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Strong training is essential to developing effective practice facilitators (PFs) or coaches to support improvements in primary care practices. This case study profiles the Practice Facilitator Certificate Program at Millard Fillmore College of the University at Buffalo (UB) of The State University of New York. Available to the public, this program is an online distance-learning course that seeks to develop the knowledge and skills needed to build organizational capacity for change and support meaningful quality improvement (QI) in diverse medical practices. The course was designed and developed by national experts who drew heavily upon the training modules in the ������Ƶ (AHRQ) Practice Facilitation Handbook.¹

The program offers several lessons for others interested in developing and delivering training for practice facilitators:

• Building on existing partnerships and leveraging existing resources can help form a robust training program.
• Having a well-formulated structure aids in developing an online course.
• Involving experienced online instructional design support during course development is crucial.
• Combining classroom and field experiences is an effective teaching approach.
• Incorporating elements of adult learning theory supports student engagement and learning.
• Planning ahead can reduce technical challenges in an online learning environment.
• Using an instructor who has both content expertise and online teaching experience is critical.
• Investing in ongoing QI efforts helps ensure program quality.
• Marketing is important and can be challenging.

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I. Background and motivation for developing the PF training program

The Millard Fillmore College Practice Facilitator Certificate Program began as a project of the Coalition of Coordinated Networks (CoCoNet2), a group of six primary care practice-based research networks (PBRNs) funded in 2012 by AHRQ² to stimulate innovation in the delivery and organization of primary care and to accelerate QI in primary care practices.³ In the past, members of CoCoNet2 routinely worked with practice facilitators, each training their own staff for this work. As a result, they saw a potential benefit to developing a standardized and centralized training program that would allow them to leverage each other’s expertise and take advantage of economies of scale. In addition, the consortium expected that such a training program would be important for meeting the growing demand for well-trained PF staff to support ongoing reform of the Nation’s health care delivery system. Three goals of this collaborative effort were (1) developing a standardized program for training individuals with little or no PF experience to effectively support practices in implementing organizational change, (2) offering certification to experienced PFs already working in the field, and (3) building a nationwide community of PFs to share ideas and learn from each other.

Two factors converged within CoCoNet2 to support the project. First, staff at one of the CoCoNet2 member organizations, L.A. Net Community Health Resource Network (L.A. Net), in partnership with AHRQ, had recently completed a guide to assist in the training of new PFs—The Practice Facilitation Handbook—and suggested that the Handbook could be used as the foundational content of a standardized training program. Second, a researcher with another CoCoNet2 member organization, Upstate New York Network (UNYNet), who is on the faculty at the UB Department of Family Medicine, suggested that housing the training program at a university would bring credibility to the program. Consequently, he approached the associate dean of Millard Fillmore College—the university’s college for continuing education and professional studies—as a potential partner and offered to support the development, launch, and pilot of the first session using CoCoNet2 member resources and grant funds. The associate dean agreed to partner with the UB Department of Family Medicine and CoCoNet2, as the intent of the course matched the mission of the college to help professionals start or build a career and update their credentials. The college was also interested in being the first to offer a university-based PF training and certificate program in a job market sector they perceived as expanding.

The pilot course was offered in summer 2013, followed by a second course in fall 2013 and a third course in spring 2014. The goals and focus of the training program have remained the same over time.

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II. High-level design of the PF training program

The Practice Facilitator Certificate Program is an online distance-learning course available to interested students nationwide. The program consists of 13 weekly online seminars that include lectures and virtual group discussions led by an experienced instructor, guest presentations by national experts, and weekly reading and other assignments. The program also includes a fieldwork preceptorship, which provides practical training in the field overseen by an experienced PF. Millard Fillmore College is the academic home to the program within UB and supports and facilitates the delivery of the course; the UB Department of Family Medicine and others from CoCoNet2 are responsible for recommending faculty and ensuring that the course design and content are of high quality. The Millard Fillmore College associate dean who initially agreed to the college’s participation described the course as innovative in that it effectively brings together internal resources and resources from other organizations to build a program that helps adults who are seeking career opportunities.

