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Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov

Contract No. HHSA290200900019I/HHSA29032006T

Prepared by:
Mathematica Policy Research
Princeton, NJ

Authors:

  • Kristin Geonnotti, Ph.D., Mathematica Policy Research
  • Erin Fries Taylor, Ph.D., M.P.P., Mathematica Policy Research
  • Deborah Peikes, Ph.D., M.P.A., Mathematica Policy Research
  • Lisa Schottenfeld, M.P.H, M.S.W., Mathematica Policy Research
  • Hannah Burak, B.A., Mathematica Policy Research
  • Robert McNellis, M.P.H., P.A., Agency for Healthcare Research and Quality
  • Janice Genevro, Ph.D., Agency for Healthcare Research and Quality

Principal Investigators:

  • Deborah Peikes, Ph.D., M.P.A., Mathematica Policy Research
  • Erin Fries Taylor, Ph.D., M.P.P., Mathematica Policy Research

March 2015 AHRQ Publication No. 15-0015-EF

Acknowledgements

We thank the following individuals for their helpful perspectives and insights in the preparation of this white paper:

Technical Expert Panel Members

  • Bruce Bagley, M.D., President and CEO, TransforMED
  • Sharon Donnelly, M.S., Senior Vice President, Corporate Strategy, HealthInsight
  • Robert Gabbay, M.D, Ph.D., Chief Medical Officer and Senior Vice President, Joslin Diabetes Center, Harvard Medical School
  • Amy Gibson, R.N., M.S., Chief Operating Officer, Patient-Centered Primary Care Collaborative
  • James W. Mold, M.D., M.P.H. George Lynn Cross Research Professor, Director of Research, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center
  • Julie Schilz, B.S.N., M.B.A., Director, Care Delivery Transformation, WellPoint

Other Contributors

  • Perry Dickinson, M.D., Professor, Department of Family Medicine, University of Colorado
  • Marie Maes-Voreis, R.N., M.A., Director, Health Care Homes, Minnesota Department of Health
  • David Meyers, M.D., Acting Director, Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality
  • David Share, M.D., M.P.H., Senior Vice President, Value Partnerships, at Blue Cross Blue Shield of Michigan
  • Jonathan Sugarman, M.D., M.P.H., President and CEO, Qualis Health
  • Janet Tennison, Ph.D., M.S.W., Project Coordinator, HealthInsight

The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

None of the authors has any affiliations or financial involvement that conflicts with the material presented in this report.

This document is in the public domain and may be used and reprinted without permission except those copyrighted materials that are clearly noted in the document. Further reproduction of those copyrighted materials is prohibited without the specific permission of copyright holders.

Suggested Citation

Geonnotti K, Taylor EF, Peikes D, Schottenfeld L, Burak H, McNellis R, Genevro J. Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators. AHRQ Publication No. 15-0015-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2015.

Introduction

In an effort to create a high-quality health care system in the United States, many payers, providers, delivery systems, and other organizations are supporting the use of quality improvement (QI) initiatives to improve the performance of primary care practices.1 QI requires that practices continually assess performance, plan changes in areas where improvements are warranted, monitor the effects of those changes, and refine as needed. Engaging primary care practices in these activities is an important component of efforts to improve population health, enhance patient and provider experiences, and reduce the cost of care. However, these activities are not routinely integrated into primary care, and engaging in QI activities will be a new endeavor for most practices.

External support organizations can offer assistance to build and sustain QI capacity in a meaningful and systematic way, but may benefit from strategies to help them engage with the primary care practices.2 Examples of external organizations that support practices in undertaking QI activities include organizations that provide practice facilitation (or coaching) services, such as QI organizations, regional extension centers, Area Health Education Centers, and professional societies and payers; and other health care organizations that own or contract with practices, such as accountable care organizations, integrated delivery systems, patient advocacy organizations, and medical groups. The individuals who support practices have a variety of titles, including practice facilitators, coaches, QI consultants, and extension agents. In this paper, we refer to these external change agents as practice facilitators.

Getting practice buy-in to undertake QI is challenging. This paper provides strategies for practice facilitators and the organizations that train and deploy them, based on the experiences of experts in the field. This paper is written for practice facilitators and the organizations that train and deploy them for the challenging task of encouraging primary care practices to undertake QI activities. Although generally payers do not reimburse practices directly for QI work, some reward or penalize practices as part of either pilots or ongoing programs. Such programs typically are based on the quality and cost of care, which may involve publishing quality metrics or providing enhanced reimbursements to practices that offer more comprehensive or coordinated care. These programs often require practices to become recognized as patient-centered medical homes (PCMHs).

It can be challenging to encourage primary care practices to engage in QI, even when the potential benefits to the practices and their patients are clear. Because primary care clinicians and staff often feel intense time pressures, and because practices often operate on thin profit margins, the perceived costs of engaging in QI may seem to outweigh the anticipated benefits. Even when practices recognize the importance of improving their performance, or are financially incentivized to do so, they may not know where or how to begin QI activities, or how to make QI an integral and systematic part of their work. Even the most determined practice is likely to benefit from assistance in developing new skills to meet its improvement goals, including identifying areas for improvement, understanding and using data, planning and making system-level changes, and tracking performance over time. Although this paper focuses on how practice facilitators can engage primary care practices in QI, we note that there are other supports that can help practices begin QI activities, including data feedback and benchmarking, academic detailing and expert consultation, and shared learning or learning collaboratives (Taylor et al., 2013a).

This paper answers three questions:

  • How can practice facilitators begin to engage clinicians and staff in QI initiatives?
  • How can practice facilitators assess a practice’s readiness for QI initiatives?
  • How can practice facilitators gain initial buy-in and then maintain it for meaningful and sustained QI initiatives?

