12 research outputs found

    Trust and Reflection in Primary Care Practice Redesign.

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    OBJECTIVE: To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH). DATA SOURCES/STUDY SETTING: Primary data were collected as part of the American Academy of Family Physicians\u27 National Demonstration Project of the PCMH. STUDY DESIGN: We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices. DATA COLLECTION/EXTRACTION METHODS: We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method. PRINCIPAL FINDINGS: Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection. CONCLUSIONS: Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign

    Manifestations and Implications of Uncertainty for Improving Healthcare Systems: An Analysis of Observational and Interventional Studies Grounded in Complexity Science.

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    BACKGROUND: The application of complexity science to understanding healthcare system improvement highlights the need to consider interdependencies within the system. One important aspect of the interdependencies in healthcare delivery systems is how individuals relate to each other. However, results from our observational and interventional studies focusing on relationships to understand and improve outcomes in a variety of healthcare settings have been inconsistent. We sought to better understand and explain these inconsistencies by analyzing our findings across studies and building new theory. METHODS: We analyzed eight observational and interventional studies in which our author team was involved as the basis of our analysis, using a set theoretical qualitative comparative analytic approach. Over 16 investigative meetings spanning 11 months, we iteratively analyzed our studies, identifying patterns of characteristics that could explain our set of results.Our initial focus on differences in setting did not explain our mixed results. We then turned to differences in patient care activities and tasks being studied and the attributes of the disease being treated. Finally, we examined the interdependence between task and disease. RESULTS: We identified system-level uncertainty as a defining characteristic of complex systems through which we interpreted our results. We identified several characteristics of healthcare tasks and diseases that impact the ways uncertainty is manifest across diverse care delivery activities. These include disease-related uncertainty (pace of evolution of disease and patient control over outcomes) and task-related uncertainty (standardized versus customized, routine versus non-routine, and interdependencies required for task completion). CONCLUSIONS: Uncertainty is an important aspect of clinical systems that must be considered in designing approaches to improve healthcare system function. The uncertainty inherent in tasks and diseases, and how they come together in specific clinical settings, will influence the type of improvement strategies that are most likely to be successful. Process-based efforts appear best-suited for low-uncertainty contexts, while relationship-based approaches may be most effective for high-uncertainty situations

    A Survivor\u27s Guide for Primary Care Physicians.

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    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

    Delivery of clinical preventive services in family medicine offices.

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    BACKGROUND: This study aimed to elucidate how clinical preventive services are delivered in family practices and how this information might inform improvement efforts. METHODS: We used a comparative case study design to observe clinical preventive service delivery in 18 purposefully selected Midwestern family medicine offices from 1997 to 1999. Medical records, observation of outpatient encounters, and patient exit cards were used to calculate practice-level rates of delivery of clinical preventive services. Field notes from direct observation of clinical encounters and prolonged observation of the practice and transcripts from in-depth interviews of practice staff and physicians were systematically examined to identify approaches to delivering clinical preventive services recommended by the US Preventive Services Task Force. RESULTS: Practices developed individualized approaches for delivering clinical preventive services, with no one approach being successful across practices. Clinicians acknowledged a 3-fold mission of providing acute care, managing chronic problems, and prevention, but only some made prevention a priority. The clinical encounter was a central focus for preventive service delivery in all practices. Preventive services delivery rates often appeared to be influenced by competing demands within the clinical encounter (including between different preventive services), having a physician champion who prioritized prevention, and economic concerns. CONCLUSIONS: Practice quality improvement efforts that assume there is an optimal approach for delivering clinical preventive services fail to account for practices\u27 propensity to optimize care processes to meet local contexts. Interventions to enhance clinical preventive service delivery should be tailored to meet the local needs of practices and their patient populations

    How Complexity Science Can Inform a Reflective Process for Improvement in Primary Care Practices.

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    BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices\u27 vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements

    A Practice Change Model for Quality Improvement in Primary Care Practice.

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    Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements\u27 evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice

    Understanding Organizational Designs of Primary Care Practices.

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    During the past decade, many hospitals experienced difficulty integrating primary care practices into their health systems. We hypothesized that this difficulty may be, in part, a result of limited understanding of practice organizational designs. The structure and function of practices have not been well studied. In this article, we answer the following questions: Are practices all the same, or do variations in their organizational design exist? Do hospital designs predict the designs of affiliated practices? If variation exists, what are the management implications? Eighteen family practices, including nine affiliated with five separate hospital systems, were studied using an in-depth comparative case study design. A content analysis of the rich descriptive data from these cases indicates that a great variety exists in the organizational design of primary care practices, and this variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. In fact, both affiliated and independent practices exhibited a range of design characteristics, some of which did not fit traditional models. Hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices. Practices response to environmental change was greater when practice autonomy was highest. These findings suggest that a science of practice organizational design separate from that of hospitals is needed to help explain the success and failure of practices within health systems and to provide information for planning practice change
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