The course was developed by national experts who are members of CoCoNet2 and draws heavily on the training modules in the ������ƵPractice Facilitation Handbook. Because the Handbook was designed as a downloadable print resource to be used by trainers when teaching new PFs, Millard Fillmore College course developers had to transform and add to the content so that it could be used in an online learning environment. In doing so, they combined some topics covered in the Handbook as separate modules into a single classroom session, reorganized the overall sequence of modules, and created a set of presentation slides. Course sessions use, adapt, and add to the Handbook’s original learning objectives and suggested readings and activities.

The course uses online instruction and a supervised preceptorship to provide PFs with the knowledge and skills needed to support meaningful QI in diverse medical practices. Priority topics include QI and measurement skills, organizational assessment, and team building. As is fitting for an online program aimed at adult and continuing education students, the course takes a practical and shared approach to learning in which both instructors and students learn from one another. Likewise, the course follows adult learning principles by making content relevant to students’ professional and personal experiences and by inviting students to reflect upon and share their knowledge and experiences with the class.

III. Training program description

The goal of the course is to teach core competencies of PF work, as well as specialized skills facilitators will need when working with a medical practice. Course learning objectives include understanding the scope of PF services, using assessment tools to identify practice needs and drive QI, collecting and applying performance data for QI, and applying QI methodologies to improve patient care and organizational systems

Program content. At the beginning of the course, students are asked to complete a professional development plan, in which they assess their previous experience working in health care settings, supporting quality improvement, and collecting and analyzing data. This information is used by the instructor to focus the course content on the needs of students enrolled in each particular session.

Core competencies. Core competencies are skills that are valuable for PFs regardless of the substantive focus of their work, such as QI methodologies and measurement skills.

Students learn about the history of various QI approaches, as well as the evidence and context for using each approach. QI topics and skills covered during the course include workflow mapping and redesign, Plan-Do-Study-Act (PDSA) cycles, root-cause analysis, academic detailing, developing QI plans, and supporting practices in implementing change.

Measurement skills addressed during the course include selecting and developing measures, conducting readiness and organizational assessments, measuring and benchmarking clinical and organizational performance, conducting chart audits, and preparing and presenting data to practices in a way that helps them identify areas for improvement and that stimulates a desire to change.

Specialized skills and topics. The course also develops students’ ability to conduct specific tasks with diverse medical practices as part of the facilitation process. Specialized skills and topics include: understanding practice facilitation as a resource for practice improvement, team building, implementing the chronic care model⁴ and patient-centered medical home (PCMH), understanding electronic health records (EHRs) and their meaningful use, and tracking progress and outcomes of PF services.

The course begins with developing students’ understanding of the role of the PF and the contributions that PFs can make to a medical practice. Students learn the common elements of the facilitation process, basic premises for working with medical practices, and tactics for introducing and preparing practices to work with a PF.

Students develop the ability to build strong relationships and teams within practices so that facilitation can be effective. Specialized skills include strategies for running successful meetings, identifying staff members who are appropriate for specific projects, and creating QI teams to facilitate projects and organizational change.

The course builds students’ knowledge in care model implementation and PCMH transformation through understanding of self-management support, population management, registries, and team-based care. There are also sessions on understanding EHRs, helping practices attain meaningful use of health information technology, and using clinical and administrative data for QI purposes. The course concludes with a session on documenting the content and outcomes of facilitation services to track practice priorities and monitor progress.

Assessment of student learning. The course is graded on a pass-fail basis. To pass the course, students must attend or make up each of the weekly sessions (a maximum of two make-up sessions are allowed), complete all required readings, complete the two required assignments satisfactorily and on time, submit weekly reflection journals, contribute productively during online sessions and via discussion boards, and satisfactorily complete a 40-hour preceptorship. Although there are no specific exams for the course, students complete a self-assessment both before and after the course. This self-assessment measures students’ knowledge and confidence levels regarding several topics related to working with practices including using assessment tools, facilitating meetings, leading teams, conducting PDSA cycles, working with clinical data, and developing QI plans. Fieldwork preceptors assess students’ professionalism, motivation, critical thinking skills, and ability to complete common facilitator tasks (conducting PDSA cycles; workflow mapping and redesigning; collecting, managing, and interpreting data; and facilitating team meetings).

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Program delivery. Educational content is delivered to students via weekly online sessions, materials, assignments, discussion boards, journals, and the fieldwork preceptorship.