The paper distills the wisdom of experts who have honed their approaches through working with thousands of practices on QI and practice redesign initiatives. There are two parts of this paper: Section 1 provides a conceptual background and a framework for thinking about how to engage primary care practices in QI. Section 2 provides tactical strategies for practice facilitators. We begin in Section 1 by briefly discussing previous literature on strategies for and barriers to gaining practice buy-in for QI work. We next describe our primary data sources for this paper—discussions with a technical expert panel and a series of interviews with experts who are experienced in providing support for QI efforts to primary care practices. We then describe the importance of understanding practice readiness to engage, providing a conceptual framework for how a practice makes changes. In Section 2, we provide practical strategies for practice facilitators to use to gain initial buy-in from practices as well as tips for maintaining meaningful and sustained engagement in QI efforts. Finally, we discuss the challenges and opportunities that arise from coordinating across multiple QI initiatives—to consider both how to reduce the burden of multiple performance metrics on practices and how facilitators can help practices understand this external context.

Section 1: A Framework for Thinking About How to Engage Practices in QI

The Literature on Obtaining Practice Buy-In for QI

Gaining the trust of practices and getting their buy-in for QI efforts is a critical step in achieving improved care and ultimately transforming primary care practice (Hasselman, 2011; Safety Net Medical Home Initiative, 2013; Johnson and Stewart, 2008). Yet clinicians and practice staff may not engage in QI or practice redesign efforts for a variety of reasons, including a lack of the following: financial resources, time, a culture that supports change, leadership support, or organizational structure or processes focused on improvement efforts (Goldberg et al., 2013; Rittenhouse et al., 2011; Fernald et al., 2011). In fact, practice facilitators themselves report several barriers related to obtaining buy-in during the facilitation process, including challenges with practice engagement (e.g., lack of interest or trust), resistance to change, and competing priorities (Liddy et al., 2014).

A few studies have identified strategies that help to facilitate practice buy-in for QI work in primary care. One recent study investigated the implementation of a statewide PCMH initiative in Pennsylvania and identified three lessons learned for obtaining practice buy-in and engagement: (1) effectively communicating and internally campaigning for the PCMH model; (2) using a variety of resources, such as staff, funding, and learning collaboratives, to implement the PCMH; and (3) creating a team environment and engaging the entire staff in the work (Bleser et al., 2014). Another study—which examined the Physician Group Incentive Program (PGIP) of Blue Cross Blue Shield Michigan (BCBSM) (Share and Mason, 2012)—identified five activities that contributed to engaging practices successfully (Lemak et al., 2013): (1) developing a vision for improving primary care; (2) deliberately fostering partnerships between participating practices; (3) using existing infrastructure provided by physician organizations; (4) leveraging the payer’s influence and resources to support practices; and (5) proactively managing program trade-offs, such as balancing the need for accountability with reporting requirements and administrative burden.

Importantly, practices may experience their QI efforts with practice facilitators in different ways, and their perceptions are likely to vary based on practice factors (such as staff’s willingness to change) as well as differences in the ways that facilitators or coaches engage with them. One study explored the experiences of practices that engaged with facilitators in a PCMH pilot, finding that even practices that worked with the same organization reported widely different experiences (Bitton et al., 2012). Some practices felt that practice facilitators were crucial to their change efforts, whereas others reported that the facilitators could have been more helpful in supporting practice change.

Although these few studies provide some basic information on what may be effective in engaging practices in QI efforts, the literature remains scant, and more information is needed about specific tactics used successfully by practice facilitators to engage primary care practices in QI work.

Approach and Methods for This Paper

To distill strategies for engaging practices in QI, we used three sources of information for this paper. We first conducted a targeted environmental scan of the published and unpublished literature on engaging practices in QI initiatives, focusing on strategies that various external organizations use to achieve practice buy-in as well as internal factors that may make practices more or less receptive to working actively with external support organizations. Next, in March 2014, we convened a technical expert panel of six experts who are nationally recognized in providing technical assistance and support to primary care practices as they undertake QI activities and practice redesign, to provide us with substantive and technical feedback on our approach and learn from their experiences.3

Methods
  • Literature scan
  • Best practices from:
    • Expert panel with expertise in QI and practice redesign
    • Four experts from organizations providing QI support to practices

Finally, in May and June 2014, we conducted in-depth interviews by telephone with four additional experts recommended by the panel to discuss their organizations’ experiences with and expertise in initiating QI activities.4 These additional experts represent a payer, a QI organization, a State Department of Health, and an academic institution; each of these experts has years of experience in refining their approaches to providing QI support to practices. The panel and interview respondents also provided feedback on a draft of this paper. These 10 experts represent decades of collective organizational and personal experience in transforming more than 6,000 practices in 44 States.5  Based on insights from these experts, we distilled lessons learned about engaging primary care practices in QI efforts. Although these lessons and best practices do not necessarily reflect evidence-based practices, they nonetheless provide important insights and key considerations for practice facilitators working with practices to improve the quality of care.

Understanding Practice Readiness to Engage

A critical first step in facilitating QI efforts with primary care practices is understanding whether the practice is ready to engage. This helps the facilitator and the practice to determine whether it is an appropriate time to work together and, if so, allows facilitators to tailor the approach in a way that best suits the practice’s needs (including the frequency and intensity of this work). We conceptualize a practice’s readiness to engage with a facilitator based on two primary components:

“In any large system, you have the bell-shaped curve of practices. Some are ready to go. Some are not going anywhere soon. If you get them in a big room and you try to give them the same message, it is often less than effective.”

Bruce Bagley, M.D.
President and CEO, TransforMED

  • Willingness to change is the motivation and receptivity that individuals in a practice demonstrate toward engaging in the QI process and working with a practice facilitator. This can also be thought of as a practice’s commitment to change.6
  • Organizational stability and resources involves the presence of practice leadership, adequate financial and other resources (including time) devoted to making changes, a practice culture with a positive attitude toward change, and the absence of a disruptive level of organizational stress (Solberg, 2007; Cohen et al., 2004; Bodenheimer et al., 2004). This creates capacity in the practice to engage in QI; taken together, these concepts can also be called a practice’s capacity for change.7

Both of these components can fall along a continuum, and a practice’s placement on this continuum can change over time.

In reflecting on the most critical elements of practice readiness to engage, spanning both willingness to change and organizational stability and resources, the experts consulted for this paper emphasized three components of particular importance for facilitators to consider:8

"Leadership is critical. If practice leaders are engaged and have a vision to share for what needs to take place, that sets the practice up to move forward."

