 prac- for change. The dominant reasons for participating in tice settings after their first and their last visit (4 of the the intervention was to get help with the DCM (because 13 facilitator visits were joint visits where collaborating it became mandatory), or because the visits were seen as practices where present; hence, a total of 18 practices an occasion to get started with developing more system- were represented). The group interviews lasted approxi- atic procedures for chronic care check-ups. A few prac- mately 1 h, and we strived to include all GPs and staff tices had merely signed-up because a colleague had who had been present at the facilitation visits. Table 1 mentioned the intervention. Most of the observed prac- presents an overview of the data material. As shown, the tices chose the DCM as their main topic while two prac- data collection was not complete in all practice settings. tices focused mainly on developing new chronic care We audio recorded the interviews, transcribed them ver- procedures for diabetes and COPD (i.e. written descrip- batim, and analysed them using thematic analysis [23]. tions of the workflow in the practice for a given disease, We used the software program NVivo in the coding and e.g. division of labour between GPs and nurses and theme constructing process for the interviews. We amount and content of systematic check-ups). The grouped codes in themes and sub-themes and then re- topics of the visits are described in Table 1. lated the themes to each other and to the entire data At the first visits, the practices decided on the topics material, thus refining and connecting them. The obser- of the visits. However, there was no introductory dia- vations were primarily used to qualify the interview logue about the practices’ expectations or preferred fa- guides, but from the observation notes and audio cilitation approach and a limited clarification of their Table 1 Participating practices and data material “X” = Observed visits. “-” = Not observed visits or not interviewed. Shaded areas are not conducted visit Due et al. BMC Family Practice (2018) 19:75 Page 4 of 9 existing level of knowledge within the chosen topic. Dur- attention towards some of the addressed issues, e.g. ing the visits, the facilitators mainly engaged in various annual chronic disease check-ups and the webpage forms of knowledge dissemination, practical support and for municipal chronic care activities. However, some process management. Although the intervention design practices did not express any tangible changes and also comprised a more coaching based approach to sup- some reported limited or no impact from the visits. port internal discussions and reflections (e.g. about exist- ing and future procedures) this approach was not enacted Knowledge and skills during the observed visits. Still, the majority of the re- The facilitators provided factual knowledge about Inter- spondents were pleased with the visits and did not wish national Classification of Primary Care (ICPC) diagnosis for this sort of facilitation approach. Several respondents coding of individual consultations in the electronic pa- appreciated the knowledge and inspiration offered by the tient records, the content of chronic disease check-ups, facilitators, and some did not envisage that there was suffi- the DCM, and websites on professional guidelines and cient time at the visits for more elaborate discussions municipal chronic care services to which GPs can refer about their practice organisation. Nevertheless, two prac- patients. This was either done by presentations, by tices were quite dissatisfied with the visits because they showing demo versions of the DCM, by demonstrating had mainly expected the facilitators to engage the partici- relevant websites, or by hands-on guidance in the prac- pants in an inspirational discussion about what changes tices’ electronic patient record systems [9]. Prior to the were needed and how to implement them. Instead, they visits, most practices had not used the DCM. Some had experienced the facilitators taking an educative stance not yet installed it and some had not managed to set up which did not involve asking the participants reflective the programme to generate accurate data. Further, they questions and which lacked a focus on implementation: rarely diagnosis-coded individual consultations and they had little knowledge (and made little use of) the various it is not what a facilitator is supposed to do. When websites introduced by the facilitators. On this back- [the facilitator] is sitting on the side-line if you [the ground, the practices experienced that the facilitation practice] are sitting and talking in the group, it is pri- visits increased their knowledge and awareness both marily making sure you do not lose focus, but also pro- of new tools and how to use them, and of errors in viding ideas in the process, saying… So that was what the set-up of the DCM. Some respondents stated that I had expected more of, more on the side-line, and the knowledge provided by the facilitators ensured a then that we as a practice had tried to talk about how faster implementation process due to knowledge being we would organise this. (GP, Practice 12) more easily accessible, and others perceived the knowledge, especially about the correct set-up of the One of these practices described that they rarely set time DCM, as being essential for progress, because they aside for discussions about practice development. There- would not have figured it out themselves: fore, they had hoped that the visits would have focused more on supporting their internal discussions and devel- We found out that we did not do it, that the computer opment processes, but they related that if a temporary was not set up properly... it turned out that the nurses’ doctor in training had not