Weekly online sessions. The course includes 13 weekly sessions hosted on the UB online learning platform. Students link to the platform from their own computers to view course materials, participate in class sessions, and interact with the instructor and other students in real time. Each session lasts 90 minutes and includes a formal presentation delivered by the course instructor. Students with prior experience related to course content are occasionally asked to give presentations. National experts also are invited to present guest lectures occasionally.

Pre-session reading and materials. Each online session has requirements for pre-session preparation. Most sessions require completion of readings prior to class. Readings are often chapters from the ������ƵPractice Facilitation Handbook, case studies, or journal articles. Other pre-session materials include examples of practice assessments or other QI tools and links to YouTube videos showcasing specific PF strategies. All pre-session materials are posted on the online learning platform along with questions that students prepare to answer during the session.

Assignments. Students complete two assignments during the course. In the first, students develop and describe each of the steps in a hypothetical PDSA cycle that could be used to measure the effects of a change implemented by a practice. In the second, students map a workflow and describe the steps involved in the work process, explain the usefulness of mapping the process, identify the staff involved in carrying out the process, and explain how the student would help a team use the workflow map to make and sustain change.

Online discussion boards. At three points during the course, students participate in an online discussion board viewed by the entire class to reinforce concepts from the readings and to encourage critical thinking and discourse. In each of the three discussion boards, students are required to post one substantive comment in response to the topic posed by the instructor and another in response to a classmate’s comment.

Journals. Students submit weekly journal entries to the instructor in which they reflect on what they learned during the seminar and fieldwork and discuss how they will apply what they learned.

Preceptorship. The course requires completion of a 40-hour preceptorship to provide students with hands-on experience, enable them to apply course materials, and further build students’ knowledge and skills. The preceptorship experience can be spread throughout the 13-week course or completed during a 1-week intensive period concurrent with the course or soon after its completion.

Knowledge Network. Students are provided an opportunity to participate in an online learning community (the Knowledge Network) of PFs who are participating in or who have graduated from the program where members can post questions, answer questions, and share resources and ideas.

Methods of instruction. The course includes didactic instruction paired with self-reflection and experiential learning. Didactic teaching methods including instructor-led lectures and student pre-session reading are used to help students build a knowledge base. Experiential learning methods including assignments and supervised practice and application during the preceptorship are used to build skills. Students also complete journals reflecting on knowledge gained during lectures and on their experiences applying knowledge and skills during the preceptorship.

The course strives to be interactive. During the first weekly session, the instructor emphasizes expectations for student participation in online discussions and discussion boards. She makes clear that students are expected to come to each session prepared to answer questions posted on the learning platform, calls on students during class time, and occasionally asks students to make a formal presentation during a future session. She also uses online collaboration tools, including online polling and a chat room feature that enables students to type questions and comments readable by the rest of the class to see to invigorate discussion.

Duration and intensity. The course requires a commitment of approximately 92 hours, including 19.5 hours of class time (13 weeks at 90 minutes per session), 32.5 hours of reflective learning (including pre-session reading and materials, assignments, discussion boards, and journals), and 40 hours of fieldwork.

IV. Trainees

Millard Fillmore College allows for a maximum of 20 students in each session, with an ideal class size of 12 to 15 students to cover costs. However, according to the course instructor, approximately 7 to 8 students per class is optimal from a teaching perspective. This is due to the difficulty of maintaining a high level of interaction and participation with larger class sizes in an online platform. On average, the number of students in each class has been 14 students.

Students must meet certain eligibility requirements in order to take the course, including having both a bachelor’s degree and relevant occupational experience. The majority of students that have enrolled in the course thus far have experience working in health care settings and have included physicians, health care administration staff, and nurses as well as PFs who want more training or certification. Many students have come from university- or community-based PBRNs and some from individual or group medical practices, including community clinics. Host organizations or practices commonly pay tuition on behalf of the student as a professional development investment.

Given that practice facilitation is an emerging field, marketing the Practice Facilitator Certificate Program has been a challenge. In addition to a general lack of awareness of the PF role in the marketplace, there is also limited understanding of the variety of work PFs do. Millard Fillmore College has found word-of-mouth to be most effective in spreading news of the program; as students gain certification and apply the techniques they have acquired in their home organizations and practices, other individuals and practices are learning about the program and expressing interest. The college plans to increase marketing efforts with a focus on expanding the national reach of the program. Additionally, the college plans to capitalize on existing relationships with PBRNs affiliated with CoCoNet2 and is evaluating the possibility of reaching out to national professional organizations such as the Patient-Centered Primary Care Collaborative. Millard Fillmore College is also reaching out to regional workforce development initiatives and medical practices as well as on-campus academic departments.

