A CULTURE OF QUALITY IMPROVEMENT: THE PRINCE GEORGE COACHING MODEL
Background
The Prince George Division of Family Practice (PG Division) was selected as a prototype community for the Attachment Initiative (AGP4Me) in June of 2010. The Division already had a good sense of the needs in the community and the broad strokes of a vision and strategy for going forward (the official Vision and Strategic Directions document - Appendix 1 - was not completely articulated and formalized until late 2011). It was felt that increasing the job satisfaction of the existing physicians as well as supporting them to find efficiencies and build capacity within their offices was a necessary part of the strategy. A portion of the attachment funding was immediately allocated to this support and in December of 2012 the person with the ‘right fit’ to move this vision forward was found. With a combination of clinical and quality improvement knowledge, as well as previous success engaging physicians in improvement activities, she immediately began coaching in Family Practice offices in Prince George. With this, the concept of ‘by the shoulder coaching’ in physician practices was born in BC.
By March 2011, through the financial support of the Maximizing Clinical Value Project (PITO), there was already phenomenal uptake and success. Twenty practices were deeply engaged in analyzing their practice data and were using this to make significant improvements in patient care and office efficiency.
The PG Division began to be convinced that coaching was the way forward for quick and deep engagement of Family Physicians in meaningful self-reflection and practice improvement. With the belief that the trust physicians had already placed in Divisions made them the ideal vehicle for a coaching program, the PG Division began to request further funding to support the development of this initiative. In the spring of 2012 GPSC responded to the request and the Integrated Practice Support
Initiative (IPSI) was created.
By bringing together the Northern Health (NH) Regional Support Team (PSP Program), NH Integrated Primary and Community Care Program work, and other Provincial programs like PSP, PITO, AGP4Me and the Provincial Divisions Office, IPSI allowed the PG Division to strengthen important partnerships, and demonstrate how integration could work in the community.
It is important to acknowledge that none of this could have happened without a very strong relationship with the Health Authority. Northern Health and the PG Division have forged a partnership that, as both are very aware, is essential to achieving success toward the shared vision. It is a strong, authentic, and resilient relationship in all aspects of the varied work accomplished together, including: practice support, Integrated Primary and Community Care Program (IPCCP), in-hospital primary care for both Assigned and Unassigned patients, Residential Complex Care, and Healthy Communities, to name a few.
All of these opportunities and resources have been essential building blocks for the model described in this document, a model that is truly a ‘Culture of Quality Improvement’ and often referred to as ‘The Prince George Coaching Model’.
The coaching model draws closely on the Vision and Strategic Directions on which all of the Prince George Division work is based (see Appendix 1) and is closely allied with the Northern Health Vision and Strategic Plan.
By March 2011, through the financial support of the Maximizing Clinical Value Project (PITO), there was already phenomenal uptake and success. Twenty practices were deeply engaged in analyzing their practice data and were using this to make significant improvements in patient care and office efficiency.
The PG Division began to be convinced that coaching was the way forward for quick and deep engagement of Family Physicians in meaningful self-reflection and practice improvement. With the belief that the trust physicians had already placed in Divisions made them the ideal vehicle for a coaching program, the PG Division began to request further funding to support the development of this initiative. In the spring of 2012 GPSC responded to the request and the Integrated Practice Support
Initiative (IPSI) was created.
By bringing together the Northern Health (NH) Regional Support Team (PSP Program), NH Integrated Primary and Community Care Program work, and other Provincial programs like PSP, PITO, AGP4Me and the Provincial Divisions Office, IPSI allowed the PG Division to strengthen important partnerships, and demonstrate how integration could work in the community.
It is important to acknowledge that none of this could have happened without a very strong relationship with the Health Authority. Northern Health and the PG Division have forged a partnership that, as both are very aware, is essential to achieving success toward the shared vision. It is a strong, authentic, and resilient relationship in all aspects of the varied work accomplished together, including: practice support, Integrated Primary and Community Care Program (IPCCP), in-hospital primary care for both Assigned and Unassigned patients, Residential Complex Care, and Healthy Communities, to name a few.
