How do practice coaches support practices in making organizational changes necessary to improve care?

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Ambulatory transformation initiatives, such as TransforMED and the Safety Net Medical Home Initiative, emphasize the importance of addressing organizational change as part of any quality improvement effort. The TransforMED investigators have identified a capability of practices they term “adaptive capacity” that indicates, in their view, a practice’s ability to undertake rapid and ongoing change.  Many QI experts have suggested that defining and implementing systematic ways to assess whether a practice is “well functioning” and whether it has adaptive capacity can improve its readiness to undertake and sustain transformation.  
 
The Waterline Model has been adapted by practice coaching programs to identify “rough water” cues, when teams should move from “task” talk to “maintenance” talk. Maintenance issues (issues ” under the waterline”) are those that have to do with underlying beliefs, values, and assumptions that individuals bring to a group setting. Maintenance includes structural issues (clarity about goals, roles, and decision making), team effectiveness (participation, influencing, conflict resolution, and interaction patterns), interpersonal issues (how two people communicate with each other and how to respond to one-on-one conflict), and intra-personal issues (how individuals experience the process working together).  
 
The South Central Pennsylvania alliance developed a Team Maturity Assessment Tool that defines the culture of a practice in four categories: leadership, collaboration, continuous improvement, and culture of learning. Based on the inputs, it provides recommendations for improvement steps on team culture concepts and generates a tailored action plan log sheet. The tool is designed to be completed by each team member and automatically creates graphs that can be used to communicate results to staff. 
 
Once practice coaches have identified organizational change issues, methods and techniques should be used to foster new habits of communication with staff and clinicians. Practice coaches should build into the coaching arrangement how and in what ways they will coach practice leaders to foster and accelerate adaptive capacity.
 
Compiled by Jen Powell, an AF4Q technical advisor working with the Improving Performance in Practice (IPIP) Technical Support Team.