Perry Dickinson, M.D.
Professor, Department of Family Medicine, University of Colorado

  • Practice Leadership: The commitment of both practice leadership and staff to QI activities is critical to effectively engage a practice in QI efforts. It is important that practice leader(s) have a clear vision of what needs to be accomplished so they can provide a clear roadmap for others in the practice to follow. One expert suggested that leaders who use a facilitative approach—that is, providing direction in a nondogmatic style with concern for both what the group is achieving and how they are achieving it—may be most effective at driving change efforts and building buy-in at many levels of the practice. First, practice leaders with the influence and authority to redirect resources, staff, and time to new QI efforts must demonstrate their commitment to QI. After this step, effective leadership of day-to-day QI activities might come from anyone on the team, including a physician, nurse practitioner, physician assistant, nurse, medical assistant, or office manager.
“Will and desire alone are not enough. Practices need leadership and the financial stability to devote energy to move beyond simply providing face-to-face fee-for-service patient care…if they don’t have this, they are unlikely to succeed in transforming.”

Jonathan Sugarman, M.D., M.P.H.
President and CEO, Qualis Health

  • Resources: Although practices may share in cost savings that result from QI efforts (depending on financial arrangements with payers), initial efforts to implement QI often introduce new costs. These may include time demands on staff that take them away from billable activities, or the cost of purchasing technology tools. Many primary care practices operate on thin margins and may not be able to absorb the initial costs associated with engaging in new QI activities without financial incentives. Practices in stronger financial health or with external financial supports are more likely to be able to engage in QI. Practices may also require other nonfinancial resources to engage in QI activities, such as training, education, or physical space.
  • Practice Culture: Regardless of whether there are financial incentives in place, sustained QI and practice redesign activities ultimately require the intrinsic motivation of clinicians and practice staff. Engagement in these initiatives is more likely to be productive when clinicians and practice staff decide to participate because the QI efforts align with their fundamental norms and values—that is, when the practice team views QI efforts as a way to provide better care to their patients, not just another revenue stream for the practice or a bothersome bureaucratic burden.
    “If physicians and their practice staff are forced to change, responding to extrinsic motivation, they usually do the least necessary. When they and their organizational leaders embrace a shared vision and own practice transformation, operating from intrinsic motivation, they usually do the most possible.”

    David Share, M.D., M.P.H.
    Senior Vice President, Value Partnerships, Blue Cross Blue Shield of Michigan

    A practice with a positive attitude toward change as a whole may be more ready to engage; thus, it is important for practice facilitators to have a strong understanding of a practice’s culture before embarking on efforts to build buy-in. When a practice is intrinsically motivated toward improvement, staff are likely to be more motivated to prioritize participation in QI efforts. In addition to a culture that embraces change, a practice must not have a disruptive level of organizational stress. Practice staff should demonstrate a high degree of trust, teamwork, and good communication skills to be ready for engaging in QI activities effectively.

As described above, both willingness to change and organizational stability and resources must be present to some degree for a practice to be ready for engaging with a practice facilitator. Although some practices may be willing to change, they may not have sufficient organizational stability and resources to allow them to be ready for engaging in QI activities and achieving meaningful practice change. Conversely, other practices may have a reasonable level of organizational stability and resources but not be willing to engage in QI.

Figure 1 depicts a simple two-by-two matrix of practice willingness to change and organizational stability and resources; in reality, however, each dimension is a continuum and practices can lie anywhere in the figure’s space, rather than in one of the four discrete boxes. It is important for a practice facilitator to understand where a practice falls to determine whether it will be receptive to receiving support; this information also could be useful in guiding the way a facilitator might approach the practice. A facilitator can use practice assessments (described in more detail below, with assessment tools provided in the Resources section) to assess a practice’s readiness to engage.

Figure 1: Practice Readiness to Engage: Matrix Showing Practice Willingness to Change and Organizational Stability and Resources

Figure 1 depicts practice readiness to engage by showing a two by two matrix of practice willingness to change and organizational stability and resources. Willingness to change is on the top x-axis, and organizational stability and resources are on the right y-axis. The upper right green box depicts the ideal practice, which is both willing to change and stable. The other three blue boxes are suboptimal in one or both of these areas.

  • Other contextual factors: A number of other contextual factors may affect practice readiness to engage. For example, structural characteristics—such as the size, age, and maturity of the practice, and whether it is situated within a broader health system or is an independent entity—are likely to influence readiness. In addition, the way in which individuals in the organization communicate with each other is likely to influence readiness to engage with a practice facilitator. Finally, competing demands also warrant careful consideration. Facilitators should carefully consider any other initiatives in which the practice may be engaged to determine whether staff have the “bandwidth” to devote their attention to a new initiative. Facilitators can benefit from an honest conversation with practice leaders about competing demands, priorities, and ideal timing before beginning QI efforts; this conversation can inform their decisions about how and when to best support the practice’s QI goals. For instance, installing a new electronic health record (EHR) is often a time-consuming activity that may prevent a practice from being able to adequately invest in beginning a new QI effort. In this case, it may be best for the practice and the facilitator to jointly determine priorities for change and undertake additional QI initiatives after EHR adoption is complete.
“There will be practices that aren’t ready. All you can do is seed them and come back to them.”

Sharon Donnelly, M.S., Senior Vice President, Corporate Strategy, HealthInsight

Using Practice Assessments

Practice facilitators can use assessment tools to determine whether a practice is ready to engage in QI and how best to work with the practice staff. Experts suggest several specific ways in which practice-based assessments can be used:

  • Assess a practice’s broad readiness to engage in QI work. Practice facilitators can use assessments to help gain a better understanding of the components of readiness to engage, including a practice’s willingness to change and its organizational stability and resources for engaging in QI. More specifically, a facilitator might assess whether practice leaders are engaged, the presence of resources such as an EHR, and how the practice currently approaches care delivery.
 “[We are] more likely to be working with practices that are already engaged. We specialize in feeding the hungry fish, and it’s much more fun that way.”