V. Faculty

The course instructor is an adjunct faculty member hired by Millard Fillmore College on a course-by-course contract basis. She was identified and recommended by several members of CoCoNet2 due to her depth of experience in PF, involvement in the development of the ������ƵPractice Facilitation Handbook, and experience using the Handbook.  Millard Fillmore College instructional design staff members assist with development and implementation of online course content and provide ongoing technical support throughout the duration of the course. In addition, there are two to three guest speakers per course who give presentations on specific topics in their area of expertise, such as the meaningful use of EHRs. At the end of the course, students evaluate the effectiveness of the instructor and provide course feedback. The associate dean also consults with the instructor routinely to review progress toward achieving course objectives.

According to Millard Fillmore College staff, CoCoNet2 members, and others involved with the training program, instructors should have several key qualities to effectively teach the PF course. As basic qualifications, the instructor must have significant experience in facilitating practice transformation, be actively involved in the field, and have previous experience supervising or training practice facilitators. PF students come from varying professional backgrounds and have different levels of expertise in the subject. Because of this diversity, the course instructor noted the importance of being able to adapt to the flow and content of the course as needed. As with any traditional course, instructors must be effective teachers with a strong understanding of pedagogy and an ability to lead group discussions.

Those involved in the development and delivery of the training program also pointed out that there are a number of unique qualities required of the instructor due to the online format of the course. It is helpful for the instructor to have previous online teaching experience and a high degree of comfort with technology. The instructor must be a dynamic, organized, and adaptable facilitator of learning to maintain a high level of student interaction in a virtual environment.

VI. Program administration

The administrative structure for the Practice Facilitator Certificate Program includes several organizational entities. Millard Fillmore College is responsible for academic and administrative oversight of the program. The UB Department of Family Medicine is responsible for curriculum development and instruction. CoCoNet2 members serve as expert consultants to both the college and the department on program content and delivery

As the academic and administrative home to the program, Millard Fillmore College provides general support to ensure that the program conforms to university standards, facilitates registration and communication with interested students, and provides marketing support. The college funds instructional design and development, information technology support, and the instructor’s salary and benefits. Additionally, the college coordinates access to the online distance-learning platform used by the program.

The UB Department of Family Medicine is a critical partner in offering the program. Not only did a member of the department’s faculty initiate the development of the program, but as a part of CoCoNet2, he continues to provide expert consultation and program oversight. The department also funds an educational administrative assistant, who supports course administration and program development, creates course evaluation materials, and oversees the application and certification of preceptor sites.

CoCoNet2 members were heavily involved in and funded the development of the program, including the transformation of the ������ƵPractice Facilitation Handbook into an interactive online learning course. Members met with the instructional design staff while the program was in development and met regularly with the course instructor and other Millard Fillmore College and UB Department of Family Medicine staff during the pilot session to provide ongoing feedback and support.  CoCoNet2 members continue to serve in an advisory role supporting ongoing course development and delivery.

Funding. The initial development of the course was sponsored as a CoCoNet2 project with grant funding from AHRQ. The instructor, a staff member of one of the CoCoNet2 member sites, donated her time during the pilot. Additionally, students who participated in the pilot session did not pay tuition since all were affiliated with CoCoNet2 PBRN sites or were staff at Millard Fillmore College. During the pilot, the college paid costs for the instructional design and technology support staff.

After completion of the pilot, the program transitioned to a self-supporting model. Funding for the program includes student tuition ($4,000) and in-kind donations of time from UB Family Medicine staff and CoCoNet2 members. If a student completes the preceptorship at a certified site, the site receives a $1,000 incentive. The associate dean described the program thus far as a break-even course in that tuition generated enough revenue to cover all direct costs. Future course offerings are expected to cover both direct and indirect costs.