All of these opportunities and resources have been essential building blocks for the model described in this document, a model that is truly a ‘Culture of Quality Improvement’ and often referred to as ‘The Prince George Coaching Model’.
The coaching model draws closely on the Vision and Strategic Directions on which all of the Prince George Division work is based (see Appendix 1) and is closely allied with the Northern Health Vision and Strategic Plan.
Vision
All citizens of Prince George will have access to quality, coordinated, sustainable, integrated, longitudinal care in an appropriately supported Primary Care Home that is integral to improving quality of life for all.
Strategic Direction
Developing and supporting excellent Primary Care Homes
A primary care home is where people establish a long term relationship with a multidisciplinary team that includes a physician and through this team receive health care and are supported in managing their own health.
A primary care home is where people establish a long term relationship with a multidisciplinary team that includes a physician and through this team receive health care and are supported in managing their own health.
Principles
1. Physicians for Physicians
Quality improvement in primary care should always be physician lead. As the Primary Care Home is where the majority of primary care occurs, physicians have a unique viewpoint on where quality improvements can be effective within the system. As a result, uptake of initiatives will be stronger if they are seen to be physician lead and have substantial physician input. A strong collective voice for Family Physicians is essential for the success of Primary Care reform.
2. Data Driven
Data drives change. We believe that creating opportunities to look at individual practice data and comparing to evidence-based standards and population data creates a culture of quality improvement that results in better health outcomes for patients. To do this well, accurate real-time data at both a practice and population level is essential.
3. Partnerships
Transformation is not possible without partners. In order to have sustained system-wide change it is crucial that we join with others and align our resources and strategies towards the same vision. As a group of physicians we can do things that are significant within our own realm, but these are small in comparison to the needs and what can be achieved through partnerships.
4. Collective Responsibility for Collective improvement
The whole is bigger than the sum of its parts. Every member, employee and partner feels individual responsibility and accountability for the success of the whole in achieving the vision: everyone has a role in driving change, everyone coaches everywhere.
Quality improvement in primary care should always be physician lead. As the Primary Care Home is where the majority of primary care occurs, physicians have a unique viewpoint on where quality improvements can be effective within the system. As a result, uptake of initiatives will be stronger if they are seen to be physician lead and have substantial physician input. A strong collective voice for Family Physicians is essential for the success of Primary Care reform.
2. Data Driven
Data drives change. We believe that creating opportunities to look at individual practice data and comparing to evidence-based standards and population data creates a culture of quality improvement that results in better health outcomes for patients. To do this well, accurate real-time data at both a practice and population level is essential.
3. Partnerships
Transformation is not possible without partners. In order to have sustained system-wide change it is crucial that we join with others and align our resources and strategies towards the same vision. As a group of physicians we can do things that are significant within our own realm, but these are small in comparison to the needs and what can be achieved through partnerships.
4. Collective Responsibility for Collective improvement
The whole is bigger than the sum of its parts. Every member, employee and partner feels individual responsibility and accountability for the success of the whole in achieving the vision: everyone has a role in driving change, everyone coaches everywhere.
Governance Structure for the Coaching Model
The following committees and working groups make up the core of the Prince George model and
coaching structure. See Appendix 2 for structure schematic.
The Division of Family Practice board: The nine elected and two ex-officio members (Chief Medical Information office of Northern Health and the Head of the Department of Family Practice) of the board represents the 105 Family Physicians of Prince George who are members of the Division.
Joint Leadership Committee: The Division board and senior staff, and Northern Health leadership make up the joint leadership committee (with mechanisms for engaging others, for example patients or municipal government). The Board and the Joint Leadership Committee provide guidance to the work of the following committees and working groups.
Committee Supporting Primary Care Homes: A sub-committee of the Division Board, which assesses and applies quality improvement strategies as needed to all aspects of primary care from inside the practice, as well as working with others where primary care interfaces with the larger health care system and the community. Membership includes: five physicians, the Division Executive Director, the Division Clinical Programs Lead, Practice Coaches, and the Prince George Primary Care Lead (NH). Other frequent contributors include the NH Regional Support Team Lead (PSP) and the Applied Informatics for Health
Society (AIHS – EMR Vendor).