Bruce Bagley, M.D.
President and CEO, TransforMED

  • Consider alternatives if the practice isn’t ready. Experts had varying opinions about the degree to which they could change a practice’s “placement” on a continuum of readiness to engage, but most agreed that it is very challenging and time consuming to push a practice too hard when it may not be ready. It may be more practical and efficient to “meet them where they are” and employ some “low-touch” strategies described below, such as periodically sending the practice information or checking in, to establish a connection on which to build when the practice is ready for change.
  • Provide a framework for engaging in change.Some practice assessments may also include a gap analysis, which a practice facilitator can use to assess a practice’s current needs, “pain points,” and resources. This can help the facilitator figure out where to focus initial change efforts.
    “These [assessments] provide a framework for how to tackle change…If you use them well, they can build rapport…The assessment and feedback process is critical, and motivating, and a key way to get [practices] on board.”

    Perry Dickinson, M.D., Professor Department of Family Medicine, University of Colorado

    For example, a gap analysis might include questions about the type of EHR a practice is using, whether the practice is already working on obtaining meaningful use designation, and how the staff are using the EHR.9 Used in this way, an assessment can help to offer targeted solutions and create a broader roadmap for change, so practice facilitators can tailor their support to the needs of each practice.
  •  Track progress over time. A practice facilitator can use an initial assessment to track change and provide feedback to the practice on its performance over time. However, it is important to recognize that significant practice change takes time, and some characteristics measured by quality assessments may be hard to change in the short term. Facilitators should frame feedback in a way that avoids making a practice feel demoralized, instead using the feedback as a motivator. Facilitators can also repeat assessments periodically to quantify and track a practice’s progress.

Practice assessments often include several elements, such as the following:

  • Willingness to change and organizational functionality to engage in QI
  • Presence of practice resources
  • Leadership engagement
  • Progress toward QI or transformation goals

Although readiness assessments can be helpful, experts suggest that they may be most valuable when used judiciously, so that practices do not feel overburdened with the amount of paperwork they need to complete. When using readiness assessments, consider doing so only when the practice facilitator is prepared to use the information gained from the assessment. Also consider how the facilitator will show the practice that the information gathered from the assessment(s) is being used to facilitate change in a meaningful way.

A Model for Organizational Change as Practices Engage in QI

Change is difficult, and both individuals and organizations go through various stages when doing so.  A practice’s undertaking of QI activities—which by definition involve change—can be viewed through the lens of Prochaska’s transtheoretical model of behavior change (1992).10 Although this model traditionally has been used to assess an individual’s willingness to change, it can also be applied to understand the processes a practice goes through as it contemplates undertaking QI activities. The transtheoretical model includes five stages of change:

  1. Precontemplation: no intention to change a behavior in the near future
  2. Contemplation: awareness of a desire to change a behavior, but ambivalence between the pros and cons of change may prevent movement to the next stage
  3. Preparation: pros begin to outweigh the cons, and action is intended in the near future
  4. Action: actual change in the behavior begins, but a relapse into old behaviors is still likely
  5. Maintenance: successful attainment and maintenance of new behavior

Just as individuals progress through these stages when making a behavior change, practices may move through similar stages as they contemplate and embark on organizational change with the support of a practice facilitator. Practices might move through these stages in a linear fashion but can also move backward to a previous stage, move forward again, or remain in the same stage for long periods of time.

Typical stages of a practice facilitator’s work with a practice closely mirror the stages of the transtheoretical model, as shown in Figure 2. The first stage of a practice facilitation intervention—when the facilitator has an opportunity to first contact the practice and assess its readiness to engage—may occur when the practice is in either the precontemplation or contemplation stage. As the practice progresses to preparation (and assuming that practice staff have agreed to work with a facilitator), the facilitator is now ready to orient them to the project, engage the team, work with it to plan a kickoff meeting, and conduct a more thorough assessment with formal goal setting for QI activities. Stage 4 involves active QI, in which the practice facilitator assists the practice in developing its capacity for improvement and implementing specific improvements based on the goals set during stage 3. Last, as the practice moves into the maintenance phase, the facilitator will support the practice by helping it hold the gains, working to develop systems to monitor improvements and maintain them in the long term.

Figure 2: Transtheoretical Model Stages of Change, And Corresponding Stages of a Facilitation Intervention

transtheoretical change model

Source: Typical stages of a practice facilitation intervention shown in the second column are adapted from: Knox L, Taylor EF, Geonnotti K, et al. Developing and Running a Primary Care Practice Facilitation Program: A How-To Guide. (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO 5.) AHRQ Publication No. 12-0011. Rockville, MD: Agency for Healthcare Research and Quality; December 2011.

Section 2: Strategies for Engaging Practices in QI Efforts

Having described how a practice facilitator determines a practice’s readiness to engage, Section 2 turns to several strategies, described below, which may be helpful in building relationships, gaining initial buy-in, and maintaining that buy-in for meaningful and sustained QI work.

Gain Initial Practice Buy-In

1. Set the Stage for a Future Relationship With Practices Not Yet Ready to Engage

Although it can be difficult to “get a foot in the door” of practices, practice facilitators can use several methods to encourage them to move through the stages of change as they work toward QI or practice redesign goals. For practices not yet ready to engage, initial strategies can focus on making it easy for them to turn to an external organization for support when they become ready to engage in QI efforts. In particular, acting as a consistent source of helpful information will keep a practice facilitation organization on a practice’s radar. This can include sending the practice relevant articles and providing opportunities to engage in learning collaboratives or other similar activities or events. For a practice in the precontemplation phase—that is, one that may not yet be ready to engage in QI—there may be value in instilling an awareness of a changing health care environment that is beginning to place a higher priority on QI work. Facilitators could send information to the practice about how other practices in the community (or beyond) are engaging in QI, as payers increasingly push for value in health care. Practice facilitators also might make sure that practices are aware of the supports available to them.

