Emerging Methodologies for Systems Improvement in Primary Care

             Developed at the University of Oklahoma, UNYNET is testing the efficacy of Practice Enhancement Assistants or PEAS in improving quality in Primary Care Offices. The strength of PEAS is that the help to overcome the burden of competing demands while at the same time have the ability to share best practices rapidly between offices. We have two AHRQ grants, one regarding geriatric drug safety and the other regarding chronic kidney disease that will test the usefulness of PEAS in underserved office settings compared to usual care and on-site physician education.

Practice Enhancement Assistants

Summary Information

Practice Enhancement Assistants

Practice enhancement assistants (PEAs) are individuals who develop a relationship with a group of practices over a period of time, generally eight practices per PEA, in order to help them to evaluate and improve their quality of care.   This is generally accomplished through practice audits and feedback, patient satisfaction surveys, staff training, “cross-fertilization” (sharing of ideas among the eight practices), coordination of quality improvement initiatives, and provision of specific materials and resources (flow sheets, computer training, etc.). The idea for the PEA concept came from England, where “practice facilitators” have been a feature of the national health program for some time, and from Canada, where similar outreach workers have been an important part of a successful initiative to increase rates of delivery of preventive services by primary care physicians in Ontario. 

It has been our experience that physicians who are involved in research projects from design to results tend to have less trouble integrating the findings into their practices.  The obstacles that we have encountered are often technical (e.g. How, exactly do you do that? or Where can I get one of those?) or they have to do with the large differences that exist between practices (e.g., “I see how it works, but I’m not sure how to make it fit in our system.”).  Based upon the experience of several investigators in the United States and England, we have concluded that facilitators who go into the practices to help physicians and their staff implement new methods may be an effective way to overcome most of these obstacles (Modell et al, 1998; Bryce et al, 1995; Carroll et al, 1994; Carney et al, 1992). 

Such facilitators, which we plan to call Practice Enhancement Assistants (PEA’s), could accomplish several other useful tasks as well.  These tasks can be divided into three categories: facilitation of the research process itself, facilitation of practice enhancements (implementation), and facilitation of communication.  PEAs will be individuals with Master’s degrees (e.g., in health promotion sciences) or nursing degrees who will be assigned as the functional link among members of UNYNET, PCRI, and The University at Buffalo.  Each PEA will be assigned to 8 practices, visiting each one every two weeks on a predictable schedule, spending the day assisting the practice with identified objectives and obstacles, and meeting with the physicians and key support staff at lunch on those days.  They will also spend one day per week at the OCFMR discussing the needs of their practitioners and learning more about how to address them.


Roles and functions of Practice Enhancement Assistants

  1. Facilitation of practice enhancements
    • help physicians and staff to implement changes in their practices (e.g. implementing changes suggested by OKPRN research or clinical practice guidelines)
      1. identify the changes that practices want to make
      2. provide information about how others are doing it
      3. grunt work (e.g. getting flowsheets , logbooks, etc.)
    • conduct periodic chart audits and time/motion studies and providing feedback to the practitioners and staff regarding performance in areas of concern or proposed change.

  2. Facilitation of communication including use of information technologies
    • train physicians and staff to use information systems (e.g. e-mail , internet, palm pilot)
    • assist practices with glitches and problems that occur in their use of information technologies
    • Identify practice/community needs regarding consultations/referrals from OUHSC faculty
    • Identify practice/community needs for CME and communicate these to the DFPM and the CME office at the OUHSC.
    • Cross-pollination (sharing good ideas from one practice/physician with others)

  3. Facilitation of research
    • train physicians and staff to follow study protocols
    • collect data for studies requiring intermittent data collection
    • audit and or pull charts for others to audit (e.g. research assistant)
    • provide additional study cards and other materials
    • transport study data to the Center
    • update practices regarding the status and findings from recent or ongoing studies
    • collect new research ideas from practitioners and staff
    • collect ideas for improving research protocols
    • get feedback on the types of studies being done
    • get feedback on manuscripts prior to submission



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