Integrated Health Services Steering Committee: A Prince George steering committee, co-chaired by the NH Health Services Administrator and Division Executive Director to provide oversight and guidance to the implementation of Integrated Primary and Community care and how the larger health care system interfaces with Family Physician’s Practices. Membership includes: the NH Directors of Mental Health and Addictions, Community Care, Acute Care, and Population Health; the PG Division physician lead; NH Physician lead; and a patient representative.
coaching structure. See Appendix 2 for structure schematic.
The Division of Family Practice board: The nine elected and two ex-officio members (Chief Medical Information office of Northern Health and the Head of the Department of Family Practice) of the board represents the 105 Family Physicians of Prince George who are members of the Division.
Joint Leadership Committee: The Division board and senior staff, and Northern Health leadership make up the joint leadership committee (with mechanisms for engaging others, for example patients or municipal government). The Board and the Joint Leadership Committee provide guidance to the work of the following committees and working groups.
Committee Supporting Primary Care Homes: A sub-committee of the Division Board, which assesses and applies quality improvement strategies as needed to all aspects of primary care from inside the practice, as well as working with others where primary care interfaces with the larger health care system and the community. Membership includes: five physicians, the Division Executive Director, the Division Clinical Programs Lead, Practice Coaches, and the Prince George Primary Care Lead (NH). Other frequent contributors include the NH Regional Support Team Lead (PSP) and the Applied Informatics for Health
Society (AIHS – EMR Vendor).
Integrated Health Services Steering Committee: A Prince George steering committee, co-chaired by the NH Health Services Administrator and Division Executive Director to provide oversight and guidance to the implementation of Integrated Primary and Community care and how the larger health care system interfaces with Family Physician’s Practices. Membership includes: the NH Directors of Mental Health and Addictions, Community Care, Acute Care, and Population Health; the PG Division physician lead; NH Physician lead; and a patient representative.
Coaching Strategy
The coaching strategy is an over-arching framework for all practice improvement in Primary Care Homes in Prince George. While it is dependent on a robust EMR and accessible accurate practice and population data, it is not just about EMR optimization. It is about the meaningful use of all types of data to objectively assess and plan strategic improvements in all aspects of patient care from office flow to complex care for individual patients. It draws on many teaching and learning methodologies to support
physicians and their practice teams as they strive towards a common vision of quality Primary Care. The methodologies currently available in Prince George include: one-on-one coaching, peer mentoring, group learning, and other reflective practice opportunities (corridor conversations, Family Practice Resident audits).
One-on-one Coaching
Provided by non-physician coaches, guided by the Dartmouth Coaching Model (see Appendix 4). Coaches are hired for ‘right fit’ and come from various backgrounds and disciplines, both professional and paraprofessional. They work with physicians and their practice teams to assess practice, analyze data, set goals, test change ideas, and evaluate / reinforce / sustain change (see Appendix 3 – Coach Improvement Approach). Coaching starts ‘where the physician is at’ and topics could range from office
management, to EMR optimization, to quality patient care.
Peer Mentoring
Both physicians and MOAs can be Peer Mentors. They are selected by the CSPCH and are usually ‘Super users’ or early adopters who are committed to the vision and strategic directions of the Division. Mentees are able to choose from a slate of available mentors. The support may vary from EMR optimization, billing, office tips, care planning, or chronic pain management etc. Peer mentoring is delivered in coordination with all other quality improvement activities including 1:1 coaching. Peer mentoring is the option of choice when topics are more clinically complex in nature or with physicians who are less engaged in quality improvement.
Group Learning
This includes traditional ‘peer-to-peer user groups’, McMaster Practice Based Small Group learning modules (PBSG), topic-specific sessions, UBC Family Practice Resident audit and research findings, and CME. These group learning sessions originate from, and are organized by, the Division of Family Practice and partners, and are guided by the CSPCH. All of these sessions have practice coaches either embedded or aligned to ensure spread of the learnings and continual building of the culture of quality improvement in Prince George.