single-handedly taken upon computer was not set up to register the diagnosis- her the task of making new procedures, they would not coding, which we had done through half a year. have accomplished much. In the other practice, the GPs (Nurse, Practice 7) were so disappointed with the facilitation style (being too educative and not enabling internal discussions) that Respondents generally described the content of the they declined more visits. visits as relevant, because they had chosen the topics Across the observed practices, profound changes in themselves, and because these topics were closely related direct patient care were generally not initialised after to their daily practice and specific challenges (experi- the facilitation visits, but there were several examples enced prior to and in-between visits). The respondents of practices having initiated changes in some areas. also found that conducting the facilitation meetings in Several practices increased their use of diagnosis cod- the practice constituted a beneficial frame for knowledge ing and some installed and signed-up for the DCM, provision. Contrary to lectures in larger settings, the fa- corrected the system set-up, and improved their data cilitation visits focused on them, there were no disturb- registration. However, none came as far as using the ing questions from other practices, and they felt safe DCM data for quality improvement. Two practices asking questions and revealing their weak points. Like- formulated new chronic care procedures, and one of wise, some appreciated that joint meetings in the prac- them had begun to implement it after the last visit. tice increased the likelihood of the knowledge being Additionally, a few practices expressed increased applied, and relieved the GPs from spending time Due et al. BMC Family Practice (2018) 19:75 Page 5 of 9 conveying it to the staff. However, other GPs preferred So a small action card. How to do it… because we meetings without the staff so that the meetings focused cannot remember it now, right. (GP, Practice 13) on the needs of the GPs. Regarding patient related data for quality improve- ment, the practices generally did not review their own Motivation and confidence to change data prior to or in between the visits. However, practices According to most respondents the facilitation visits in- that looked at such data during the visits valued this ex- creased their motivation and confidence to change. They perience. For them, the facilitation visits improved their experienced the process of change as demystified and appreciation of the relevance of patient data, helped more manageable because the facilitators showed that them to identify problems, gave them an opportunity to the DCM was easier to use than they had assumed, and consider data (which they could not usually find time the facilitators’ descriptions of their own chronic care for), and reinforced them to improve the registrations procedures gave them something to build upon: even more. A few practices also improved their skills in using their information systems due to the hands-on ap- It might seem a bit less unmanageable and hopefully a proach. The practices were generally satisfied with the little less time consuming than I feared it would be. technical knowledge of the facilitator. Nevertheless, (GP, Practice 5) some facilitators lacked knowledge about the specific IT systems used by the practice (there are 11 IT systems in And Danish general practice), and several times they asked practices to contact their IT-providers with questions It was really good to get it [description of facilitators’ and problems they could not handle themselves. Some chronic care procedures], so you did not have to practices would have preferred a facilitator that had ex- reinvent the wheel. (Nurse, Practice 7) perience with their specific IT system, while others did not perceive this as a barrier. Several practices experi- Further, the facilitators’ descriptions of the benefits enced IT challenges such as limited user-friendliness, er- they had gained from making the changes in their rors in setting-up the DCM, and insufficient support own practices as well as the content of their chronic from their IT system providers between the visits. This care procedures inspired the practices by increasing seemed to slow down the implementation process as their sense of the changes being usefulness in daily some practices did not complete tasks or did so at a practice. Most GPs found that it added to the cred- slower pace. ibility of the facilitators that they were peers with At the first visit, the facilitators did not clarify exactly personal experience and knowledge of life in general what the visited practices wanted to focus on within a practice. This meant that the GPs generally perceived given topic or the level of their existing knowledge. Thus, the facilitators’ statements as relevant, trustworthy, although most practices reported that they obtained new and transferable to their own practice: knowledge from the facilitation visits, some of the know- ledge provided was not new to everyone in the practices. I think it is true that a general practitioner will reach While the GPs had generally gained little new knowledge us more easily. We listen because there is a from the presentations on medical and organisational as- professional respect ... We listen more sharply and take pects of chronic care, the practice staff often found this it more seriously … than if it was a nurse… she would knowledge more relevant; not because it directly affected initially have to struggle against whether we could use their own work, but because it improved their under- it for anything. (GP, Practice 2) standing of the GPs’ work. There were also several exam- ples of participants forgetting the knowledge provided The GPs did not