title: Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration.
abstract: BACKGROUND
  Facilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement.
  
  
  METHODS
  We conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators.
  
  
  RESULTS
  The external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach's role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time.
  
  
  CONCLUSIONS
  This study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts.
authors.affiliation: VA Center for Applied Systems Engineering, VISN11 - Veterans Engineering Resource Center, Roudebush VAMC, Indianapolis, IN, USA. balmatee.bidassie@va.gov.
authors.forename: Balmatee
authors.initials: B
authors.lastname: Bidassie
authors.affiliation: HSR&D VA Stroke QUERI Center and VA Center for Health Information and Communication (CHIC), Roudebush VAMC, Regenstrief Inc, Indiana University School of Medicine, Indianapolis, IN, USA. Linda.Williams6@va.gov.|Departments of Communication, General Internal Medicine and Geriatrics, and Neurology, Indiana University School of Medicine, Indianapolis, IN, USA. Linda.Williams6@va.gov.
authors.forename: Linda S
authors.initials: LS
authors.lastname: Williams
authors.affiliation: VA Center for Applied Systems Engineering, VISN11 - Veterans Engineering Resource Center, Roudebush VAMC, Indianapolis, IN, USA. Heather.Woodward-Hagg@va.gov.
authors.forename: Heather
authors.initials: H
authors.lastname: Woodward-Hagg
authors.affiliation: HSR&D VA Stroke QUERI Center and VA Center for Health Information and Communication (CHIC), Roudebush VAMC, Regenstrief Inc, Indiana University School of Medicine, Indianapolis, IN, USA. Marianne.Matthias@va.gov.|Departments of Communication, General Internal Medicine and Geriatrics, and Neurology, Indiana University School of Medicine, Indianapolis, IN, USA. Marianne.Matthias@va.gov.
authors.forename: Marianne S
authors.initials: MS
authors.lastname: Matthias
authors.affiliation: HSR&D VA Stroke QUERI Center and VA Center for Health Information and Communication (CHIC), Roudebush VAMC, Regenstrief Inc, Indiana University School of Medicine, Indianapolis, IN, USA. Teresa.Damush@va.gov.|Departments of Communication, General Internal Medicine and Geriatrics, and Neurology, Indiana University School of Medicine, Indianapolis, IN, USA. Teresa.Damush@va.gov.
authors.forename: Teresa M
authors.initials: TM
authors.lastname: Damush
mesh_terms: D003142:Communication; D003299:Cooperative Behavior; D006801:Humans; D007407:Interviews as Topic; D010348:Patient Care Team / Q000458:organization & administration*; D017064:Process Assessment, Health Care; D024382:Professional Role; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*; D020521:Stroke / Q000628:therapy*; D013689:Telephone; D014481:United States; D014493:United States Department of Veterans Affairs