Implementation of Quality Improvement Skills by Primary Care Teams: Case Study of a Large Academic Practice

Abstract

Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects.
To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams.
We obtained qualitative and quantitative information about existing primary care team QI initiatives.
Eleven interdisciplinary primary care teams and 4 facilitators/coaches.
We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators.
In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress.
In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

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Journal of Primary Care & Community Health
2014, Vol. 5(2) 101 –106
© The Author(s) 2014
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DOI: 10.1177/2150131913520601
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Case Study
Introduction
Background Knowledge
Improving care delivery through evidence-based continu-
ous quality improvement (QI) is a key component of the
patient-centered medical home (PCMH) model.1-3 PCMH
team members are expected and encouraged to work
together to implement improvement initiatives to enhance
the quality of care for their patients. In theory, the PCMH
model is well suited to QI work because of its emphasis on
longitudinal multidisciplinary patient-centered collabora-
tions.4,5 However, little is still known about QI work
within the context of PCMH teams6,7 despite the recent
rapid uptake of the PCMH model by large health care sys-
tems such as the Veterans Health Administration (VHA).8
To begin to address this knowledge gap, we initiated an
examination of QI work in our local PCMH clinic
environment.
Local Context
Our large academic primary care practice converted to a
PCMH care model in May 2011. This transformation was
part of VHA’s (our clinic’s health care system) large-
scale effort to move to the PCMH model (known within
VHA as patient-aligned care teams or “PACT”).8 As part
of PCMH implementation, clinical staff engagement in
QI work was encouraged via several system-wide initia-
tives, including distribution of nationally developed
520601JPCXXX10.1177/2150131913520601Journal of Primary Care & Community HealthWatts et al
research-article2014
1Louis Stokes Cleveland Department of Veterans Affairs Medical Center,
Cleveland, OH, USA
2Case Western Reserve University School of Medicine, Cleveland,
OH, USA
Corresponding Author:
Brook Watts, Louis Stokes Cleveland Department of Veterans Affairs
Medical Center, 10701 East Boulevard (111W), Cleveland, OH 44106, USA.
Email: brook.watts@va.gov
Implementation of Quality Improvement
Skills by Primary Care Teams: Case
Study of a Large Academic Practice
Brook Watts1,2, Renée H. Lawrence1, Simran Singh1,2, Carol Wagner1,
Sarah Augustine1,2, and Mamta K. Singh1,2
Abstract
Background: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a
key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within
the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI
projects. Objective: To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to
(b) develop action plans to facilitate QI work into primary care teams. Design: We obtained qualitative and quantitative
information about existing primary care team QI initiatives. Participants: Eleven interdisciplinary primary care teams
and 4 facilitators/coaches. Methods: We conducted unstructured interviews and gathered documentation from primary
care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators.
Results: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described
multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim
statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an
intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement
a project credited a data/informatics facilitator for their progress. Conclusions: In this large academic primary care clinic
setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few
sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of
QI initiatives by primary care teams were identified.
Keywords
primary care, patient-centered care, patient care team, quality improvement

102 Journal of Primary Care & Community Health 5(2)
materials that encouraged team-centered QI activities and
discussions of QI-related topics at national PCMH meet-
ings.9 In our local context, a variety of QI training oppor-
tunities were offered, including (a) basic training in
QI-specific methodology (2 separate 2-hour sessions) and
(b) a 2-day Yellow-Belt Lean Six Sigma certification pro-
gram that covered introduction to QI methodology, iden-
tification and incorporation of optimal tools to address
clinical quality challenges, and completion of a final writ-
ten test for certification.10
Additionally, consistent with prior work suggesting that
formal training in QI may not be sufficient for successful
implementation of improvement techniques,11-13 other
QI-specific resources were also provided to staff: at least 2
hours weekly without direct patient care responsibilities,
open access to local QI experts, assistance with data gath-
ering, and access to a project coach with Lean Six-Sigma
master black belt certification.