2. Build Trusted Relationships With Practices

Although gaining trust can be challenging, it is an essential first step to engaging a practice in QI work. Experts suggest several strategies that practice facilitators can use to help build trust with practices:

  • Establish a “relationship by proxy” by partnering with organizations already trusted by the practice. Working with organizations that the practice already knows and trusts, such as an Area Health Education Center (AHEC), State primary care association, or Practice-Based Research Network (PBRN), can help convince practices to extend that trust to a practice facilitation organization.
  • Partner with local entities. Working with community groups—particularly those with which the practice is familiar and that understand the practice’s concerns as a member of the same community—can help to build trusted relationships between practice facilitators and the practice. For instance, experts suggest that familiar physician organizations can motivate collective responsibility for undertaking QI or broader practice redesign efforts. Similarly, working closely with a community agency on a particular initiative (e.g., a county health improvement plan) can motivate practices to work with a facilitator or practice facilitation organization as part of a broader mission.
“If you work with the early adopter practices—the opinion leader practices—ask them to invite other practices. That seems to work.”

James W. Mold, M.D., M.P.H.
George Lynn Cross, Research Professor, Director of Research, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center

  • Work with early adopters/opinion leaders. Working with practices that are willing to be early adopters and whose staff include opinion leaders in the community is an effective way to establish credibility and can be a powerful motivator; facilitators can tell their success stories in working with these practices.
  • Use practice facilitators who will be seen as credible to practices. Facilitators who share a background with practice staff are likely to be seen as more credible than, for example, an academic who has never worked in a primary care practice. Practice facilitators with clinical backgrounds in primary care—who “speak the language” of practices—are often better equipped to understand their challenges and build trust. Some practice facilitation organizations hire experienced clinical professionals, such as nurses, to ensure that they can connect with front-line staff and clinicians in a practice; others hire clinicians who still work part time in a primary care setting. It is also important for the individuals providing facilitation support to practices to maintain transparency about the planned QI initiative, particularly if the facilitators work for a State agency or payer and are helping the practice work toward State- or payer-mandated PCMH recognition, for example. In this type of situation, it is important that practice staff do not feel that their work with a practice facilitator is merely to obtain a “regulatory stamp of approval,” but rather that they are truly being supported in achieving the goals they have set for QI or practice transformation.
“We hired nurses and people who work in clinics to establish trust. I worked in a clinic for over 30 years, and we hire others with that clinical experience. We hire people that understand the language of practices and QI, who can say ‘I sat in your chair’—so that there is trust.”

Marie Maes-Voreis, R.N., M.A.
Director, Health Care Homes,
Minnesota Department of Health

  • Approach conversations as “respectful negotiations.” Approaches that simply tell practices what to do when setting priorities for QI initiatives are unlikely to be effective in the long run. A commitment to collaboration (and humility) will go a long way in supporting practice staff and working with practices to identify and achieve those goals most important to them. To work toward a sustainable model, the practice will ideally choose its goal for the first QI initiative it undertakes, see the path forward, and have a direct hand in creating a shared vision for a redesigned practice. This approach is similar to the shared decisionmaking approach that clinicians are encouraged to adopt with their patients. When approaching these conversations with the practice, facilitators should keep in mind that some previous approaches to improving care may not have been as successful as the practice originally had hoped.
  • Ensure transparent communication. Experts recommend that practice facilitators encourage openness and transparency with practices when undertaking QI. Facilitators may even wish to establish a communication team as a subgroup of the QI team to ensure that the process is transparent to all practice staff. This team could communicate about what the initiative is and why it is occurring, the ultimate goals or outcomes, and steps needed to achieve it. Practice communication can occur in staff meetings and through blogs, newsletters, or bulletin boards located in the practice.

3. Target the Most Appropriate Person in the Practice

“I interviewed practices that had already adopted EHRs and with only one exception, it was an exceptional office manager that made it happen. Ideally, you are going in and working with a physician champion and then an office manager to make it happen. It depends on the dynamics of what you have when you show up. I’ve gone in and done successful projects with a medical assistant who was really a leader.”

Sharon Donnelly, M.S., Senior Vice President, Corporate Strategy, HealthInsight

When working to engage practices in QI efforts, it is important for practice facilitators to identify the most appropriate practice leaders—those individuals responsible for decisionmaking who need to be convinced that QI is an important and worthy undertaking. These people should have the most influence in a practice, regardless of their titles. For example, in one practice, a clinician may be the one responsible for making important decisions, whereas in another practice, the office manager may play this role. Those with the most influence may be an individual, two people, or a small group of clinicians and/or staff; practice facilitators can identify these people (either formally, using assessment instruments, or informally, through discussions) when first beginning to work with a practice. Any efforts to gain buy-in should be tailored to this specific audience. Also, facilitators generally may not need to bring all staff in the practice on board immediately but may find that it is more effective to work with the key opinion leaders first, who can then help to bring others in the practice along. Experts suggest that it may be beneficial to first work with those natural leaders willing to serve as champions and provide strong leadership, a clear vision, and the guidance necessary for practice engagement.

Practice structure and ownership may also influence ability to obtain buy-in. Whereas a small independent practice can decide to engage in QI when it is willing to do so, a practice that is part of a larger organization or integrated delivery system may not always be able to begin a QI process even if practice leadership want to do so. In these cases, practice facilitators should try to understand the larger organizational structure and work with appropriate decisionmakers at such organizations to ensure buy-in at all levels.

4. Tailor the Message

When practice facilitators interact with practice leaders and staff, they should consider tailoring messages to their target audience:

“…QI efforts can help physicians get back to practicing medicine like they had originally intended—to rediscover the joy in it. This messaging is effective for physicians.”

Robert Gabbay, M.D., Ph.D.
Chief Medical Officer and Senior Vice President, Joslin Diabetes Center, Harvard Medical School

  • If the audience is composed of clinicians: Effective messaging strategies often include those that allow clinicians to see how engaging in QI may help them to rediscover a way of practicing medicine closer to the style they envisioned when they began their careers. Practice facilitators can convey the message that QI has the potential to use the strengths of nonclinical staff to perform administrative work, allowing clinicians to use their skills and training to deliver care more efficiently. This should reduce the time burden on the clinicians or allow them to focus on more complex clinical cases, and ultimately improve care for the patients they serve.
  • If the audience is an office manager: Many office managers are accustomed to working in an extremely busy environment, in which they perform many diverse functions and may even thrive on the practice’s hectic pace. Effective messaging strategies will need to take this mentality into account when describing how a more efficient, streamlined workflow and processes can benefit the practice. Office managers often are focused on developing and maintaining efficiency and value. They may fear that QI will detract from the practice’s mission or bottom line; focusing on how QI can solve problems and enhance value may resonate with them.
  • If the audience includes other staff: Messaging should include information about how QI efforts can make their jobs more rewarding. Whereas some staff members may respond to the rewards of new challenges, others may respond to the promise of QI to reduce waste and streamline processes (most staff like going home on time). For example, a practice could increase influenza immunization rates if front-desk staff begin asking every patient if he or she has received a flu shot. In this way, all staff, including the receptionist, could contribute to improving processes and patient health outcomes, which is likely to be rewarding for everyone.

