1
|
Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
Collapse
Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| |
Collapse
|
2
|
Lyles CR, Handley MA, Ackerman SL, Schillinger D, Williams P, Westbrook M, Gourley G, Sarkar U. Innovative Implementation Studies Conducted in US Safety Net Health Care Settings: A Systematic Review. Am J Med Qual 2018; 34:293-306. [PMID: 30198304 PMCID: PMC7243669 DOI: 10.1177/1062860618798469] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Little is known about dissemination and implementation in safety net settings. The authors conducted a literature review of innovation/implementation studies in US safety net health care settings between 2008 and 2017. Each article was coded for (1) intervention characteristics, (2) implementation stage, (3) internal versus external ownership, and (4) prespecified implementation outcomes (eg, acceptability and fidelity). Twenty studies were identified; the majority were implemented within community clinics or integrated safety net systems (15 articles), most involved care process improvements (13 articles), and most were internally developed (13 articles). The internally developed innovations reported fewer barriers to acceptability among staff/providers, higher leadership involvement and organizational alignment, greater amounts of customization to the local setting, and better sustainment. Future work should harness the high levels of alignment and acceptability in implementation research within safety net settings, with an eye toward maintaining fidelity to facilitate dissemination across sites.
Collapse
|
3
|
Turner A, Mulla A, Booth A, Aldridge S, Stevens S, Begum M, Malik A. The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [PMID: 29972636 DOI: 10.3310/hsdr06250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BackgroundThe Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.ObjectivesThe three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.DesignThere were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.Main outcome measuresThe quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.Data sourcesSearches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.Review methodsA realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.ResultsDelivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.Strengths and limitationsThe project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.ConclusionsMultispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.Future workA set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.Study registrationThis study is registered as PROSPERO CRD42016039552.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Alison Turner
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Abeda Mulla
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shiona Aldridge
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Sharon Stevens
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Mahmoda Begum
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| | - Anam Malik
- The Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
| |
Collapse
|
4
|
Quigley DD, Predmore ZS, Chen AY, Hays RD. Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients. Qual Manag Health Care 2018; 26:7-14. [PMID: 28030459 PMCID: PMC11087016 DOI: 10.1097/qmh.0000000000000118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform. METHODS We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns. RESULTS We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients. CONCLUSIONS NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.
Collapse
Affiliation(s)
- Denise D Quigley
- RAND Corporation, Santa Monica, California (Dr Quigley); RAND Corporation, Boston, Massachusetts (Mr Predmore); AltaMed Health Services Corporation, Los Angeles, California (Dr Chen); and UCLA, Division of General Internal Medicine & Health Services Research, Los Angeles, California (Dr Hays)
| | | | | | | |
Collapse
|
5
|
Mendel P, Chen EK, Green HD, Armstrong C, Timbie JW, Kress AM, Friedberg MW, Kahn KL. Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process. Health Serv Res 2017; 53:2523-2546. [PMID: 29243823 DOI: 10.1111/1475-6773.12803] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To understand the process of practice transformation by identifying pathways for attaining patient-centered medical home (PCMH) recognition. DATA SOURCES/STUDY SETTING The CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration was designed to help FQHCs achieve NCQA Level 3 PCMH recognition and improve patient outcomes. We used a stratified random sample of 20 (out of 503) participating sites for this analysis. STUDY DESIGN We developed a conceptual model of structural, cultural, and implementation factors affecting PCMH transformation based on literature and initial qualitative interview themes. We then used conventional cross-case analysis, followed by qualitative comparative analysis (QCA), a cross-case method based on Boolean logic algorithms, to systematically identify pathways (i.e., combinations of factors) associated with attaining-or not attaining-Level 3 recognition. DATA COLLECTION METHODS Site-level indicators were derived from semistructured interviews with site leaders at two points in time (mid- and late-implementation) and administrative data collected prior to and during the demonstration period. PRINCIPAL FINDINGS The QCA results identified five distinct pathways to attaining PCMH recognition and four distinct pathways to not attaining recognition by the end of the demonstration. Across these pathways, one condition (change leader capacity) was common to all pathways for attaining recognition, and another (previous improvement or recognition experience) was absent in all pathways for not attaining recognition. In general, sites could compensate for deficiencies in one factor with capacity in others, but they needed a threshold of strengths in cultural and implementation factors to attain PCMH recognition. CONCLUSIONS Future efforts at primary care transformation should take into account multiple pathways sites may pursue. Sites should be assessed on key cultural and implementation factors, in addition to structural components, in order to differentiate interventions and technical assistance.