Reflective Practice Opportunities
The culture of coaching in Prince George extends beyond formal sessions. Physicians take every opportunity to collaborate with their peers and reflect on their practice, for instance through informal support to colleagues in the Doctors’ lounge or corridor conversations. This is particularly common through the Division-led network for unassigned inpatients and residential complex care physician programs.
All of these strategies are brought together to form a united approach to the vision of practice improvement in Prince George. Coaches and mentors ‘chart’ on their work with individual physicians in a coaching instance of the MOIS EMR, which allows for tracking progress and successes over time, as well as providing coordination and communication between coaches. For instance, if a peer mentor has been involved with a physician in the past, a one-on-one coach going in to work on EMR optimization can see what has been achieved in past coaching sessions. Strategies can also be implemented with more than one person on the practice team when assisting a physician to reach their goals. For instance a physician who participates in a group session on chronic pain management may request assistance from a peer mentor in working chronic pain assessments into their flow of practice, while a 1:1 coach works with the MOAs to implement office flow and management changes that will assist the physician in completing these assessments. Together these strategies lead to a seamless approach to quality
improvement that allows physicians to access the most appropriate support for their needs.
physicians and their practice teams as they strive towards a common vision of quality Primary Care. The methodologies currently available in Prince George include: one-on-one coaching, peer mentoring, group learning, and other reflective practice opportunities (corridor conversations, Family Practice Resident audits).
One-on-one Coaching
Provided by non-physician coaches, guided by the Dartmouth Coaching Model (see Appendix 4). Coaches are hired for ‘right fit’ and come from various backgrounds and disciplines, both professional and paraprofessional. They work with physicians and their practice teams to assess practice, analyze data, set goals, test change ideas, and evaluate / reinforce / sustain change (see Appendix 3 – Coach Improvement Approach). Coaching starts ‘where the physician is at’ and topics could range from office
management, to EMR optimization, to quality patient care.
Peer Mentoring
Both physicians and MOAs can be Peer Mentors. They are selected by the CSPCH and are usually ‘Super users’ or early adopters who are committed to the vision and strategic directions of the Division. Mentees are able to choose from a slate of available mentors. The support may vary from EMR optimization, billing, office tips, care planning, or chronic pain management etc. Peer mentoring is delivered in coordination with all other quality improvement activities including 1:1 coaching. Peer mentoring is the option of choice when topics are more clinically complex in nature or with physicians who are less engaged in quality improvement.
Group Learning
This includes traditional ‘peer-to-peer user groups’, McMaster Practice Based Small Group learning modules (PBSG), topic-specific sessions, UBC Family Practice Resident audit and research findings, and CME. These group learning sessions originate from, and are organized by, the Division of Family Practice and partners, and are guided by the CSPCH. All of these sessions have practice coaches either embedded or aligned to ensure spread of the learnings and continual building of the culture of quality improvement in Prince George.
Reflective Practice Opportunities
The culture of coaching in Prince George extends beyond formal sessions. Physicians take every opportunity to collaborate with their peers and reflect on their practice, for instance through informal support to colleagues in the Doctors’ lounge or corridor conversations. This is particularly common through the Division-led network for unassigned inpatients and residential complex care physician programs.
All of these strategies are brought together to form a united approach to the vision of practice improvement in Prince George. Coaches and mentors ‘chart’ on their work with individual physicians in a coaching instance of the MOIS EMR, which allows for tracking progress and successes over time, as well as providing coordination and communication between coaches. For instance, if a peer mentor has been involved with a physician in the past, a one-on-one coach going in to work on EMR optimization can see what has been achieved in past coaching sessions. Strategies can also be implemented with more than one person on the practice team when assisting a physician to reach their goals. For instance a physician who participates in a group session on chronic pain management may request assistance from a peer mentor in working chronic pain assessments into their flow of practice, while a 1:1 coach works with the MOAs to implement office flow and management changes that will assist the physician in completing these assessments. Together these strategies lead to a seamless approach to quality
improvement that allows physicians to access the most appropriate support for their needs.