Peer-to-peer education can often be an effective tool in delivering these messages to clinicians and staff—others in a similar position may recently have had a positive experience with undertaking QI. For instance, it can be powerful for a clinician contemplating working with a practice facilitator to meet with another clinician who recently benefited from a QI initiative. Ideally, practice facilitators can bring clinicians and staff from the same local community together in a learning community or more informal network to share experiences.

Messages should also be tailored in a way that acknowledges the practice’s willingness to change and its organizational stability, and responds to its particular needs and characteristics. For example, a practice further along in the stages of change will need a different message from one in the precontemplation stage. Similarly, if a practice is facing a particularly challenging or thorny operational issue, it may be useful to frame QI support as a way to help practice staff improve this issue and other similar challenges.

5. Use Appropriate Messaging Techniques

Though all messages should be tailored to a specific audience, experts suggest five broad messaging techniques when building buy-in with practices.

  • Use data feedback and benchmarking. Providing practices with information on their performance compared with external benchmarks (such as regional or national averages) and helping to target areas for improvement requires thoughtful and effective communication. It is important to deliver this information in a nonjudgmental way, acknowledging strengths as well as opportunities for improvement. Think of this messaging as similar to the way a clinician talks to a patient about self-management—providing feedback designed to motivate and support rather than to judge. For example, facilitators can use information to show a practice how it compares with others and then ask, “What can we do to help improve these numbers?”
“The key is to step back and help them develop a vision of how the work can fit into their value system—what they do and what they want to accomplish. Many practices have to do a lot of this work and don’t want to hear about the one more thing you want them to do. Figure out their values and motivations—if you can do that well, they’ll join.”

Perry Dickinson, M.D. Professor,
Department of Family Medicine, University of Colorado

  • Engage in storytelling/painting a picture. Illustrating the ways in which practice facilitators can help practices engage in QI and ultimately function more smoothly can be an effective messaging technique, as long as it is targeted to specific recipients. Stories from similar practices that have engaged in QI can be particularly effective. Specifically, stories told to clinicians and staff should be tailored to this audience. For example, a story about how a clinician was able to lighten her workload by transferring some of her administrative work to other staff may be a great message for a clinician, but not as appropriate for front-line staff. If applicable and available, showing video recordings of staff from other practices can be an effective way to share these stories. The experts suggest that, as much as possible, practice facilitators should share stories of people similar to the target audience so the stories resonate with the audience, and practice staff can envision what these changes would look like for them.
  • Identify “pain points” and offer solutions. After conducting an initial needs assessment, practice facilitators likely will have identified a practice’s “pain points”—that is, areas in which the practice is facing challenges and knows that change is needed—and be able to offer concrete solutions that can be accomplished through QI. For example, most practices will be aware of the importance of being able to recruit new clinicians. However, many recently trained clinicians who have been taught to practice using an EHR may avoid working for a practice without electronic records. Thus, a practice that finds it challenging to recruit new clinicians may recognize this pain point and be willing to engage with a facilitator to address the issue of EHR adoption. Moreover, successful work on the first QI project could lead to additional redesign efforts in the future.
  • Identify and draw on a practice’s core values and larger mission. QI efforts are most successful when practices are intrinsically motivated to do the work—that is, when they are convinced the work is necessary for improving care delivery and the health of their patients, independent of external incentives. Experts suggest that it is crucial to identify a practice’s values and demonstrate how QI efforts will enhance its ability to deliver care aligned with these values. Most practice staff will find it compelling if a practice facilitator can demonstrate the potential of QI to improve health outcomes for their patients while also improving job satisfaction for practice team members.
“The world is changing around them and we are trying to help them thrive in this world.”

Sharon Donnelly, M.S., Senior Vice President, Corporate Strategy, HealthInsight

  • Emphasize broader changes in the health care field. Stressing that the field as a whole is headed toward ongoing QI and delivery system redesign can help convince practices that engagement in QI is necessary. Even if a practice currently is not being paid to engage in QI efforts, such scenarios as being financially rewarded for improved patient outcomes or seeing their quality measures publicly reported are increasingly likely in the future. For this reason, it is beneficial for practices to engage in QI sooner rather than later to ensure that they are prepared for these inevitable changes and perhaps even able to serve as leaders and examples for other practices. Further, professional organizations are creating new standards and expectations about what it means to provide high-quality patient care. These expectations include QI efforts and practice redesign. Although knowing about new standards or expectations may not affect any individual practice’s willingness to change, it likely will shift expectations for primary care practice in general toward accepting QI and practice redesign. Pointing out these shifts in the primary care landscape can help orient a practice toward engagement in QI.

Maintain Buy-In for Meaningful and Sustained QI Efforts

Although the strategies described above can help practice facilitators gain initial buy-in by practices, it is crucial for facilitators to employ techniques that maintain and further build a collaborative relationship with them. The systemic and cultural changes required for ongoing QI efforts can be difficult for practices and lead to “change fatigue.” Because of these challenges, experts recommend several techniques for continuing to support practices as they move through the stages of change, develop QI capacity and infrastructure, and make QI an integral part of their organizations.

