Appendix – Partnering With Other Groups

This manual and the accompanying tools are designed to guide you through the process of practice improvement. The manual emphasizes that improvement is a team sport, an activity that is most productive when you are able to meaningfully involve others at your practice. This appendix expands the bounds of the team idea to include partnering with other practices and organizations.

The focus of this partnering is to pool your efforts, to help each other meet the “Improvement in Practice” requirements of your medical specialty board that are part of a maintenance of certification process (or for some of you the requirements of the Accreditation Council for Graduate Medical Education). One or two times every three years, practicing physicians are required to complete a “Part 4 Maintenance of Certification” Improvement in Practice process that involves assessing quality of care, choosing and implementing an improvement plan, re-assessing, and learning from the process. It simply makes sense for groups to support each other in this when it is feasible and likely to be helpful to do so.

Most medical specialty boards certify one physician at a time, but recognize the value of partnerships that allow greater learning and more impactful practice improvement. The tips in this appendix are based on our experience in helping physicians in diverse practice settings to engage in a group approach to meeting Improvement in Practice requirements.1

There are three levels of partnership for practice improvement:

  1. with other physicians and colleagues in your own practice (as described in this manual),
  2. with other practices with which you have informal relationships (such as the practices of close colleagues, nearby practices, practices who happen to be affiliated with the same hospital(s) with whom you have noticed you have a lot in common, ditto with practices where the physicians belong to the same medical society or medical system, etc.) The hallmark of these relationships is that they tend to be informal. These informal relationships have usually been initiated and are sustained by you or your counterpart in the other practice.
  3. with groups with which you have an affiliation that might provide a support structure that could be used to support this sort of partnering around improvement efforts (your local medical society chapter, other professional organizations, affiliated hospitals, practice-based research networks, academic partners, quality improvement organizations, regional extension services, community or regional learning collaboratives, etc.)

Physicians in one Northeast Ohio program (www.jabfm.org/content/26/2/149.full) found that working with other physicians in their practice took a bit more work to get started compared to just starting a Part 4 Maintenance of Certification project on their own. But this extra work in talking with colleagues at the start was more than compensated for by the ability to conduct a more meaningful project, and by the ability get help from each other and from staff members. The steps for this collaborative approach are described in Chapters 1 & 2 in the manual – “Deciding What to Work On,” and “Building an Improvement Team.”

When it comes to reporting your individual contribution to the improvement effort to your board, it depends on the sort of project you are working on, but generally speaking, the change you make in your practice will be something that you all work on together. You’ll want to keep track of how that affected your particular group of patients (values at baseline and values after you have made your change). And you will want to keep notes about your individual contribution to the group effort. This means what you did well and what you think you might do differently in the future to improve your contribution to this kind of effort.

Since all physicians need to complete at least one, and up to two, Part 4 Maintenance of Certification projects every three years to maintain board certification, meeting this requirement together can be a way to start a conversation with other physicians or practices in your area that you think you might be able to learn from. You may see the possibility of providing some welcome mutual support to one another over an extended period of time.

Some partnering practices decide to try the same project and compare notes along the way at either the physician or the staff level via emails, phone conversations, lunch meetings, side conversations at other meetings, or other informal methods. Others decide to do the same baseline assessment, comparing notes concerning their initial data, but then each chooses their own particular piece to work on and their on particular approach to change intended to improve the situation. Then they share what they did and their outcomes to see what they are able to learn from one another’s respective efforts. Comparing notes at the end ensures not only that everyone learns from their own practice improvement project, but also that they learn what worked for others, and are then able to consider what they might want to adapt to their own settings and carry forward in the way of most workable approaches.

Almost all practices have some sort of affiliation that can serve as a foundation for group work to meet Part 4 Maintenance of Certification requirements. The easiest to begin are organizations in which physicians and/or their practice staffs already get together and can use these gatherings as venues to look for shared opportunities to collaborate in some fashion around their practice improvement work. This sort of partnering frequently enables those involved to take advantage of the opportunity to learn from the diversity of practice approaches that get shared, and to build on and in turn enhance organizational infrastructure.

Almost every locality has some venues where clinicians get together, and some organizations with a mission to support practice quality or improvement. Examples include: medical specialty society state and local chapters, other professional organizations, small hospitals, Quality Improvement Organizations (QIOs), Practice-Based Research Networks (PBRNs), Regional Extension Centers (RECs) that support electronic medical record implementation, various learning collaboratives, academic partners, and health-oriented voluntary and community organizations (including disease specific groups).

An Example

Physicians in a rural county were increasingly concerned about coordination of care at the time of discharge. Most of them provided this continuity themselves, but a growing number were having more hospital-based physicians take over some or all of the care for their hospitalized patients. At the same time, the local hospital was quite concerned about improving its post discharge coordination of care, given the new CMS reimbursement rules.

The hospital had been supporting, for some time, a regional Institute to support practice improvement among family practices affiliated with the hospital. Since physicians already were getting together periodically for this, the Institute provided a perfect focus for the physicians to work together on a common project that met MOC requirements, and engaged the resources of the hospital to support their work together.

The idea was to see if they could develop an enhanced system of communicating relevant information about patients to primary care practices at the time of discharge and working collaboratively to set up proximal post charge appointments. The physicians came up with questions to ask patients about their post-discharge experience. The hospital agreed to add these questions to the post-discharge survey they already conducted with patients, and to provide individual and group average reports to the physicians. Overall, they focused on the patient experience of ease and success getting a follow up appointment post-discharge.

This led to a group discussion over supper at the hospital conference room, and a general plan for a protocol for the discharging physician and staff working collaboratively with area practices to work to routinely schedule a follow up visit within 48 hours to one week, depending on the patients’ illness severity and social complexity. With this common intervention, each practice made its own decisions about how they would accommodate this in their schedules. The physicians/practices tried this out for two months, with a few calling each other to share experiences.

Then the hospital re-assessed with the patient surveys, and the physicians re-examined their individual and group data (over supper again). When two re-hospitalizations were discovered among patients with 7-day appointments, they refined the protocol to require an appointment or phone follow up for all patients within 72 hours. And based on sharing experience with how their staffs integrated these appointments, individual physicians made small adjustments at their practices. This was reported to the ABFM under the auspices of an “approved ABFM alternate module,” but also could be done as a “self-directed module,” and, soon, as a “patient experience module” that will be available to all ABFM Diplomates in the near future.

Increasingly, larger groups and organizations, including health systems, health networks, regional health Collaboratives, CMS funded Quality Improvement Organizations and some medical societies are offering or contributing to the support of practice improvement coaching or facilitation. Practice improvement coaches tend to be able to encourage and support better follow-through, greater teamwork within practices and more partnering across practices. If this sort of improvement coaching is available to you, you might well want to consider taking advantage of it. (Note: Coaches often support large, single issue improvement efforts – such as implementation of the Patient Centered Medical Home or a regional diabetes care initiative.) A supplemental resource (“Concise Practice Improvement Manual Coaching Guide”) has been developed to assist coaches supporting practices using this manual. Click here to open and download this guide.