Collapse
Affiliation(s)
| | | | | | | | | | - Amii M Kress
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mark W Friedberg
- RAND Corporation, Boston, MA.,Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Katherine L Kahn
- RAND Corporation, Santa Monica, CA.,David Geffen School of Medicine at UCLA, Los Angeles, CA
| |
Collapse
|
6
|
Tomoaia-Cotisel A, Farrell TW, Solberg LI, Berry CA, Calman NS, Cronholm PF, Donahue KE, Driscoll DL, Hauser D, McAllister JW, Mehta SN, Reid RJ, Tai-Seale M, Wise CG, Fetters MD, Holtrop JS, Rodriguez HP, Brunker CP, McGinley EL, Day RL, Scammon DL, Harrison MI, Genevro JL, Gabbay RA, Magill MK. Implementation of Care Management: An Analysis of Recent AHRQ Research. Med Care Res Rev 2016; 75:46-65. [PMID: 27789628 DOI: 10.1177/1077558716673459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.
Collapse
Affiliation(s)
- Andrada Tomoaia-Cotisel
- 1 The RAND Corporation, Boston, MA, USA.,2 University of Utah, Salt Lake City, UT, USA.,3 London School of Hygiene and Tropical Medicine, London, UK
| | - Timothy W Farrell
- 2 University of Utah, Salt Lake City, UT, USA.,4 VA Geriatric Research, Education, and Clinical Center, Salt Lake City, UT, USA
| | - Leif I Solberg
- 5 HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | | | | | | | | | - Diane Hauser
- 7 Institute for Family Health, New York, NY, USA
| | | | - Sanjeev N Mehta
- 12 Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Robert J Reid
- 13 Group Health Research Institute, Seattle, WA, USA
| | - Ming Tai-Seale
- 14 Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | | | - Janice L Genevro
- 20 Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Robert A Gabbay
- 12 Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
7
|
Eiff MP, Green LA, Holmboe E, McDonald FS, Klink K, Smith DG, Carraccio C, Harding R, Dexter E, Marino M, Jones S, Caverzagie K, Mustapha M, Carney PA. A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:1293-1304. [PMID: 27028034 DOI: 10.1097/acm.0000000000001167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training. METHOD In this mixed-method pilot study (2012-2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members' confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis. RESULTS Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members' confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains ("Continuity of Care," "Support/Care Coordination") improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change. CONCLUSIONS Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.
Collapse
Affiliation(s)
- M Patrice Eiff
- M.P. Eiff is professor and vice chair, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. L.A. Green is professor of family medicine, Epperson-Zorn Chair for Innovation in Family Medicine and Primary Care, University of Colorado, Denver, Colorado. E. Holmboe is senior vice president, Milestone Development and Evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. F.S. McDonald is senior vice president, Academic and Medical Affairs, American Board of Internal Medicine, Philadelphia, Pennsylvania. K. Klink is director, Medical & Dental Education, Department of Veterans Affairs Office of Academic Affiliations, Washington, DC. D.G. Smith is director, Graduate Medical Education, Abington Memorial Hospital, Abington, Pennsylvania, and clinical associate professor of medicine, Temple University School of Medicine, Philadelphia, Pennsylvania. C. Carraccio is vice president, Competency-Based Assessment Program, American Board of Pediatrics, Chapel Hill, North Carolina. R. Harding is research assistant, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. E. Dexter is biostatistician, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. M. Marino is assistant professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon. S. Jones is program director, Virginia Commonwealth University-Fairfax Residency Program, Fairfax, Virginia. K. Caverzagie is associate dean for educational strategy, University of Nebraska School of Medicine, Omaha, Nebraska. M. Mustapha is assistant professor, Department of Internal Medicine and Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota. P.A. Carney is professor of family medicine, School of Medicine, and professor of public health, School of Public Health, Oregon Health & Science University, Portland, Oregon
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Lanham HJ, Palmer RF, Leykum LK, McDaniel RR, Nutting PA, Stange KC, Crabtree BF, Miller WL, Jaén CR. Trust and Reflection in Primary Care Practice Redesign. Health Serv Res 2016; 51:1489-514. [PMID: 26611650 PMCID: PMC4946034 DOI: 10.1111/1475-6773.12415] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
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' 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.