Here, we report a case study to better understand how
successful resources have been at enabling QI work by
PCMH teams. We examine (a) progress of QI work and
(b) the barriers and/or facilitators to QI work reported
by PCMH teams. We use the Standards for Quality
Improvement Reporting Excellence (SQUIRE) frame-
work to report our findings.14
Methods
Data Collection and Analysis
In order to understand QI project progress and to identify
challenges and facilitators to QI work, we performed unstruc-
tured interviews with PCMH team members. Face-to-face
discussion occurred with at least one member of each of the
clinical teams, and in most cases, multiple members.
Consistent with frameworks for understanding factors related
to successful implementation (eg, RE-AIM: Reach
Effectiveness Adoption Implementation Maintenance; CFIR:
Consolidated Framework for advancing Implementation
Research),15,16 these interviews were used in conjunction
with documentation (eg, aim statements) gathered from team
members to characterize the team QI work and to identify
challenges and facilitators to project implementation.
Ethical Issues
Discussions with team members were informal and volun-
tary. No names are included in the summary of projects,
though local identification of specific team projects is pos-
sible. To ensure a variety of perspectives, we sought author-
ship representation on this article to include facility clinical
(SA) and quality (BW) leadership, PCMH providers (SS,
MKS), and a PCMH nurse case manager (CW).
Setting
Our work focused on the Louis Stokes Cleveland Veterans
Affairs Medical Center outpatient primary care clinic
site, an inner-city campus with numerous physician and
nurse practitioner trainees. Within the clinic, there are 11
PCMH teams, each with a panel of approximately 1000
patients. Each team is composed of a physician or nurse
practitioner provider, a registered nurse (RN) care man-
ager, a licensed practical nurse, and a clerical staff mem-
ber. Other supporting clinical staff (eg, pharmacists,
social workers, mental health providers) are readily avail-
able in the clinic setting. The standard VHA comprehen-
sive electronic medical record is used for all clinical
documentation.
Results
Quality Improvement Implementation Progress:
Alignment With QI Standards?
Table 1 presents the key findings related to team QI work.
Overall, despite available resources, little progress con-
sistent with QI standards was reported. All eleven PCMH
teams in our primary care clinic are represented (100%
sample). Each team identified a focus for a team project.
The first 2 projects listed in Table 1 did not identify an
intervention as a starting point; thus 9 of the 11 projects
(82%) demonstrated a choice of project focus consistent
with QI work standards. In the 18-month follow-up
period, none of the teams developed a formal aim state-
ment for their project. Eight of the 11 teams (73%) devel-
oped any type of project plan beyond the initial team
discussion. Of the 4 teams that implemented a change
(last 4 rows of Table 1, representing 36% of the 11 proj-
ects), 2 of the initiatives are still in place, both sustained
by the same nurse care manager, though no assessment of
the impact of the change has taken place. None of the
teams completed assessment of change impact or reported
any further changes they had made as a result of project
assessment.
Implementation Challenges and Facilitators
Table 2 summarizes themes identified from interviews
related to challenges to and facilitators of QI work. Although
traditionally accepted facilitators (eg, QI training, leader-
ship buy-in) were in place, QI work remained limited sug-
gesting the barriers outweighed the facilitators. For
example, only 1 of the 11 teams (9%) met (only once) with
an improvement coach despite awareness and availability
of this resource.

Watts et al 103
Table 1. Summary of Patient-Centered Medical Home (PCMH) Team Projects and Assessment of Alignment with Quality
Improvement (QI) Standards.
Team Intended Project Focus
Information Provided by Team Member(s)
Regarding QI Project Progress
Alignment With QI Work
Standards?