perceive the descriptions of the facilita- during the visits and several participants still had ques- tors’ own practice organisation as something to be directly tions about the correct use of the DCM after the last visit. copied, but as a credible source of inspiration. The prac- Some felt that too little time had been spent on some of tices generally did not experience disadvantages from the the topics, that the visits had not been sufficiently struc- facilitators being peers. Some could not see how the facili- tured and requested more written material on both the tators could have other professional backgrounds, while a DCM and the facilitators’ organisation: few did not regard the peer component as crucial for the process. However, one of the previously mentioned dissat- One might have been given a sort of a template. isfied practices felt provoked when the facilitator pre- Because the problem is that you forget it a bit sented them with factual and experience-based knowledge afterwards…what is it you need to remember to because they did not perceive the facilitator as an expert implement it… perhaps one might have needed that. or someone with an outstanding practice but just as a Due et al. BMC Family Practice (2018) 19:75 Page 6 of 9 random GP. Also, while most GPs were motivated by Second, practices reported that the visits supported the visits, some still expressed a feeling of obligation task definition and delegation and increased the sense of toward the DCM and doubted whether they would obligation, agreement, and mutual responsibility because use the system beyond the required registrations: the whole practice attended the visits. However, from the observations it was clear that the clarity and system- Well, it is the obligation that does it, because it is atisation of task definition and delegation varied and oc- something that we have to do. If we had not had to, casionally clear tasks were not explicitly defined. the question is whether we would have done it. That I Third, several practices described how the return of don’t know. (GP, practice 3) the facilitator at subsequent visits came to function as a reminder and deadline during the process. According to Additionally, the technical problems experienced in some respondents this speeded up the change process the process triggered increased frustration with the and ensured the completion of initiated projects that DCM: otherwise might not have been prioritised in a busy working day: Well it is just difficult to mobilise any energy among the doctors, who are to sit and code, if the shit does So you knew, that you had a meeting at this and that not work, excuse my directness. Then I bloody do not date and suddenly, you were a bit more motivated to want to, and again I swear. Then I do not want to sit go in and code and do things…. So the meetings have there and spend my time on something like that. Then another function than just being a meeting, they also it must be left to its own device until it is working. (GP, have the function of keeping you up to scratch. (GP, Practice 1) practice 3) Thus, several practices managed to perform their dele- Internal conditions for change gated tasks and/or to set a deadline for their implemen- Three aspects of the intervention, which did not re- tation before the next visit. Still, most practices rarely late to the specific content of the visits nor to the discussed the tasks or changes in the time between the specific skills and actions of the facilitator, influ- visits and they explained this limited attention to the enced the change process and how the practices change process by referring to the daily time pressure in assessed the intervention. general practice. First, the visits offered an occasion to focus on and initiate changes and provided protected time for this, which was much valued by the respondents, Discussion whoreportedonbusyworkdays wheretimewas Most of the respondents from general practice reported usually not set aside for practice development meet- that facilitation visits had increased their knowledge and ings with both GPs and staff attending. Thus, the skills in relevant areas as well as their awareness of the visits were described as a timeout for development need for change and their belief that change was possible that accentuated the focus on the chosen topics: and manageable. They also described having carried out tasks that otherwise would not have been completed, It also just helps quite a lot by creating a focus, and they pointed to various features of the intervention because we devote an hour to it and sit here all of us that helped to generate these influences. Nevertheless, together. Instead of in our busy workdays, where we the impact of the facilitation visits mostly concerned in- just quickly went in and looked, and had set aside half tentions to change (or initial changes) rather than actual an hour and then were fifteen minutes late and just changes in chronic care management, and the study got to look at something. Then this gives it much focus. identified several factors which impeded the change (GP in training, Practice 2) process. Below we discuss these results using the theor- etical model of behavior change proposed by Michie et However, sometimes the observed visits were de- al. [24], the COM-B model. According to the COM-B layed and sometimes people were absent or left dur- model, the three critical prerequisites for behavior ing the meeting. Thus, while most respondents – change are: Capability (knowledge and skills required for practical reasons – appreciated having the facili- for change), Opportunity (enabling environmental re- tator meetings in the clinic, some mentioned that sources), and Motivation [24]. Applying the COM-B this also increased the risk of interruptions and de- model to our results, the various