Collapse
Affiliation(s)
- Holly Jordan Lanham
- Department of Medicine/Hospital Medicine & Department of Family and Community MedicineThe University of Texas Health Science CenterSan AntonioTX
- South Texas Veterans Health Care SystemSan AntonioTX
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
| | - Raymond F. Palmer
- Department of Family and Community MedicineThe University of Texas Health Science CenterSan AntonioTX
| | - Luci K. Leykum
- South Texas Veterans Health Care SystemSan AntonioTX
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
- Department of Medicine/Hospital MedicineThe University of Texas Health Science CenterSan AntonioTX
| | - Reuben R. McDaniel
- Department of Information, Risk and Operations ManagementMcCombs School of BusinessThe University of Texas at AustinSan AntonioTX
| | | | - Kurt C. Stange
- Departments of Family Medicine, Epidemiology and Biostatistics, and SociologyCase Comprehensive Cancer CenterCase Western Reserve UniversityClevelandOH
| | - Benjamin F. Crabtree
- Department of Family Medicine & Community HealthRutgers Robert Wood Johnson Medical SchoolNew BrunswickNJ
| | - William L. Miller
- Department of Family MedicineLehigh Valley Health NetworkAllentownPA
| | - Carlos Roberto Jaén
- Departments of Family & Community Medicine, and Epidemiology and BiostatisticsResearch to Advance Community Health CenterThe University of Texas Health Sciences CenterSan AntonioTX
| |
Collapse
|
9
|
White D. Identifying potential academic leaders: Predictors of willingness to undertake leadership roles in an academic department of family medicine. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:e102-e109. [PMID: 27331226 PMCID: PMC4755654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To identify variables associated with willingness to undertake leadership roles among academic family medicine faculty. DESIGN Web-based survey. Bivariate and multivariable analyses (logistic regression) were used to identify variables associated with willingness to undertake leadership roles. SETTING Department of Family and Community Medicine at the University of Toronto in Ontario. PARTICIPANTS A total of 687 faculty members. MAIN OUTCOME MEASURES Variables related to respondents' willingness to take on various academic leadership roles. RESULTS Of all 1029 faculty members invited to participate in the survey, 687 (66.8%) members responded. Of the respondents, 596 (86.8%) indicated their level of willingness to take on various academic leadership roles. Multivariable analysis revealed that the predictors associated with willingness to take on leadership roles were as follows: pursuit of professional development opportunities (odds ratio [OR] 3.79, 95% CI 2.29 to 6.27); currently holding at least 1 leadership role (OR 5.37, 95% CI 3.38 to 8.53); a history of leadership training (OR 1.86, 95% CI 1.25 to 2.78); the perception that mentorship is important for one's current role (OR 2.25, 95% CI 1.40 to 3.60); and younger age (OR 0.97, 95% CI 0.95 to 0.99). CONCLUSION Willingness to undertake new or additional leadership roles was associated with 2 variables related to leadership experiences, 2 variables related to perceptions of mentorship and professional development, and 1 demographic variable (younger age). Interventions that support opportunities in these areas might expand the pool and strengthen the academic leadership potential of faculty members.
