How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?

Deborah J. Cohen, Bijal A. Balasubramanian, Stephan Lindner, William L. Miller, Shannon M. Sweeney, Jennifer D. Hall, Rikki Ward, Miguel Marino, Rachel Springer, K. John McConnell, Jennifer R. Hemler, Sarah S. Ono, David Ezekiel-Herrera, Andrea Baron, Benjamin F. Crabtree, Leif I. Solberg

Research output: Contribution to journalArticlepeer-review


INTRODUCTION: To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS: Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS: Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

Original languageEnglish (US)
Pages (from-to)1115-1127
Number of pages13
JournalJournal of the American Board of Family Medicine : JABFM
Issue number6
StatePublished - Dec 23 2022


  • Cardiovascular Diseases
  • Leadership
  • Linear Models
  • Population Health Management
  • Primary Health Care
  • Quality Improvement
  • Surveys and Questionnaires
  • Workforce

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Family Practice


Dive into the research topics of 'How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives?'. Together they form a unique fingerprint.

Cite this