By Dr. Oona Hayes
Quality improvement (QI) work and data-driven practice improvement are vital tools that support Joy in Work, lifelong learning and system improvement. Clinician engagement with data-driven practice improvement is also one of the priorities of the Family Practice Services Committee (e.g. panel management). There are calls for “more data” to support health care system change yet moving from our current system to one informed and supported by data is a massive effort in change management. As one of the medical directors at the Health Data Coalition, I’m passionate about promoting the use of data to transform primary care at a practice and community level. The following outlines my thoughts on the key factors that promote primary care clinician engagement with QI and data-driven practice improvement.
The Prosci “ADKAR” change management science framework helps me categorize the factors that promote clinician engagement with data-driven practice improvement and QI. The “ADKAR” model refers to the sequential steps change leaders must satisfy to engage individuals successfully in change – Awareness, Desire, Knowledge, Ability, Reinforcement. Clinicians reading this will see the parallels to motivational interviewing science. The Prosci model understands that organizational change is dependent on successful engagement of individual constituents. It’s worth highlighting again that these steps are sequential and therefore, later steps will not be effective if earlier steps are not satisfied.
Clinicians need to first have an awareness of what is being asked of them and why. When I did my medical training and residency, teaching focused on the care of individual patients. There was an awareness of “population” health and “public health”, but its practice was deferred to those who specialized in that area. Charting was done on paper, and this limited the ability to look for trends in larger groups of patients. Medical training is still focused on the care of the individual patient while we are being asked to care for our attached patient population by ensuring that an increasing proportion of them have access to our services while:
- ‘choosing wisely’;
- promoting increased evidence-based anticipatory guidance, screening and prevention measures;
- recalling people with chronic disease;
- providing access to care, continuity of care as well as care coordination;
- providing supports for or advocating for the social determinants of health (e.g. income in the face of injury or disability, reduced prescription costs, social connection, education, impacts of colonization and other traumas), which arguably make the biggest difference to health status.
Population health is primary health and clinicians take care of patients and communities. Data from our practices helps us understand the factors impacting our patients’ health. The advent of electronic medical records (EMRs) has created the ability for clinicians to easily look at practice-level data. Looking at aggregate patient data reveals trends that bring insights into the health status and needs of larger groups. Clinicians can use practice and community level data to consider ways of working differently to meet the needs of their community, such as working with other health professionals.
Secondly, clinicians must desire the change, they must be motivated to engage in activities that support change. Extrinsic motivators, such as financial incentives, can be helpful but they are unlikely to support lasting change. Intrinsic motivation, doing something because you feel it’s the right thing to do, is powerful but cannot be relied upon in the absence of other enablers of change. Unfortunately, asking clinicians to change will cause some to feel threatened and then be less likely to change. Our brains are wired for survival and constantly scan for perceived threats. Dr. David Rock’s NeuroLeadership model shows that humans can react negatively if they perceive threats to five social domains: Status, Certainty, Autonomy, Relatedness and Fairness. Change will always affect a person’s sense of certainty and other social domains may be threatened as well. For clinicians to desire change, they need to know their concerns are being meaningfully addressed. One common concern is that doing QI and data-driven practice improvement takes extra time from patients or from the clinician time outside of work. Clinicians might simply be unable to provide extra time or effort to change efforts when there are so many other urgent asks of their time. Asking a clinician to take on extra work without taking away other work will trigger a sense of injustice and result in inaction. These social domains can be used to bolster motivation, as well. Primary care clinicians interface with all other aspects of the health and social welfare systems and recognize there is an urgent need for change in other areas to support patients. Clinicians will be more likely to desire change if they know there will be meaningful change in multiple parts of the system that impacts patients, not just theirs. Intrinsic motivation for data-driven practice change could be increased by linking its use to continuing professional development/professional status. Medical practice requires a commitment to life-long learning to stay up to date with developments in the field. We are not just learning from experts and studies, though, we learn from our patients and our experience and must translate this new knowledge into practice. Clinicians could be shown how QI can increase their control over the aspects of their practice that matter to them. Clinicians will be more motivated to engage in changes if they can be assured that there will be more certainty and agreement about: what is being asked of them; fears of loss of professional autonomy and independence; as well as the sustainability and depths of supports available to patients and the clinicians holding the responsibilities of attachment.
The knowledge of how to do QI and data-driven practice improvement is well supported in B.C. through the Physician Quality Improvement (PQI) Initiative and the Practice Support Program (PSP). The HDC Discover application is a free tool that clinicians can use to do QI on their practice and to contextualize their practice data to others in the province. Community level data also provides insights that can inform other supports, such as Primary Care Networks or Divisions of Family Practice.
Clinicians’ ability to engage in QI and data-driven practice improvement is maximized by ensuring obstacles to implementation are managed and that their confidence in this new competency is supported by mentors or coaches.
Finally, these skills and changes need reinforcement. Clinicians need to implement these skills on an ongoing basis. Making data-driven practice improvement part of the ongoing workflow in primary care will take time. The hope is that practice improvements will improve joy in work and patient care, reinforcing and sustaining change. However, change is often not linear, and it can invoke unintended consequences or “failures”. Learning and pivoting from these is part of QI methodology and is best facilitated by having a robust awareness and trust in the overarching aim and one’s knowledge and ability to change. HDC Discover is a tool that provides clinicians with ongoing feedback on measures relating to panel management and quality improvement. Clinicians can use data from HDC Discover to track measures over time. The momentum of groups of clinicians working on practice improvement will hopefully reinforce each other’s efforts, as HDC Discover also tracks community level data.
One key to enabling a shift to ongoing data-driven practice improvement and quality improvement in health care is to support this change for the individual clinicians delivering the care. Each step of the “ADKAR” model needs to be addressed before moving on to the next one and eventual success. Clarifying the specific changes individual clinicians are being asked to adopt and what success looks like will help build understanding and momentum. The desire to change will increase if clinicians feel their concerns are heard and addressed. The key factors are present in BC. Supports such as the PQI, PSP and HDC enable clinicians to learn and practice these new skills. We must move to a more data informed and supported health system. I look forward to working with our partner organizations to promote, support and sustain clinician engagement with data for practice improvement and positive changes to patient and community care in B.C.
Let me know what you think would help advance clinician engagement with data-driven practice improvements or if you want to take advantage of the available practice supports. Please contact me here.