Collapse
|
10
|
Fontaine P, Whitebird R, Solberg LI, Tillema J, Smithson A, Crabtree BF. Minnesota's Early Experience with Medical Home Implementation: Viewpoints from the Front Lines. J Gen Intern Med 2015; 30:899-906. [PMID: 25500785 PMCID: PMC4471008 DOI: 10.1007/s11606-014-3136-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 10/16/2014] [Accepted: 11/14/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evidence is evolving about the impact of patient-centered medical homes (PCMHs) on important outcomes in primary care. Minnesota has developed its own PCMH certification process, envisioned as an all-payer initiative with an emphasis on patient-centeredness, which may add unique experiences and outcomes to the national discussion. OBJECTIVE We aimed to identify the facilitators and barriers encountered by nine diverse primary care practices selected from the first 80 to achieve PCMH certification in Minnesota. DESIGN This was a qualitative analysis of semi-structured, in-person interviews. PARTICIPANTS Thirty-one administrative and clinical leaders, including clinic managers, physician champions, medical directors, nursing supervisors, and care coordinators participated in the study. KEY RESULTS Six factors emerged as most important to the efforts to become PMCHs: leadership support, organizational culture, finances, quality improvement (QI) experience, information technology (IT) resources, and patient involvement. Facilitators included committed leadership at local and higher levels, prior experience and ongoing support for QI initiatives, and adequate financial and IT resources. Reimbursement was a significant barrier due to perceived inadequacy and inconsistent participation by health plans. The unsuitability of electronic medical records (EMRs) to PCMH documentation requirements likewise presented ongoing challenges. Many interviewees described patient input as helpful to their clinics' PCMH-related changes and were enthusiastic about their "patient partners." The majority of interviewees felt that becoming a PCMH was right for patients and was personally worthwhile, even while acknowledging the tremendous effort involved and voicing skepticism about reimbursement over the short term. CONCLUSIONS The experience of participants in Minnesota's state-wide initiative to legislate PCMH transformation provides a broad view of facilitators and barriers. Unique facilitators included a requirement for patient involvement, which pushed practices to create patient-centered innovations, and new reimbursement models based on quality indicators for a population. Among barriers were the costs to practices and patients, and EMRs that failed to accommodate PCMH requirements.
Collapse
Affiliation(s)
- Patricia Fontaine
- HealthPartners Institute for Education and Research, PO Box 1524, MS 23301A, Minneapolis, MN, 55440-1524, USA,
| | | | | | | | | | | |
Collapse
|
11
|
Kozakowski SM, Eiff MP, Green LA, Pugno PA, Waller E, Jones SM, Fetter G, Carney PA. Five Key Leadership Actions Needed to Redesign Family Medicine Residencies. J Grad Med Educ 2015. [PMID: 26221432 PMCID: PMC4512787 DOI: 10.4300/jgme-d-14-00214.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership. OBJECTIVE We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change. METHODS The Preparing the Personal Physician for Practice (P4) project (2007-2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign. RESULTS Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience. CONCLUSIONS Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.
Collapse
|
12
|
Reasons for non-response to a direct-mailed FIT kit program: lessons learned from a pragmatic colorectal-cancer screening study in a federally sponsored health center. Transl Behav Med 2015; 5:60-7. [PMID: 25729454 DOI: 10.1007/s13142-014-0276-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Colorectal cancer screening rates are below optimal. As part of a pilot clinic-based pragmatic study aiming to raise rates of colorectal-cancer screening, we explored patients' reasons for not responding to a direct-mailed screening invitation. We conducted telephone interviews with patients who were mailed a fecal immunochemical test (FIT) but who did not return it to the lab. Interviews were audio-recorded, transcribed, and coded for thematic analysis. We met our goal of 20 interviews (10 in English and 10 Spanish; 75 % female). Reasons for not completing tests were fear of results or cost of follow-up colonoscopy (n = 9); not having received the test in the mail (n = 7); concerns about mailing fecal matter or that test results could be mixed up (n = 6); and being busy or forgetful (n = 4). Efforts to improve uptake of colorectal cancer screening in a direct-mailed program ought to address concerns identified in our study.
