External facilitators and interprofessional facilitation teams: a qualitative study of their roles in supporting practice change

Background Facilitation is a powerful approach to support practice change. The purpose of this study is to better understand the facilitation roles exercised by both external facilitators and interprofessional facilitation teams to foster the implementation of change. Building on Dogherty et al.’s taxonomy of facilitation activities, this study uses an organizational development lens to identify and analyze facilitation roles. It includes a concise definition of what interprofessional facilitation teams actually do, thus expanding our limited knowledge of teams that act as change agents. We also investigate the facilitation dynamics between change actors. Methods We carried out a qualitative analysis of a 1-year process of practice change implementation. We studied four family medicine groups, in which we constituted interprofessional facilitation teams. Each team was supported by one external facilitator and included at least one family physician, one case manager nurse, and health professionals located on or off the family medicine group’s site (one pharmacist, plus at least one nutritionist, kinesiologist, or psychologist). We collected our data through focus group interviews with the four teams, individual interviews with the two external facilitators, and case audit documentation. We analyzed both predetermined (as per Dogherty et al., 2012) and emerging facilitation roles, as well as facilitation dynamics. Results A non-linear framework of facilitation roles emerged from our data, based on four fields of expertise: change management, project management, meeting management, and group/interpersonal dynamics. We identified 72 facilitation roles, grouped into two categories: “implementation-oriented” and “support-oriented.” Each category was subdivided into themes (n = 6; n = 5) for clearer understanding (e.g., legitimation of change/project, management of effective meetings). Finally, an examination of facilitation dynamics revealed eight relational ties occurring within and/or between groups of actors. Conclusions Facilitation is an approach used by appointed individuals, which teams can also foster, to build capacity and support practice change. Increased understanding of facilitation roles constitutes an asset in training practitioners such as organizational development experts, consultants, facilitators, and facilitation teams. It also helps decision makers become aware of the multiple roles and dynamics involved and the key competencies needed to recruit facilitators and members of interprofessional facilitation teams. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0458-7) contains supplementary material, which is available to authorized users.

"Doctor L was thrilled about the kinesiologist and the role she will be assuming with patients. He wants us to organize a meeting with the doctors from his clinic, so they will feel confident about referring patients to the kinesiologist." (EF field notes-T3-FMG1)

Communication of vision and project guidelines (A3)
Communicating the vision is recognized as a key factor for the success of change/project implementation [1,5]. It involves relaying change-related information in every possible way, as well as showing by example [1]. Facilitation roles within this theme are aimed at communicating the vision or "direction in which an organization needs to move" [1:99], by using techniques such as mentoring and storytelling, or by providing an understanding of the project through information on research protocol, project organization, new tools, evidence used, etc.
Excerpts related to TRANSIT: "If we hadn't had a facilitator, I don't think we would have worked towards these objectives… We wouldn't have had any direction, in fact. So I think that her role was really to define what the research was about." (Interview T6-IFT4) "Regarding the community pharmacists that work outside [the clinic] … many of those that work for the same company as me have come to me… asking for details, but again, it's all about communication… We did the letter probably a little late, since many of them had already seen patients with health booklets before they received any explanation. I gave them a maximum of information, but it's not always easy… they ask many questions about the project, it requires having enough time to clearly explain to everyone." (Interview T6-IFT4) Empowerment of others to act towards change (A4) Although "empowering group members" was seen as a single facilitation activity by Dogherty et al. [6], we have found that this theme encompasses a large number of facilitation roles. Similarly to Kotter's description of empowering others to act [1], these facilitation roles are aimed at removing obstacles to change, changing structures and processes as needed, creating local ownership, and allowing change actors to move forward towards change/project implementation. Application of the PDSA (plan-do-study-act) cycle (A5) Although Young considered "planning" and "preparation" separately, he identified "do-checkact" as one of the main themes recurrent across his change literature review, describing it as keeping the transition aligned and steering towards what needs to be delivered [7]. Since we found that all four steps of Deming's well-known PDSA cycle were emerging and looping throughout TRANSIT's implementation process, we decided to keep them together under this theme. The loop concept is recognized in project management (re: planning loops [8]), as well as in change management, especially with regard to the learning organization approach (i.e. singleloop and second-loop learning) [7,9]. Used by practice facilitators [10] and other change agents, the PDSA cycle is a method that helps to structure improvement projects [11]. Facilitation roles under this theme are aimed at setting up plans (e.g. project management plan, schedules, budget plans, communications), steering and managing implementation efforts, monitoring progress and verifying the success or failure of actions implemented, and making adjustments as needed.
Excerpts related to TRANSIT: "Doctor C suggests that before the end of the meeting we make a list of actions and assign these actions to those concerned. A list of actions was sent later that day to all IFT members." (Minutes T6-FMG4) Consolidation and continuity of improvements (A6) One of the concerns raised by interprofessional facilitation teams was how they could keep the project going after external facilitators left, or ensure improvement results were maintained. Kotter highlights the importance of keeping the process alive, as well as ensuring leadership succession [1]. The facilitation role under this theme is aimed at making sure that the positive outcomes of the change/project are maintained even after the facilitation team has dissolved or the facilitator has left (meaning that he/she "passed the baton" [12]). This theme has to do with creating a context that allows dialogue [13]. It includes facilitation roles aimed at making meetings happen (e.g. reaching participants to schedule meetings, sorting out logistics), structuring the meetings, and guiding the group through the agenda in respect of all individuals.