VII. Monitoring the quality of the PF training program

Millard Fillmore College and UB Department of Family Medicine have established mechanisms to monitor the quality of the content and delivery of the training program and have demonstrated a commitment to ongoing quality improvement. The first session of the course was considered a pilot, and all staff and students associated with the course participated actively in providing or responding to feedback. Methods used to monitor and improve the program during the pilot included:

• Student feedback. Students were asked to complete two mid-course and one end-of-course evaluation. Each evaluation included four general questions asking students to assess how helpful the content had been in providing them with knowledge they could apply, identify information they considered most and least helpful, and share recommendations for improving the content or delivery of the course. Additionally, the Millard Fillmore College marketing and development director enrolled as a student in the course and was able to provide feedback both as a student and university representative.
• Biweekly QI team meetings. A QI team including the course instructor, the college’s associate dean and marketing and development director, the UB Department of Family Medicine faculty liaison, the administrative assistant, and the instructional design staff person met biweekly to discuss how the course was proceeding and any modifications that could be implemented immediately. The team discussed curriculum development, course and session learning objectives, student performance and feedback, and strategies for reaching out to the market.
• Ongoing consultation. In addition to the biweekly meetings, the course instructor and instructional design staff person met at least weekly to discuss recommendations and changes that needed to be made to the format and content of the online curriculum.

A number of changes were made to the course in response to feedback gathered during the pilot session. Overall, students were pleased with the course content and no major changes were made. Students and the instructor alike, however, reported that the course was too long and that the required preceptor hours were too extensive. In response, the course was modified from its original 16-week format to the current 13 weeks. The only topic dropped from the course was panel management (because it was considered by the instructor to be more technical than most students required), but other topics were combined into single sessions. Preceptor hours were reduced significantly, from 104 to 40 hours. With regard to course delivery, students reported that the course was not as interactive as they had expected. In response, the instructor began to more fully utilize the chat room and online polling collaboration tools of the online platform to draw students into dynamic group discussions. Some of the challenges faced during the pilot were related to the learning management system or to students’ ability to effectively apply technologies to participate in the course.

Now that the course is out of the pilot phase, the College and the Department of Family Medicine continue to monitor the quality of the program. The university administers course evaluations, and the QI team meets once a month to discuss, evaluate, and identify any modifications needed. Because he is ultimately responsible for ensuring that the program meets university standards for quality, the associate dean also asks the instructor to report on her experience.

The college and the UB Department of Family Medicine were approached by a researcher interested in conducting a formal evaluation of the program; planning is currently underway.

Student outcomes and placements. To date, 28 students have successfully completed the course and received PF certificates. Two students were unable to complete the course due to difficulty making the required time commitment. Since most students who have taken the course have done so under the auspices of their employers, host organizations, or medical practices rather than independently, they have continued to work for those entities after completing the program. In many cases, this is expected by the employer who either subsidized or fully paid for the student’s time and tuition. Thus far, the majority of students have been affiliated with PBRNs; a few were staff members of a medical group practice.

VIII. Next steps

Millard Fillmore College plans to continue to refine and expand offerings of the Practice Facilitator Certificate Program. Depending on demand, the college plans to offer two to three sessions per year. Program leadership, staff and the instructor will continue to review the course and make adjustments to content and format based on student feedback. The course is also continually updated to reflect new developments in the field in order to ensure that the material remains current and relevant.

The long-term vision of Millard Fillmore College is to have a nationally known and recognized standardized training program for practice facilitation. In addition, they hope to build a learning community of PFs, starting with a listserv that includes current students and past graduates of the certificate program. The eventual goal is to extend this community to include PFs nationwide and not just those affiliated with the program.

The college also plans to launch an intensive marketing campaign to spread the word about the course and recruit students. Program leadership and staff are currently identifying a number of strategies targeted at both the national and local level. Based on the current success of the program and established relationships with PBRNs nationwide and medical practices locally, the college is expecting a continued increase in demand for the course and other programs like it.

IX. Lessons learned

A number of lessons emerge from the experiences of the Millard Fillmore College, the UB Department of Family Medicine, and the CoCoNet2 partnership that could be useful to others interested in developing a PF training program:

Building on existing partnerships and leveraging existing resources can help form a robust training program. The Practice Facilitator Certificate Program grew out of a partnership between university partners (Millard Fillmore College and the UB Department of Family Medicine) and external organizations (CoCoNet2’s affiliated members), each of which contributed expertise and resources. The course benefited from existing resources including AHRQ’s Practice Facilitation Handbook and grant funding to CoCoNet2, the content expertise and PF training experience of CoCoNet2 members, the course administration and marketing skills of the college and the Department of Family Medicine staff, and a UB faculty champion who was a driving force for the program’s development.

