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- Healthcare quality improvement
- Health services research
- Implementation science
- Quality improvement methodologies
Practice transformation efforts in healthcare, like the patient-centred medical home model in primary care, have spurred the development of multiple quality improvement (QI) and implementation strategies to support effective change. Nonetheless, uncertainty about how to implement and sustain change in complex healthcare settings1 2 continues to pose significant challenges. Even when practices are receptive,3 limited QI expertise, constrained resources,4 and associated staff morale and burnout5 can impact success. Although efforts among clinicians to improve primary care by embracing a culture of QI continue,6 healthcare systems are increasingly hiring additional personnel, like practice facilitators, with key performance improvement skills to promote and support change.7
However skilled, practice facilitators cannot implement change alone. Their primary function is to enable transformation by activating the healthcare context, the innovation being implemented and the actors implementing the innovation towards successful implementation of practice improvements.8 9 Compared with other individuals participating in QI efforts (eg, quality managers), facilitators are typically appointed to their role by the organisation’s leadership, have been formally trained in QI, and have project-specific content knowledge and varying levels of facilitation experience (novice to expert).10–12 Facilitators can be internal or external to the organisation and typically support change by engaging teams in activities like task management, process monitoring, relationship building, motivation and accountability checks,13 14 during inperson or distance-based (phone or video) encounters. Successful facilitators tailor the innovation to the local context, effectively integrate into the team responsible for QI, push through resistance from recipients of the innovation and remain flexible.15 Providing this type of facilitation in a dynamic (and sometimes dysfunctional) context can be emotionally and mentally taxing, with facilitators risking the same work-related stress and emotional exhaustion (burnout) as the healthcare staff they support,16 potentially defeating the purpose of facilitation.
Facilitation is complex, with obstacles to implementation and sustainment. As the evidence for the effectiveness of facilitation grows,17 18 research is warranted that focuses on understanding the individuals conducting facilitation and not just the facilitation activities they perform. Resources to help facilitators manage morale and motivation challenges in themselves are underexplored in research and underemphasised in facilitation training. We posit that strategies to promote facilitators’ resilience throughout the facilitation process may positively impact their effectiveness—their ability to enable other clinical and non-clinical staff to implement change—and thereby enhance QI outcomes. We present a case study of a facilitation model used as part of a QI initiative in a large integrated healthcare system that provided facilitator support, outline the challenges facilitators encountered and provide preliminary recommendations for how facilitators can manage challenges to build resilience.
A case study of enhanced facilitator support
The Coordination Toolkit and Coaching project
The Coordination Toolkit and Coaching (CTAC) project is a QI effort of the Care Coordination Quality Enhancement Research Initiative programme in the US Veterans Health Administration (VA). During CTAC, front-line primary care managers and staff engaged in QI to improve patients’ experience of care coordination between outpatient settings within and outside the VA,19 at sites experiencing care coordination barriers.20 Twelve clinics were cluster-randomised in matched pairs to a passive strategy (access to the Care Coordination online toolkit) or an active strategy (distance-based facilitation plus the toolkit) over a 12-month period. Each of two CTAC facilitators was assigned as the primary facilitator for three clinics and provided support on the second facilitator’s calls with the other three clinics. The primary facilitator organised and hosted weekly 1-hour calls for each site, answered project-related questions, provided feedback on products produced by the teams (eg, educational brochures) and assisted with QI methods (eg, usability testing, data collection and analysis). The supporting facilitator audio-recorded the calls and took notes. Significant facilitator availability and flexibility were built into CTAC to encourage engagement and project completion.
Proactive resilience: built-in support and protected time for facilitator reflection
Facilitators were responsible for documenting details about their process after each facilitation encounter using a templated reflection form. The form included information about the encounter duration and modality (eg, phone call, email, instant message), names of participants, an open-ended summary of the encounter, facilitation challenges and successes experienced during each encounter, and next steps in the facilitation process. Facilitation calls were the most frequent encounters (257 completed to date). In addition, the two facilitators debriefed after each call and kept debrief session notes. The internal CTAC team, composed of the principal investigator, project director and the two facilitators, also met weekly to debrief facilitator progress, problem-solve and think through QI strategies. Debrief activities accounted for 15%–25% of the total facilitation effort (20 hours per facilitator, per week) and were proactively built into the CTAC design as integral to maintaining facilitator resilience and continued effectiveness.
Challenges to Facilitator Morale
Facilitation can be extremely rewarding. The enthusiasm for accomplishing an intended goal through a team effort and a well-functioning facilitation approach may result in a unique synergy that can be infectious and exceptionally satisfying for all involved. Although facilitation that results in negative outcomes can be taxing, so can successful facilitation because of the inevitable setbacks in pursuit of goal attainment. Facilitation involving multiple non-face-to-face contacts per week with several teams over an extended period can be especially taxing, as the potential fatigue associated with implementation successes and challenges is experienced across sites.
Through a review of templated reflections and debrief session notes, and in discussions during weekly CTAC team meetings, we identified nine facilitation challenges:
Lack of progress or follow-through from the team on key project metrics.
Changes to the team from staff turnover or loss of interest.
Emotion/frustration directed at the facilitator, such as from lack of project progress or added burden on staff to complete project tasks.
Mismatched expectations between the facilitator and the team, such as when the primary care team expects the facilitator to implement the project alone.
Managing project timeline and deliverables as they relate to the QI project, as well as project evaluation deliverables.
Supporting QI methods and data collection, including providing education around QI strategies and data analysis.
Managing team dynamics, such as between team members with a history of conflict or between co-champions or leaders with conflicting priorities.