Excerpts related to TRANSIT: "We asked [External facilitator 2] to include… in her agenda, … a schedule with times… and when we get sidetracked, the person who manages the time [timekeeper] calls us to order, reminding us when we only have five minutes left to discuss an item." (Interview T6-IFT2) "I appreciate what she [the external facilitator] sends by email… she talks about the agenda, invites us to add other agenda items … She also sends a reminder and confirms the meeting."
(Interview T6-IFT4)

Relationship development (B2)
Relationship development is one of the aspects that groups must go through during their first step of development, often called the "forming" step [14]. Facilitation roles concerning relationship development are mostly aimed at building bridges between group members [15], but they can also occur with different actors involved with implementing the change/project. These roles are represented by activities such as each person around the table giving a presentation, preparing/sharing documents with members' contact details, running team-building activities, or meeting new members prior to their first meeting. "Emotion is to do with the fulfilment or frustration of our individual needs and interests in the forms of joy, surprise, anger, grief and so on" [16]. Facilitation roles related to this theme are aimed at creating and maintaining an open, supportive, and trusting environment; detecting the emotions expressed by change actors (verbally or non-verbally), listening to their concerns and reacting accordingly; as well as dealing with conflicts that may be roadblocks to change/project implementation (e.g. gathering opinions, verifying level of agreement, holding meetings with individuals and in groups to resolve the conflict, etc.).
Excerpts related to TRANSIT: Encouraging can take different forms, including praising, agreeing, valuing the contribution of others, demonstrating a warm and solidary attitude, showing understanding towards one's point of view, and accepting ideas or suggestions [17]. These facilitation roles are expected to provide the encouragement to work together and achieve goals, through positive reinforcement and appreciation. Facilitation has been associated with training and group development ever since Lewin's Tgroups started in the mid-1940s [18]. The facilitation role under this theme is aimed at educating, training, and coaching individuals and/or groups on: quality-improvement philosophy, methods, and skills [19,20]; values supported by the change/project; and group-or individualdevelopment-related subjects, tools, and techniques (e.g. facilitation, leadership, teamwork, problem-solving).
Excerpt related to TRANSIT: "The PDSA cycle was briefly explained during the meeting. I presented the model to them, which will allow us to evaluate the processes and activities that we will integrate into their practices." (EF Field notes-T3-FMG4) "[Regarding more advanced training on motivational interview] [The nutritionist] gathered information on next training dates and cost." (Minutes T12-FMG2)