enablers and inhibitors lays since patients were waiting before, during, or of change in the facilitation intervention and its context after the visits. may be characterized and understood as follows: Due et al. BMC Family Practice (2018) 19:75 Page 7 of 9 1. Motivation: The visits generally increased the recurring visits. Still, the intervention did not participants’ desire and confidence to make provide additional resources (time or money) for changes. Most of the GPs found it important that the change process in between visits where most of the facilitators were peers, because this helped to the work was supposed to take place. This lack of establish the credibility of the facilitators and to influence of the participants’ opportunities for increase the GPs’ perceptions of manageability and change seem critical for understanding the limited usefulness. This resembles the value that has often amount of actual changes in chronic care been ascribed to opinion leaders as change agents management generated by the intervention. Thus, [25]. In both cases, much of the influence of the contextual conditions inhibited the opportunities of change agent is linked to the legitimacy and the participants in several ways: First, the visits credibility gained by having worked under similar were sometimes delayed or interrupted due to conditions. The participants’ motivation to change urgencies in the clinic; second, the technical was also augmented by the recurrent visits which problems with the DCM wasted precious time; and served as deadlines for the completion of the third, some practices found it difficult to prioritize agreed-upon tasks. This sometimes appeared to be change efforts in between visits due to busy work more influential for generating engagement and schedules. commitment than the specific content of the facili- tation visits. Further, the DCM being mandatory Previous studies have found that GPs appreciate fa- often motivated the practices to focus on this cilitation visits for some of the same reasons as iden- change area. However, the motivation of some par- tified in this study, i.e. due to the contributions of ticipants was negatively affected during the process the facilitators (motivating; giving advice and guidance due to the technical problems with the DCM. Fur- in relation to specific problems; and helping with data ther, the practices had diverse understandings and mining and data correction) as well as the facilitation expectations in relation to the facilitation visits, and frames (offering protected time from the demands of in some cases where these expectations were not dailyworklifeand supporting afocus on change fulfilled, motivation dropped. through recurrent visits) [6, 27–31]. Meanwhile sev- 2. Capability: The capabilities of the participants eral of the points mentioned above illustrate how improved when the facilitators addressed the contextual conditions may affect a facilitation process experienced challenges of the participants and negatively, and similar impeding conditions (compet- engaged in a hands-on approach to knowledge dis- ing priorities, heavy workload and problems with in- semination. The facilitators also helped some partic- formation technology) have been identified in other ipants to focus their change efforts and define studies [6, 28, 32, 33]. Since facilitation interventions specific tasks in practices with limited traditions for always support change within a given context it is im- engaging in structured improvement processes. Yet, portant to consider how the context will enable or in some cases tasks were not made specific enough weaken the capabilities, motivations and opportunities to promote change, and further some of the know- of the participants and how to deal with these influ- ledge provided by the facilitators was redundant, in- ences when preparing the intervention – either by adequate, or forgotten. This latter problem with attempting to affect the context or by providing add- insufficient tailoring (which also concerned the mo- itional support as part of the intervention. tivational dimension, cf. above) suggests that a more Berta et al. [34]havearguedthatthe promise of fa- thorough dialogue about current knowledge and cilitation lies in its potential to stimulate higher-order preferred facilitation approach should have been learning in organizations, and not just in supporting initiated as the first step in the process. Such an ap- single-loop learning defined as corrective actions that proach could have optimized the perceived rele- “focus exclusively on improving efficiency of existing vance of the knowledge provision and the style of routines or processes” [34]. In contrast, double-loop facilitation and thereby increased the impact of the learning occurs when organizations question the “ini- visits on both capability and motivation. A study by tial goals, assumptions, and values that led to a par- Watkins et al. likewise discussed the importance of ticular workplace process” and this type of learning an introductory talk about objectives and rules of may “manifest as significant adaptive changes to engagement [26]. workplace behaviours and routines and to goals, as- 3. Opportunity: The opportunities of the participants sumptions, and underlying values”.Furthermore, for discussing and engaging in change were to some triple-loop learning is reflective “learning about learn- extent enhanced by the formal frames of the ing” where learners “focus on learning that improves intervention providing protected time at three their learning processes, in addition to adaptive Due et al. BMC Family Practice (2018) 19:75 Page 8 of 9 learning that improves production processes and opti- of facilitation are dependent on the content of the inter- mizes behaviours” [34]. However, in our study it ap- vention as well as the