A practice change model for quality improvement in primary care practice
Health Care Sciences & Services; behavior; physicians; health-care; rates; impact; sites; policy; clinical-practice; preventive service delivery
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' 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.
Cohen D; McDaniel R R; Crabtree B F; Ruhe M C; Weyer S M; Tallia A; Miller W L; Goodwin M A; Nutting P; Solberg L I; Zyzanski S J; Jaen C R; Gilchrist V; Stange K C
Journal of Healthcare Management
2004
2004-05
Journal Article or Conference Abstract Publication
n/a
Illuminating the 'black box' - A description of 4454 patient visits to 138 family physicians
cost; family; family practice; General & Internal Medicine; health-care system; managed care; medical outcomes; physician's practice patterns; physicians; physicians' offices; preventive health services; trends
BACKGROUND. The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. METHODS. Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. RESULTS. Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. Fifty-eight percent of visits were for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSIONS. Family practice and patient visits are complex, with competing demands and opportunities to address a wide range of problems of individuals and families over time and at various stages of health and illness. Multimethod research in practice settings can identify ways to enhance the competing opportunities of family practice to improve the health of their patients.
Stange K C; Zyzanski S J; Jaen C R; Callahan E J; Kelly R B; Gillanders W R; Shank J C; Chao J; Medalie J H; Miller W L; Crabtree B F; Flocke S A; Gilchrist V J; Langa D M; Goodwin M A
Journal of Family Practice
1998
1998-05
Journal Article
n/a