Development of a Theory for Understanding Engagement in Quality Improvement in Primary Care

Context: Practice redesign and quality improvement (QI) is essential for primary care practices to achieve high quality health care. Studies in non-primary care fields have identified factors that influence engagement in QI work. Less is known about factors that facilitate and inhibit QI work in primary care. Objective: To expand our theoretical understanding of factors that facilitate or inhibit engagement in QI work in primary care. Design: Cross-project evaluation of qualitative and quantitative data collected from 4 QI studies. Comparative analysis conducted. Setting: Primary care practices participating in one of 4 QI studies. Results: We describe a theoretical model that depicts the interrelationship of factors that influence practice engagement in QI work, where QI engagement is defined as the active participation in QI work through allocation of time and deliberate action. Key factors include: 1) Professional status, which refers to the relative position of individuals within the social hierarchy. In primary care, professional status varies widely, from physicians to individuals with high school degrees. 2) Psychological safety, which refers to the sense of safety individuals have within a group. When present, individuals are more likely to be active participants. 3) Leadership behavior, or the actions of those in charge that influence the involvement of others. And 4) The nature of the quality improvement target, meaning whether a target was clinical or administrative. This factor defines who should be involved in the QI process. Our theoretical model suggests that practices able to manage differences in professional status create psychologically safe environments in which QI engagement is more likely to result. Conclusions: Practice redesign and improvement in primary care is founded on the assumption that primary care practices have the capacity to experiment, innovate and change. We offer initial theoretical insight as to how to foster quality improvement work in primary care

Patient Centered Medical Home: A Journey Not a Destination

The Patient-Centered Medical Home (PCMH) is proposed as a vehicle to deliver primary health care to older adults. The PCMH has the ability to improve the quality of care and reduce unnecessary expenditures while fostering functional independence and improving quality of life. Steps to develop a PCMH for older adults include clarity of purpose, team building, process improvement, setting time for reflection and course adjustment, defining accountability, providing a supportive and safe work environment, fully utilizing capabilities of the electronic health record and building relationships with external community partners. Building and maintaining a PCMH requires payment changes in the form of blended or direct primary care payments. Some organizational structures beyond the PCMH can hinder development of the PCMH by excessive standardization and micromanaging or they can facilitate development by providing appropriate support with facilitative leadership. The PCMH is a journey, not a destination and requires ongoing evolution of medical models and attention to patient preferences

A Survivor\u27s Guide for Primary Care Physicians.

Building strong relationships among physicians and staff improves the practice\u27s ability to deal with the uncertainties of a rapidly changing environment. Interacting proactively with the economic, social, political, and cultural environment-the practice landscape-provides opportunities for adaptation and ongoing learning