Collapse
|
13
|
Mold JW, Aspy CB, Smith PD, Zink T, Knox L, Lipman PD, Krauss M, Harris DR, Fox C, Solberg LI, Cohen R. Leveraging practice-based research networks to accelerate implementation and diffusion of chronic kidney disease guidelines in primary care practices: a prospective cohort study. Implement Sci 2014; 9:169. [PMID: 25416998 PMCID: PMC4245828 DOI: 10.1186/s13012-014-0169-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 11/05/2014] [Indexed: 11/29/2022] Open
Abstract
Background Four practice-based research networks (PBRNs) participated in a study to determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease by leveraging early adopter practices. Methods Motivated practices from four PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months during wave I of the study. Each wave I practice then recruited two additional practices (wave II), which received performance feedback and academic detailing and participated in monthly local learning collaboratives led by the wave I clinicians. They received only monthly practice facilitation. The primary outcomes were adherence to primary care-relevant process-of-care recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Performance was determined retrospectively by medical records abstraction. Practice priority, change capacity, and care process content were measured before and after the interventions. Results Following the intervention, wave I practices increased the use of ACEIs/ARBs, discontinuation of NSAIDs, testing for anemia, and testing and/or treatment for vitamin D deficiency. Most were able to recruit two additional practices for wave II, and wave II practices also increased their use of ACEIs/ARBs and testing and/or treatment of vitamin D deficiency. Conclusions With some assistance, early adopter practices can facilitate the diffusion of evidence-based approaches to other practices. PBRNs are well-positioned to replicate this process for other evidence-based innovations. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0169-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- James W Mold
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, 900 NE 10th Street, Oklahoma City, OK, 73104, USA.
| | - Cheryl B Aspy
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, 900 NE 10th Street, Oklahoma City, OK, 73104, USA.
| | - Paul D Smith
- University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI, 53715, USA.
| | - Therese Zink
- Boonshoft School of Medicine, Wright State University, 3640 Colonel Glenn Highway, Dayton, OH, 45435, USA.
| | - Lyndee Knox
- Los Angeles Practice-Based Research Network (LA Net), 3940-B East Broadway, Long Beach, CA, 90803, USA.
| | | | - Margot Krauss
- Westat, 1600 Research Boulevard, Rockville, MD, 20850, USA.
| | | | - Chester Fox
- State University of New York at Buffalo, 1315 Jefferson Avenue, Buffalo, NY, 14208, USA.
| | - Leif I Solberg
- HealthPartners Institute for Education and Research, Mail Stop 23301, P.O. Box 1524, Minneapolis, MN, 55440-1524, USA.
| | - Rachel Cohen
- Westat, 1600 Research Boulevard, Rockville, MD, 20850, USA.
| |
Collapse
|
14
|
Tuepker A, Kansagara D, Skaperdas E, Nicolaidis C, Joos S, Alperin M, Hickam D. "We've not gotten even close to what we want to do": a qualitative study of early patient-centered medical home implementation. J Gen Intern Med 2014; 29 Suppl 2:S614-22. [PMID: 24715393 PMCID: PMC4070227 DOI: 10.1007/s11606-013-2690-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model's acceptability and sustainability among clinic employees. OBJECTIVE We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components. DESIGN Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews. PARTICIPANTS 241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington. APPROACH Data coded and analyzed using conventional content analysis techniques. KEY RESULTS Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics. CONCLUSIONS PACT implementation faced significant challenges in its early years. Realizing PACT's transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT's decentralized, team-based approach.
Collapse
Affiliation(s)
- Anaïs Tuepker
- Portland VA Medical Center, Health Services Research & Development/ VISN 20 PACT Demonstration Laboratory, Veterans Health Administration, Mail code R&D63, PO Box 1034, Portland, OR, 97239, USA,
| | | | | | | | | | | | | |
Collapse
|
15
|
Reid RJ, Wagner EH. The Veterans Health Administration Patient Aligned Care Teams: lessons in primary care transformation. J Gen Intern Med 2014; 29 Suppl 2:S552-4. [PMID: 24715404 PMCID: PMC4070230 DOI: 10.1007/s11606-014-2827-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert J. Reid
- Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101 USA
| | - Edward H. Wagner
- Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101 USA
| |
Collapse
|