institutional context and the the peared that the learning which emerged from the facilitators’ skills and professional background. Since fa- facilitation visits only corresponded to single loop cilitation interventions vary in their purpose and content learning. Thus, the participants mostly focused on and since they always take place in a specific context this concrete practical changes and they did not seem to put certain limits on transferability. However, as de- obtain tools to ensure future improved learning pro- scribed in the discussion, some of the ways that the cesses, or to challenge their existing values, objectives, practices were affected by facilitation in this study and or ways of working. While it is possible that a greater some of the influential contextual conditions have also ‘dose’ of the coaching approach (encouraging prac- been identified in other studies and should therefore be tices to engage in more internal reflections and dis- considered in future facilitation projects. cussions of current practices) delivered over an extended period of time might have generated the Conclusion kinds of higher order learning described by Bertha et In this study of practice facilitation in a real-life setting, al., this cannot be determined on the basis of our most of the participants from general practice experi- data. Nonetheless, the study also demonstrated that enced that facilitation had increased their knowledge in support on the level of single-loop learning was cru- some areas of chronic care and changed their percep- cial for the improvement process in the practices, and tions of the relevance and manageability of making hence the importance of single-loop learning should changes in these areas. Several elements of the interven- also be considered in future interventions. tion influenced the process positively such as the flexi- bility of the intervention (allowing participants to choose Strengths and limitations among several different topics), the provision of pro- Using interviews with participants as well as observa- tected meeting time, the legitimacy and know-how of tions of facilitation visits is a strength of this study. Al- the peer facilitators, the focus on defining and delegating though rarely used in facilitation studies, observations tasks, and the commitment associated with the deadlines provide a more nuanced picture of the facilitation set by recurrent visits. Despite the overall positive as- process when combined with the practices’ reported ex- sessments of the participants, a number of internal and periences. Thus, the observations made it possible to ex- external factors impeded the facilitation process. Some plore less idealized versions of the facilitation process of these challenges may be alleviated by a thorough ini- and to pose more nuanced and critical questions to the tial discussion of the needs, capabilities, and wishes of practices. It is also a strength that data was collected the involved practices; by employing facilitators with di- prospectively while the intervention was carried out verse skills so that the different needs and starting points since this reduced recollection bias among the partici- may be optimally matched by the individual facilitators; pants and made it possible to explore the entire process. and by adapting the intervention according to an ana- Potential limitations are that not all practices were inter- lysis of influential contextual conditions and change viewed twice and that the group interviews (where GPs opportunities. and staff were interviewed together) might have inclined Abbreviations staff not to state conflicting opinions and made GPs COPD: Chronic obstructive pulmonary disease; DCM: Data capture module; more careful about criticizing the peer facilitator. Still, GP: General practitioner; ICPC: International classification of primary care we deemed it important to give room for dialogue about Acknowledgments a common experience between the various participants. Our thanks go to the practices for participating in the study and the funding Using qualitative methods, we generated detailed know- bodies for funding the study. ledge on how practices can be influenced by facilitation, Funding connecting intervention activities and their impact, and The study was funded by The Danish Research Foundation for General uncovering types of influences, e.g. the sense of deadline, Practice, The Health Foundation, and the Research Foundation for Primary Care in the Capital Region of Denmark. These funding bodies played no role which likely would not have been identified with other in the design of the study, the collection, analysis, and interpretation of data methods. On the other hand, we do not know to what or in writing the manuscript. extend these findings apply to all the practices in the Availability of data and materials intervention, and the described impacts are not quanti- The anonymised audio files and transcribed interviews from the current tative or standardized and therefore less comparable. study are available from the corresponding author on reasonable request. However, a quantitative RCT based assessment of the Authors’ contributions intervention impact is previously reported [12]. TDD designed the study, collected the data, analysed and interpreted the Regarding the transferability of the findings beyond data, and drafted the manuscript. MBK participated in the interpretation of the specific setting both the enactment and the impact the data and the drafting of the manuscript. FBW Participated in the Due et al. BMC Family Practice (2018) 19:75 Page 9 of 9 interpretation of the data and the drafting of the manuscript. 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BMC Family PracticeSpringer Journals

Published: May 28, 2018

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