Promoting effective communication between the team and the facilitator, and within the team.
Documenting implementation and facilitation progress through project tracking systems for purposes of oversight, replication and recall.
Facilitation intensity and facilitator morale
The intensity of facilitation needed to address facilitation challenges varies based on numerous relational and contextual factors. Implementation intensity has been defined as ‘a quantitative measure of the amount of input to, or activity to support, the implementation’ of a programme or innovation.21 Building on this definition, we define facilitation intensity as a quantitative and/or qualitative measure of both the facilitation tasks and activities needed to engage and motivate implementation, and the psychological impact on the facilitator of delivering the tasks and activities. Thus, the intensity with which each facilitator experiences each facilitation encounter (eg, CTAC facilitation call) can vary even when other design factors, such as encounter duration and frequency, remain constant.
Facilitation challenges and recommendations to address them
From the CTAC facilitators’ reflections and debrief session notes, we identified two examples of facilitation challenges that required significant facilitation intensity to resolve. Both examples illustrate how facilitation effectiveness may be negatively impacted by these challenges if facilitators are not well supported:
Changes to the team
Changes in clinic staffing were not unusual during the CTAC project period, particularly among the clinic champions and other key team members and clinic leadership (supervisors and managers). Promotion to a different role, coverage for colleagues on leave and assignments to other VA clinic sites for extended periods of time were common reasons for team changes. Short absences, even from the clinic champion, were easily absorbed by remaining team members temporarily providing coverage. Permanent absences were more disruptive. The obvious resolution was to find appropriate replacements for the absentees; however, the consequences of that change—delays to the project timeline, the need to re-establish the team’s working dynamic, and bringing the new member, especially a new champion, ‘up to speed’—required higher-intensity facilitation to resolve.
Emotion/frustration directed at the facilitator
In training, facilitators are often cautioned to anticipate emotional and contested exchanges between members of the team, but rarely does training address emotional exchanges between members of the team and the facilitator. In high-intensity facilitation such as CTACs, opportunities for conflict are numerous and can become frequent if not properly managed. One CTAC site, for example, was completing usability testing on a clinic brochure to finalise it prior to printing and distribution. Two team members insisted on printing and distribution after completing only half the number of usability testing surveys planned. When the facilitator explained why it was important to collect more surveys, one team member became frustrated and exclaimed:
Whatever you want to do. If you want us to keep going, we’ll keep going…if you want us to collect more we will collect more data. We’re saying let’s go ahead and proceed and you’re kicking back on us, saying no!
The facilitator’s inability to see the team (a limitation of phone-based facilitation) made it difficult to assess the nature of the outburst and to determine if other team members felt similarly frustrated. Simultaneously, the facilitator was dealing with her own internal emotional reaction to being verbally confronted. How facilitators respond to emotional exchanges directed at them by the team can impact both the facilitator’s own perceptions of her continued ability to facilitate, and how the facilitator is viewed, responded to and relied on for the remainder of the facilitation period. Having tools to anticipate and address these challenges can build resilience.
CTAC facilitators found the facilitation challenges to be inter-related, not mutually exclusive and often experienced simultaneously. Table 1 outlines practical actions from the CTAC facilitators’ experiences that other facilitators may use to address similar challenges.
Successful QI requires a systems-based view of healthcare beyond the role of individual clinicians and the evidence-based practices that can be implemented at the point of care.22 Sustaining QI requires time, resources, motivation, data collection and analysis, achievable goals and early victories, adaptation, persistence, patient involvement, constructive criticism, acceptance of imperfection, and ongoing efforts integrated with managerial and operational priorities.6 To execute this type of QI requires skilled staff, which healthcare systems are increasingly hiring.7 Practice facilitators with operations and managerial knowledge, behavioural and team dynamics skills, and project management and QI expertise can play a pivotal role in promoting and supporting multilevel change.
However, the high-intensity facilitation associated with successful change18 can be mentally and emotionally taxing for facilitators and may result in facilitators experiencing similar burnout to the clinical teams they support, potentially defeating the purpose of facilitation. Healthcare systems can proactively enhance resilience among their facilitator workforce through training, mentorship and protected time for facilitator reflection. Equipped with specific guidance, like the recommendations made in this paper and others proposed in the literature to handle stress,23 facilitators may be better equipped to anticipate and respond to known challenges.
Grounded in the CTAC facilitators’ experiences, we identified common facilitation challenges and made recommendations to address them. Without these strategies and other resources, such as the built-in debrief sessions and protected time for self-reflection, CTAC facilitators could have become overwhelmed with the diversity of tasks required of them. Reminding facilitators that these challenges are inherent in the ebb and flow of QI and providing them with appropriate resources to anticipate, prevent and address these challenges may mitigate burnout and support facilitator morale. Debrief sessions, for example, allowed CTAC facilitators to work through challenges with active sites and to gauge the effectiveness of recommended strategies before using them with future sites.
Understanding how the experience of facilitation impacts facilitator effectiveness, and how facilitator support may minimise burnout and improve morale, is needed to address gaps in extant literature. Improved facilitator satisfaction may, in turn, promote sustainability of high-quality facilitation for continued QI. Future research could provide concrete examples of how to enhance resilience in the facilitator workforce and establish an evidence base for effective support strategies to promote facilitator resilience.
Contributors All authors included in this paper fulfil the criteria of authorship by contributing substantially to the design of the work and drafting of the paper. No one else who fulfils the authorship criteria has been excluded as an author.
Funding This study was funded by Quality Enhancement Research Initiative (QUE 15-276).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.