  • Ensure that all people with the ability to influence change are brought on board. Even if a practice facilitator initially secured buy-in from those with formal power (e.g., a lead clinician), there may be others in the practice with informal power who were not identified during that initial stage. A facilitator can maximize chances for success by engaging those individuals during QI efforts. As a way to build collaboration and sustain buy-in, practice facilitators can encourage practice colleagues to participate together to learn about the QI initiative or model and how to implement it, thinking through the process carefully.
  • Start with an “early win.” Many QI projects require extended periods of intense work before any positive results emerge, which can be discouraging for staff and may erode any initial buy-in. For this reason, a practice facilitator might demonstrate an “early win” by encouraging the practice to choose as the first QI project or initiative one that is relatively easy for the practice to pursue and that will produce benefits that appear quickly. This requires a realistic assessment of the practice’s current capacity, staffing, and needs, which can be done using an assessment tool. It is also important to align the practice’s preferences for its first QI initiative with a task that staff can realistically accomplish as an “early win.”
“A facilitator can help the practice recognize the importance of accomplishing change in small bites. Practices tend to try to do a complex change in one step across the entire practice, but then feel defeated when it doesn’t work perfectly. Practices need to learn how to take small steps. If there are failures, they will be small. Practices can learn from their mistakes and move forward.”

Perry Dickinson, M.D.
Professor, Department of Family Medicine, University of Colorado

  • Adopt strategies to ensure long-term success and mitigate the risk of “change fatigue.” When practices try to engage in too many complex QI efforts concurrently, they run the risk of experiencing “change fatigue.” It is important to build capacity incrementally, without trying to do too much too soon, thereby achieving long-term success by helping the practice change its orientation. Practice facilitators can provide positive encouragement and regular reflection on what the practice has accomplished, emphasizing that the process will take time so that staff have realistic expectations. Other steps, such as developing the capacity for team-based care, come with time. Experts suggest that practices require varying levels of regular contact, depending on their needs, but it is important to consider the extent to which a practice facilitator can provide ongoing support and feedback through regular meetings, data monitoring, and other strategies to mitigate the risk of change fatigue.
  • Harness the power of patient engagement.Engaging patients in QI efforts can help sustain practice buy-in for QI activities and is important in its own right. This approach allows practices to see how their current system works through their patients’ eyes, which can help motivate them to implement changes that will improve the patient experience (Peikes et al., 2011; Schoelle et al., 2010). Facilitators might also consider working with patient representatives or using a community engagement process to gather feedback on ways the practice might best meet its patients’ needs.
    “One thing that sustains practice change is meaningful patient engagement in QI activities. Patients often have a very different perspective on the strengths and weaknesses of a practice than do physicians. Providers want to improve things when they hear directly from patients how the system is not meeting their needs. If you get patients involved in QI, it is hard not to fix things—and many of the fixes are easy.”

    Jonathan Sugarman, M.D., M.P.H., President and CEO, Qualis Health

    Although patients and families typically are not involved in planning for QI when practices are just starting such efforts, experts suggest that patients could play an enhanced role in future QI efforts once QI work is more established. Patients and families can help to shape priorities for QI, narrow down options for how to undertake improvement activities, and help assess progress. By engaging them earlier and more meaningfully throughout the QI process, patients and families can become a catalyst in practice transformation. One example of how to successfully engage patients and families in practice transformation is to consistently demonstrate a commitment to patient centeredness. Practices can accomplish their transformation goals by adding patient partners to QI teams, revising mission statements, and celebrating wins for patients and families (Stout and Weeg, 2014).

Working With Multiple QI Programs

Organizations that pay for health care are looking increasingly for value in the care they purchase: that is, they want high-quality care at reasonable cost, with an eye toward continually improving care over time for their patients. A number of Federal programs and private payer initiatives encourage primary care practices to engage in improvement efforts by offering financial support (in the form of incentive payments, grants, and other funding) and providing other resources and supports. As part of these efforts, practices are increasingly rewarded or penalized based on the quality and cost of care, with corresponding requirements to report quality metrics. One challenge for gaining and maintaining buy-in for QI efforts is the proliferation of various efforts and initiatives, with many practices facing requests from various organizations to engage in QI work, each with its own slightly different measures and reporting requirements. It is important for facilitators to be aware of the context in which primary care practices operate and think about how they can best support practices in this environment. Facilitators should become familiar with other initiatives that a practice might leverage to support its QI work. For example, practice facilitators may learn of a local or statewide initiative that allows for additional payment when developing care plans for chronically ill patients, and can make the practice aware of this valuable opportunity.

“As we start to make a value-based payment model standard, we do need to think about standardization in our process so that we are not fragmenting the work of providers—that it’s ‘data for dollars’ for a variety of different measures. We can standardize against ‘what we know to be true’ in terms of delivering patient-centered evidence-based care, PCMH, reliability science—all of these types of elements so that the work doesn’t become payer one-offs.”

Julie Schilz, B.S.N., M.B.A.,Director, Care Delivery Transformation, WellPoint

QI efforts can be substantially more efficient and reduce burden on practices if payers are aligned and clear in their goals and the measures they are looking to improve. Moreover, whatever the level of alignment, practice facilitators can help a practice understand the synergies between the projects and incentive programs in which they participate, and, in some cases, help them identify practice changes that are requested or required by multiple programs simultaneously.

Despite good intentions, different initiatives or health plans might require participating practices to report different metrics on different reporting cycles. One recent study examined the performance measure sets used by 23 health plans and found that they used 546 distinct measures, with widespread variation in both public and private programs (Higgins et al., 2013). Measurement and data reporting are burdensome for practices, especially when they perceive these efforts to be uncoordinated and duplicative. To mitigate this burden, some States have organized statewide initiatives to help provide clear signals and minimize burden by developing a set of statewide performance measures. Several recent efforts in Maine, Wisconsin, and Vermont have aimed to align provider performance measures across payers (McGinnis and Newman, 2014). While practice facilitators cannot necessarily align performance measures, understanding this context can help them support practices as they navigate reporting requirements.

“We want practices to have flexibility on which measures to report, depending on their patients. And we want reporting to include the voice of patients, so we’re also talking about patient experience in care.”

Amy Gibson, R.N., M.S., Chief Operating Officer, Patient-Centered Primary Care Collaborative

Other efforts have brought together health plans, evaluators and researchers, unions, clinicians, hospitals, and others to come up with a standard set of quality measures. In some cases, payers have worked together as part of a multipayer demonstration project or regional coalition to develop a standard set of reporting measures. As another alternative, payers could choose to offer practices some flexibility in the measures they are required to report to allow practices to report those measures most applicable to their patient populations. In these instances, practice facilitators can play a role in helping practices clearly understand their reporting requirements and helping ensure that the perspective of the primary care practice is represented in standardization efforts.