1 Identify patients who do not receive
their primary care from VA to
evaluate impact on performance
measures
• Added a structured question to provider
note
• A team member reviews data monthly
• No changes to practice have been made
Starting point was not an
intervention/improvement;
need to think about change
concepts
2 Identify components of best practices
for PCMH RN
• Met with several RN Care Managers
• Unable to identify specific area for focus
• Did not continue working on project
Starting point was not an
intervention/improvement;
need to think about change
concepts
3 Improve the check-in process • Felt too many variables were involved
• Couldn’t identify a target for improvement
• Stopped working on project
Too broad, need to narrow focus
by developing SMART aim
statement
4 Improve A1c control in team patients • Nurse to contact patients with poor control
• Time limitations made project sporadic
• Stopped working on project and are
focusing on new national program to
implement “Personalized Health Plan,” hope
this will address quality concern
Need to narrow focus by
developing SMART aim
statement; not team based
5 Increase immunizations for diphtheria,
tetanus, and pertussis
• Didn’t have time to work on project
due to competing demands
Realistic project focus, but lack
supporting data to indicate this
is a quality concern
6 Improve hypertension management • Nurse to contact patients with poor
control
• Not able to implement due to competing
clinical demands
• Stopped working on project and are
focusing on new national program to
implement “Personalized Health Plan,” hope
that this will address quality concern
Need to narrow focus by
developing SMART aim
statement; not team based
7 Decrease the number of team patients
who are going to the emergency
department
• Team was short-staffed for several months
(LPN left)
• Stopped working on project
Too broad; not team based;
limited stakeholder involvement
8 Improve clinic discharge instruction
template
• New template introduced
• Accessed informatics/data resource person
• Provider left practice, no other
providers use template
Not team based; limited
stakeholder involvement
9 Improve prostate-specific antigen
(PSA) screening for patients 50-75
years old
• Nurse distributed education material on
PSA screening to patient prior to seeing
provider
• Some data review completed for baseline but
required time-intensive manual chart review
• Stopped working on project
Jumped to intervention; focused
on “how” rather than exploring
solutions
10 Increase number of patients with low-
density lipoprotein (LDL) at goal
• Nurse used local registry to identify and
contact patients not at goal
• Accessed informatics/data resource person
• Ongoing monthly data reviews
• Results have not been evaluated
Jumped to intervention; not
team based; person’s behavior
changed, not the system
11 Increase number of patients with
hemoglobin A1c less than 8%
• Nurse used local registry to identify and
contact patients not at goal
• Accessed informatics/data resource person
• Ongoing monthly data reviews
• Results have not been evaluated
Jumped to intervention; not
team based; person’s behavior
changed, not the system

104 Journal of Primary Care & Community Health 5(2)
Discussion
Summary
Despite leadership support, formal education sessions, ded-
icated nonclinical time, and availability of QI coaches, none
of the teams completed a single plan–do–study–act cycle.
Our findings underscore recent suggestions in the literature
that time and educational resources may not be sufficient
for frontline teams to engage in QI work.17,18 Based on the
feedback from the 11 teams and our observations of the pro-
cess, we developed a cause–effect diagram (Figure 1) to
organize the factors identified in Table 2 structuring the
“effect” as the desired outcome: Successful PCMH QI
Project. Our goal was to enable action plans to improve the
quality and quantity of QI projects in the PCMH teams.
Relation to Other Evidence
The upper half of the Figure 1, “Basic Foundation,” outlines
traditionally acknowledged factors (“causes”) of successful
QI work that are well established in the literature, for exam-
ple, get leadership support and buy-in, choose relevant proj-
ects5,18 and are consistent with the facilitators identified by
our teams. These factors and their subcomponents may pro-
vide a necessary foundation for QI work but were not suf-
ficient to propel progress in our clinical environment.
The lower half of Figure 1, “Moving Beyond Basics,”
summarizes the novel factors and their subcomponents we
identified through this evaluation initiative: Structuring
Resources, PCMH Team Development (or “PCMH
Maturity”) and System Alignment. The “Moving Beyond
Basics” factors align conceptually with the established fac-
tors; however, potentially unique nuances are identified in
the subcomponents. Further investigation will be necessary
to determine the relative importance of these factors and
their subcomponents to QI work within the PCMH model
and to develop strategies to address them.
