Evolving: A Journey in Practice Transformation

I remember driving to Chicago on my first day as a Midwest AETC Practice Transformation (PT) Coach filled with both excitement and apprehension to participate in a 3-day intensive training titled Building Blocks of High Performing Primary Care. While the concepts of PT were familiar to me after over a decade of change and analytical work, the translation to HIV care capacity building and targeted workforce development was uncharted territory for me. I left Chicago with the conviction that this was a project worth fully investing in. My enthusiasm was soon thwarted by the reality of navigating a new partnership with a clinic that was overwhelmed in their own chaos, suspicious of the project they had agreed to, and not trusting our presence in their midst. We were fortunate to secure an initial meeting with our clinic and did not initially face the roadblocks to entry of unanswered calls, shut doors, and cancelled meetings that many of our colleagues experienced. We soon learned, through an arduously fragmented, yet extensive initial assessment rollout, that new relationships are extremely fragile when the perceived demands outweigh the benefits. For many of us, the first year was a balancing act between meeting deadlines and not overburdening clinic relationships.

In April 2016, I was given the opportunity to coordinate the Midwest AETC PT project. I was excited by the opportunity to see if a deeper clinic relationship could result in more integral deeply rooted and sustainable access to quality HIV care. The past months have been testimony to the fact that 1) challenges can result in some of the most rewarding successes, 2) engaged relationships foster trust and empower change thinking, and 3) our clinic partners are not the only ones transforming. Changes implemented within one clinic have had rippling effects in promoting the integration of care, collegiality, and the development of processes and resources to advance HIV care across our communities.

While each participating clinic in the PT project is unique in terms of its current capacity to provide care, ability and interest in being change agents, and priorities for change, there have been several common project barriers:

  • High turnover. Every clinic in our project has been significantly impacted by the transition of key administrative leadership and clinical providers. The high staff turnover that plagues our Federally Qualified Health Centers (FQHCs) highlights the importance of building stability and sustainability plans. It emphasize the significance of training of HIV care teams to 1) mentor changing staff, 2) engage in referral relationships that provide continuity of care, 3) support the development of HIV care workflows, 4) focus on team building and, 5) formalize HIV-specific policies and procedures.
  • Time, resources, and competing demands. Our PT clinics have extremely busy practices with skeleton staffing levels. Continued momentum depends on creating efficiencies that expand capacity. All of our clinics are faced with other high priority competing demands vying for already limited time. Clearly articulated goals and timelines, investment in relationships, effective and affirming communication, and manageable expectations are critical strategies for staying on the radar of our partners in transformation.
  • Resistance to change. Fear and lack of understanding has led to change resistance. Identifying motivations and learning how to work through individual and group resistance has been key to project advancement. 

PT is hard and unpredictable work that requires significant investment, courage, creativity, and conviction that the ongoing coaching we provide is making a difference one patient, staff person, or provider at a time. It has been a privilege to witness the breakthroughs and changes occurring at our partner clinics. Each coach and clinic relationship is unique in the strategies used to successfully advance project goals.

Educational and Empowerment Benefits of Individualized Professional Development Plans
Individualized Professional Development Plans have become the foundation for PT at one of our participating clinics. The plans were introduced as a strategy to build relationships, trust, and buy-in by providing training opportunities to all members of the HIV team. There have been several inspiring stories resulting from the professional development plans. One team member, who started the project as a patient and volunteer, became employed as a community health worker and was recently promoted to case manager and lead on designated special projects due to his passion and hard work at the clinic. One of the most powerful successes was the recruitment of a new physician to manage the care of the clinic’s 159 PLWH. The coaches prioritized an emergency plan that included clinical shadowing and reverse shadowing with a local expert, attended a national HIV conference, provided guidelines and other resources, and provide ongoing consultation support. The physician has since become a passionate champion of the project and has begun the process of certification as an HIV Specialist through AAHIVM. An unexpected outcome of the development plans was that the HIV team attended several community-based trainings as a group. The community took notice and has been inspired by this group’s passion responding by making plans to provide further opportunities to advance the goals of the staff and the Latinx community that the clinic serves.

Tried and True Tools for Quality Improvement Build a Common Clinic Language
One of our coaches was initially met with a lot of resistance to the project. Her primary goal was to pilot universal HIV testing in a module of the clinic, but every time she would begin her efforts, the department selected for pilot would close due to high staff turnover. Frustrated, the coach attended Training on Quality Coaching coordinated by the AETC NCRC and the National Quality Center and was inspired to try some of the quality techniques and tools shared at the training with her clinic. She developed a relationship with the clinic’s quality department, and together they sponsored a clinic wide marketing and training launch of the testing project. She created an implementation team to do workflow mapping, effort/yield analysis, cause and effect fishbone diagramming, and plan-do-study-act (PDSA) cycles. She implemented a communication tool that kept the team on task to follow-ups while continually encouraging and praising team efforts. While the initial pilot was closed down due to yet another clinic department realignment, the team is intact and in the process of launching a new pilot HIV testing project. Through the process the coach has made inroads with many staff at the clinic regarding the importance of testing. Additionally, her mentorship leadership style has served to break down miscommunication and to encourage team building in an organization that was struggling with employee morale. Through diligence and continued passion, the coach is making significant inroads on changing clinic culture by promoting the use of quality tools and effective communication.

The Ripple Effect of Resource Mapping
During ongoing conversations with one of our clinics it became apparent that the case management staff felt there was a lack of culturally specific community support services for PLWH. In response to the frustration of the clinic team, the coach team facilitated a resource mapping process that revealed that there wasn’t consistent knowledge across the staff. The activity brought everyone to a level playing field regarding the availability of community resources. The coaching team developed a plan for actively engaging the community resources of interest to meet with the clinic staff for Q&A sessions. The sessions to date have been extremely beneficial to build collegial change relationships between organizations. The clinic/coach team has since been working with several agencies to improve joint processes to improve access. While these changes are being implemented to improve access for the clinic’s patients, the processes will also benefit other clinics throughout the community.

Quality Projects that have Greater Reach
Work in another one of our clinics revealed barriers to access to HIV testing resulting from consent forms not being available in the native languages of the patients. The coach team worked with a company to translate the HIV testing consent form to Bengali, Arabic, and Spanish. After receiving approval from the state’s legal department, the forms are now being used in the clinic, which could result in an increase in HIV testing. The translations are now available to the state to disseminate to other clinics with similar language needs.

Conclusions
While I think that most of my colleagues will agree that the PT project was tenuous to launch, initial investments have paved the way to make significant inroads for the duration of the project. Many of our clinics are starting to see the value of the contributions and efforts made to date and are eager to continue the deep work. I look forward to continuing the momentum of the project and have every confidence that the project will deliver meaningful and demonstrable change.

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