Having a well-formulated structure aids in developing an online course. The ������ƵPractice Facilitation Handbook was essential as a foundational document. The structure of the Handbook, including its clear learning objectives, reading assignments, and activities for each module, simplified the process of translating the content into an online format. Each module included a table that plainly laid out student expectations for assignments and the amount of time anticipated to complete them.

Involving experienced online instructional design support during course development is crucial. Developing a course for an online platform creates many unique challenges and considerations. Because of this, instructional design staff with expertise and skills in this area should be involved from an early stage. Instructional designers can assist with organizing course content, defining learning objectives, ensuring the effectiveness of instructional material, and identifying how best to engage students in an online environment. These individuals generally have a strong understanding of adult student learning needs, which allows them to identify the most effective teaching strategies and instructional media to facilitate the online learning process based on the instructor’s teaching style. In the case of the Practice Facilitation Certificate Program, the instructional designer provided invaluable expertise not only in the technological aspects of implementing the course but also in educational theory and practice.

Combining classroom and field experiences is an effective teaching approach. A program that includes both didactic and experiential learning is an effective means for building the knowledge and skills PFs will find necessary in their jobs. Requiring students to complete a fieldwork component under the supervision of a more experienced PF enables them to apply the course material and further builds the student’s knowledge and skills.

Planning ahead can reduce technical challenges in an online learning environment. Including material that requires students to download and test software programs before the first class along with tutorials welcoming students and explaining how to use the online platform dramatically lowers the number of technical obstacles encountered.

Incorporating elements of adult learning theory supports student engagement and learning. Part of offering a successful continuing education and certificate program involves understanding how adults and professionals learn best. The Practice Facilitator Certificate Program incorporates adult learning principles by using approaches to learning that are interactive, collaborative, reflective, and applied rather than simply didactic. The course also emphasizes that both the instructor and the students have life experience and knowledge to offer.

Using an instructor who has both PF content expertise and online teaching experience is critical.  In order to be successful, courses require an effective instructor. To succeed in an online distance learning course, instructors must not only have significant subject matter expertise and general teaching experience but also be experienced in online pedagogy. Also important is being skilled at encouraging dialogue and maintaining a high level of student interaction in an online setting. Finally, they must be comfortable working with technology.

Investing in ongoing QI efforts helps ensure program quality. Millard Fillmore College and UB Department of Family Medicine staff and CoCoNet2 members invested heavily in conducting a pilot session of the course, developed a variety of mechanisms to monitor the quality of the content and delivery of the program, and are committed to making ongoing improvements and changes in response to feedback. The course is continually updated to reflect new developments in the field in order to ensure that the material remains current and relevant.

Marketing is important and can be challenging. The status of PF as an emerging field presents both opportunities and challenges for marketing a PF course. Millard Fillmore College has noted that relationship marketing is crucial to the success of programs like this. Some promising approaches identified include taking advantage of existing relationships and networks, reaching out to professional organizations in the field, and working with local workforce programs and local practices. Properly defining the target market and developing an equivalent business plan are also essential to tailoring an effective marketing campaign.

The Millard Fillmore College Practice Facilitation Certificate Program uses a combination of online instruction and a supervised preceptorship to deliver content and instruction. Students enrolled in the program receive training in a variety of core competencies and specialized skills needed to support meaningful QI in diverse medical practices. The experience of the program provides an illustrative model and practical lessons for those interested in building a training program for PFs.

This case study was developed as part of a contract funded by the ������Ƶ and was authored by:

Dana Petersen, PhD., M.P.H., Researcher, Mathematica Policy Research

Liz Babalola, M.P.H., Analyst, Mathematica Policy Research

Jesse Crosson, Ph.D., Senior Researcher, Mathematica Policy Research

Erin Taylor, Ph.D., M.P.P., Associate Director of Health Research and Senior Researcher, Mathematica Policy Research

Deborah Peikes, Ph.D., M.P.A., Senior Fellow, Mathematica Policy Research

References

������Ƶ. Practice Facilitation Handbook.

Coalition of Coordinated Networks (CoCoNet2).

Millard Fillmore Practice Facilitator Certificate Program.