Interpretation and Next Steps
Specifically, development of strategies to address the
“Moving Beyond Basics” factors and subcomponents may
be important to achieving the transformative potential of
the PCMH model to facilitate successful QI work. Based on
our findings and examination of the existing literature,
below we provide some preliminary strategies that may be
helpful to translate the 3 identified factors into actionable
next steps:
1. Structuring resources—ensuring that teams do not
have competing demands or that time allotment is
done in a way to make it conducive for teams to work
together. Strategies for implementation may include
asking the team to identify a set meeting time each
week, facilitating scheduling so that all team mem-
bers can attend, providing space for the meeting, and
requesting routine documentation of the results of the
team meeting.
2. PCMH team development—recognizing the impor-
tance of establishing a PCMH teams’ ability to work
together, including meeting staffing requirements,
before engaging in QI initiatives. This component
acknowledges that expectation of QI activities may
be counterproductive when teams are struggling
with meeting the basic needs of their panel of
patients due to staffing deficiencies. Management
may be able to assist by providing teams with a
timeline of expectations (eg, “WHEN the LPN posi-
tion is filled, THEN we will plan on beginning our
QI meetings . . .”).
3. System alignment—aligning PCMH QI work trans-
parently with other performance metrics for a clinic
or facility. Although addressing this factor at a mini-
mum will require assistance from local quality man-
agement/regulatory groups, this would ideally be
Table 2. Summary of Facilitators and Challenges for Patient-Centered Medical Home Team Project Development and
Implementation.
Facilitators Identified in Team Interviews and
Resources Provided by Facility Challenges Identified in Team Member Interviews
System project champion Staff turnover/changes
Team members identified and working as a clinical
team with shared goals
Competing programs or priorities (eg, of the 3 teams who did not develop a
project plan, 2 teams (teams 5 and 6) identified competing clinical demands as a
reason that they were unable to proceed); incomplete team
Informatics/data resource person available,
knowledgeable, and helpful
No clear sense of focus (eg, team 3 stated that, despite initial enthusiasm, they
were unable to identify a focus for improvement), aim or measures
User-friendly information technology resources Not linked to performance assessment
Knowledge of quality improvement methodology/
tools
Unable to translate tools provided into doable projects
Allocated time No overlapping time for meeting as a team; competing demands create differential
use of allocated project time; separate activity from “job tasks”
Leadership support No clear sense of added value

Watts et al 105
guided by policy changes at the broader level. For
example, development of metrics to evaluate for the
presence of QI work in general may be one strategy.
Limitations
This work represents a single-site case study. However, our
clinic setting is similar to other large academic primary care
practices. In addition, we have 2 years’ experience with
integrating the PCMH care model into practice, which pro-
vides suggestions for other efforts to enable QI work to
become part of routine daily clinic practice, an important
consideration as this practice transformation continues to
spread throughout primary care.
Conclusions
Successful QI work in the PCMH model may require more
than formal education, dedicated time, and leadership sup-
port. We offer areas of further investigation and suggestions
that may ultimately facilitate the goal of sustainable inte-
gration of QI into daily practices of primary care teams.
Authors’ Note
The views expressed in this article are those of the authors and do
not necessarily represent the views of the Department of Veterans
Affairs.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
work was supported in part by the Veterans Health Administration
Office of Academic Affiliations grant titled, “Center of Excellence
in Primary Care Education.”
References
1. American Academy of Family Physicians (AAFP), American
Academy of Pediatrics (AAP), American College of Physicians
(ACP), American Osteopathic Association(AOA). Joint
principles of the patient-centered medical home. February
Figure 1. Cause–effect diagram of barriers and facilitators of patient-centered medical home (PCMH) quality improvement (QI) work.

106 Journal of Primary Care & Community Health 5(2)
2007. http://www.aafp.org/online/etc/medialib/aafp_org/doc-
uments/policy/fed/jointprinciplespcmh0207.Par.0001.File.
tmp/022107medicalhome.pdf. Accessed September 4, 2009.
2. Stewart E, Nutting P, Crabtree B, Stange K, Miller M, Jaén
CR. Implementing the patient centered medical home: obser-
vation and description of the National Demonstration Project.
Ann Fam Med. 2010;8(suppl 1):S21-S32.
3. Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC,
Jaén CR. Journey to the patient-centered medical home: a qual-
itative analysis of the experiences of practices in the National
Demonstration Project. Ann Fam Med. 2010;8(suppl 1):
S45-S56, S92.
4. Crabtree BF, Nutting PA, Miller WL, et al. Primary care
practice transformation is hard work: insights from a
15-year developmental program of research. Med Care.
2011;49(suppl):S28-S35.
5. Mills PD, Weeks WB. Characteristics of successful quality
improvement teams: lessons from five collaborative projects
in the VHA. Jt Comm J Qual Saf. 2004;30:152-162.
6. Dixon-Woods M, McNicol S, Martin G. Ten challenges in
improving quality in healthcare: lessons from the Health
Foundation’s programme evaluations and relevant literature.
BMJ Qual Saf. 2012;21:876-884.
7. Homer CJ, Baron RJ. How to scale up primary care trans-
formation: what we know and what we need to know? J Gen
Intern Med. 2010;25:625-629.
8. Klein S. The Veterans Health Administration: Implementing
Patient-Centered Medical Homes in the Nation’s Largest
Integrated Delivery System. Washington, DC: The
Commonwealth Fund; 2011.
9. Developing an infrastructure to support PCMH culture of
QI. http://www.hsrd.research.va.gov/for_researchers/cyber_
seminars/archives/679-notes.pdf. Accessed April 30, 2013.
10. Process improvement for healthcare: yellow belt training
and certification. http://weatherhead.case.edu/professional-
development/programs/process-improvement-for-health-
care.cfm. Accessed April 30, 2013.
11. Shojania KG, Grimshaw JM. Evidence-based quality
improvement: the state of the science. Health Aff (Millwood).
2005;24:138-150.
12. Pronovost PJ. Navigating adaptive challenges in quality
improvement. BMJ Qual Saf. 2011;20:560-563.
13. Boonyasai RT, Windish DM, Chakraborti C, Feldman
LS, Rubin HR, Bass EB. Effectiveness of teaching quality
improvement to clinicians: a systematic review. JAMA.
2007;298:1023-1037.
14. Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE
(Standards for Quality Improvement Reporting Excellence)
guidelines for quality improvement reporting: explanation
and elaboration. Qual Saf Health Care. 2008;17:i13-i32.
15. Glasgow RE, Vogt TM, Boles SM. Evaluating the public
health impact of health promotion interventions: the RE-AIM
framework. Am J Public Health. 1999;89:1322-1327.
16. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander
JA, Lowery JC. Fostering implementation of health ser-
vices research findings into practice: a consolidated frame-
work for advancing implementation science. Implement Sci.
2009;4:50.
17. Taylor EF, Machta RM, Meyers DS, Genevro J, Peikes DN.
Enhancing the primary care team to provide redesigned care:
the roles of practice facilitators and care managers. Ann Fam
Med. 2013;11:80-83.
18. Baskerville NB, Liddy C, Hogg W. Systematic review and
meta-analysis of practice facilitation within primary care set-
tings. Ann Fam Med. 2012;10:63-74.
Author Biographies
Brook Watts, MD, MS, is Chief Quality Officer at the Cleveland
VAMC and Associate Professor at Case Western Reserve
University School of Medicine.
Renée H. Lawrence, PhD, is a senior research and implementa-
tion scientist at the Cleveland VAMC with quality improvement
expertise.
Simran Singh, MD, is Associate Chief of Staff for Education
Safety at the Cleveland VAMC and Assistant Professor at Case
Western Reserve University School of Medicine.
Carol Wagner, RN, BSN, is a Nurse Care Manager in the Primary
Care Clinic at the Cleveland VAMC.
Sarah Augustine, MD, is Associate Chief of Medicine at the
Cleveland VAMC and Associate Professor at Case Western
Reserve University School of Medicine.
Mamta K. Singh, MD, MS, FACP, is the Physician Director for
the Center of Excellence in Primary Care Education at the
Cleveland VAMC and Associate Professor at Case Western
Reserve University School of Medicine.