Conclusions

Engaging in QI and practice redesign activities allows primary care practices to work toward improved quality, better health, improved patient and provider experiences, and reduced cost of care. Practices can benefit from the support of practice facilitators in guiding them through this process. To engage practices effectively, we recommend the following strategies for facilitators:

  • Assess the practice’s readiness to engage.
  • Develop tailored strategies appropriate for the practice.
  • Maintain practice buy-in for meaningful and sustained engagement in QI efforts.

Although it can be difficult to get a foot in the door, experts suggest that practice facilitators can build relationships with practices through partnering with trusted organizations or working with key opinion leaders. Experts suggest that facilitators identify their key audience(s) in the practice and tailor the message accordingly, incorporating data into conversations about how QI activities can offer solutions and ultimately improve the health of their patients. Finally, even after facilitators have gained initial buy-in, and a practice has begun to engage in QI activities, the systemic and cultural changes required for ongoing change can be difficult. During this time, facilitators can continue to support practices in mitigating change fatigue. There is also an opportunity to reduce the burden on practices by supporting the development of standardized quality measures and flexible reporting requirements.

By offering support through a collaborative and productive relationship, practice facilitators can help primary care practices develop an orientation toward systematic, continuous QI to improve the outcomes of primary care in the United States.

Footnotes

  1. We use the phrases “QI initiatives,” “QI activities,” and “QI efforts” here to refer broadly to both specific QI initiatives and broader efforts undertaken toward practice redesign and transformation. Go back
  2. For a more detailed discussion about building QI capacity and infrastructure, see two previous AHRQ Briefs and a Fact Sheet about QI on which this paper builds: Taylor et al., 2013a, 2013b, 2014. Go back
  3. Bruce Bagley, M.D., President and CEO, TransforMED; Sharon Donnelly, M.S., Senior Vice President, Corporate Strategy, HealthInsight; Robert Gabbay, M.D, Ph.D., Chief Medical Officer and Senior Vice President, Joslin Diabetes Center, Harvard Medical School; James W. Mold, M.D., M.P.H., George Lynn Cross Research Professor, Director of Research, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center; Julie Schilz, B.S.N., M.B.A., Director, Care Delivery Transformation, WellPoint; and Amy Gibson, R.N., M.S., Chief Operating Officer, Patient-Centered Primary Care Collaborative. Go back
  4. David Share, M.D., M.P.H., Senior Vice President, Value Partnerships at Blue Cross Blue Shield of Michigan; Jonathan Sugarman, M.D., M.P.H., President and CEO, Qualis Health; Perry Dickinson, M.D., Professor, Department of Family Medicine, University of Colorado; and Marie Maes-Voreis, R.N., M.A., Director, Health Care Homes, Minnesota Department of Health. Go back
  5. The number of States is a unique count; the number of practices is not. Go back
  6. “Commitment for change” is the term TransforMED uses to describe this concept. Go back
  7. “Capacity for change” is the term TransforMED uses to describe this concept. Go back
  8. We adapted some of the concepts in this section from the Consolidated Framework for Implementation Research (Damschroder et al., 2009). Go back
  9. See Higgins et al., 2015 for more information about using health IT to support QI work. Go back
  10. Although the TTM traditionally has been applied to individual behavior change, early literature suggests its application to organizational change. See, for instance: Prochaska et al., 2001; Garvin et al., 2013. Go back

References

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Tools and Resources

Quality Improvement in Primary Care

1. General Resources About QI in Primary Care

2. External Supports for QI in Primary Care

  • Building Quality Improvement Capacity in Primary Care: Supports and Resources. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/capacity-building/pcmhqi2.html
  • Data Feedback & Benchmarking
    Hysong S, Best R, Pugh J. Audit and feedback and clinical practice guideline adherence: making feedback actionable. Implement Sci 2006;1(9).
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  • Learning Collaboratives
    AHRQ's PBRN Peer Learning Groups: http://pbrn.ahrq.gov/peer-learning-groups
  • Bricker PL, Baron RJ, Scheirer JJ, et al. Collaboration in Pennsylvania: rapidly spreading improved chronic care for patients to practices. J Contin Educ Health Prof 2010;30(2):114-125.

Practice Facilitation

1. Overview and General Information About Practice Facilitation

2. Evidence on the Effectiveness of Practice Facilitation

  • Baskerville BN, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012;10(1):63-74. www.annfammed.org/content/10/1/63.full
  • Dickinson PW, Dickinson LM, Nutting PA, et al. Practice facilitation to improve diabetes care in primary care: A report from the EPIC randomized clinical trial. Ann Fam Med 2014 January/February;12(1):8-16.

3. Examples of Successful Practice Facilitation Implementation

4. Training Resources for Practice Facilitators

Practical Tools and Manuals for Use by Practice Facilitators

1. How to Manage Change

2. Strategies and Guides for Working with Practices

Assessment Tools

1. Assessing Practice Readiness to Engage

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    Change Process Capability Questionnaire (CPCQ). Tool available at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod6appendix.html and further described in original article: Solberg LI, Asche SE, Margolis KL, Whitebird RR. Measuring an organization's
    ability to manage change: The change process capability questionnaire and its use for improving depression care. Am J Med Qual. 2008 May-Jun;23(3):193-200.
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  • Practice Culture Assessment (developed by Perry Dickinson, MD, Professor, Department of Family Medicine, University of Colorado). Free instrument available upon request: Perry.Dickinson@ucdenver.edu
  • TeamSTEPPS Organizational Readiness Assessment Checklist, Agency for Healthcare Research and Quality. http://teamstepps.ahrq.gov/readiness/
  • Is Your Practice Ready for Change? TransforMED, http://www.transformed.com/workingPapers/AssessingChangeReadiness.pdf

2. Practice Assessment/Assessing a Practice’s Level of “Medical Homeness”

3. Examples of Assessment Use in Practice

  • Bitton A, Ellner A, Pabo E, et al. The Harvard Medical School Academic Innovations Collaborative: Transforming primary care practice and education. Acad Med 2014;89:1239-1244.
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