These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

PURPOSE We examined quality, satisfaction, fi nancial, and productivity outcomes associated with implementation of Care by Design (CBD), the University of Utah's version of the patient-centered medical home. METHODSWe measured the implementation of individual elements of CBD using a combination of observation, chart audit, and collection of data from operational reports. We assessed correlations between level of implementation of each element and measures of quality, patient and clinician satisfaction, fi nancial performance, and effi ciency. RESULTSTeam function elements had positive correlations (P ≤.05) with 6 quality measures, 4 patient satisfaction measure, and 3 clinician satisfaction measures. Continuity elements had positive correlations with 2 satisfaction measures and 1 quality measure. Clinician continuity was the key driver in the composite element of appropriate access. Unexpected fi ndings included the negative correlation of use of templated questionnaires with 3 patient satisfaction measures. Trade-offs were observed for performance of blood draws in the examination room and the effi ciency of visits, with some positive and some negative correlations depending on the outcome.CONCLUSIONS Elements related to care teams and continuity appear to be key elements of CBD as they infl uence all 3 CBD organizing principles: appropriate access, care teams, and planned care. These relationships, as well as unexpected, unfavorable ones, require further study and refi ned analyses to identify causal associations. Ann Fam Med INTRODUCTIOND espite widespread pilot implementation and favorable initial results of the patient-centered medical home (PCMH), 1 assessment of its impacts is in an early stage.2 Not enough is known about the model's implications to ascertain its results in terms of practice quality, satisfaction, or fi nances.3 Evidence is also lacking about relationships between individual elements of the PCMH model and specifi c benefi cial outcomes.In this study, in contrast to looking at the PCMH as a whole, we examined the relationship between individual elements of Care by Design (CBD), a comprehensive redesigned model of care that incorporates many elements of a PCMH, and multiple outcomes in quality of care, patient and clinician satisfaction, productivity, and operational costs.The University of Utah's Community Clinics introduced CBD in 2003. The model had 3 founding principles: appropriate access, care teams, and planned care. The transformation included expanded and new roles for support staff and redesigned workfl ows and processes. Implementation initially focused on improved access with an emphasis on same-day appointments. Appropriate access was designed primarily to improve patient satisfaction. By 2006, the model had incorporated additional elements including team-based care and more comprehensive planned care. Care teams enhanced effi ciency by using the time and skills of support staff, allowing clinicians to focus more on relationships with patients. Medical assistants (MAs)...

Objectives Assess 1) provider satisfaction with specific elements of PCMH; 2) clinic organizational cultures; 3) associations between provider satisfaction and clinic culture. Methods Cross sectional study with surveys conducted in 2011 with providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design™. Measures included the Organizational Culture Assessment Instrument (OCAI) and the American Medical Group Association provider satisfaction survey. Results Providers were most satisfied with quality of care (M=4.14; scale=1–5) and interactions with patients (M=4.12) and least satisfied with time spent working (M=3.47), paper work (M =3.45) and compensation (M=3.35). Culture profiles differed across clinics with family/clan and hierarchical the most common. Significant correlations (p ≤ 0.05) between provider satisfaction and clinic culture archetypes included: family/clan negatively correlated with administrative work; entrepreneurial positively correlated with the Time Spent Working dimension; market/rational positively correlated with how practices were facing economic and strategic challenges; and hierarchical negatively correlated with Relationships with Staff and Resource dimensions. Discussion Provider satisfaction is an important metric for assessing experiences with features of a PCMH model. Conclusions Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.

Background: Error detection and analysis alone cannot create or sustain a culture of safe, high-quality, compassionate care for patients. Some experts have endorsed a unit-based approach to improving quality, but there are few examples and those rarely focus on reducing all preventable harms and engaging frontline clinicians, patients, and families. Approach: We implemented a unit-based approach comprising seven building blocks for creating a comprehensive approach to detect and prevent harm at the unit level within a hospital: (1) unit quality council and stakeholder buy-in, (2) parent engagement and advisory council, (3) frontline clinician and parent quality improvement training, (4) measurement of organizational contextual factors, (5) electronic health record trigger development and synthesis of harm measures, (6) subcommittees to review harm, and (7) quality improvement teams. Challenges and Lessons Learned: Challenges include conceptualizing triggers for a unit unfamiliar with this methodology, establishing unit resources for collecting and analyzing data, and creating processes to integrate parents in unit quality efforts. The seven essential building blocks helped overcome these challenges and could be adopted by other healthcare organizations. Conclusion: These building blocks create a generalizable foundation for establishing a unit-based approach to detecting and preventing harm.

Poorly executed transitions in care from hospital to home are associated with increased vulnerability to adverse medication events and hospital readmissions, and also excess healthcare costs. Efforts to improve care coordination on hospital discharge have been shown to reduce hospital readmission rates but often rely on interventions that are not fully integrated within the primary care setting. The Patient Centered Medical Home (PCMH) model, whose core principles include care coordination in the posthospital setting, is an approach that addresses transitions in care in a more integrated fashion. We examined the impact of multicomponent transition management (TM) services on hospital readmission rates and time to hospital readmission among 118 patients enrolled in a TM program that is part of Care By Design, the University of Utah Community Clinics' version of the PCMH. We conducted a retrospective analysis comparing outcomes for patients before receiving TM services with outcomes for the same patients after receiving TM services. The all-cause 30-day hospital readmission rate decreased from 17.9% to 8.0%, and the mean time to hospital readmission within 180 days was delayed from 95 to 115 days. These findings support the effectiveness of TM activities integrated within the primary care setting.

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Payment for performance (P4P) has been employed in low and middle-income (LMIC) countries to improve quality and coverage of maternal and child health (MCH) services. However, there is a lack of consensus on how P4P affects health systems. There is a need to evaluate P4P effects on health systems using methods suitable for evaluating complex systems. We developed a causal loop diagram (CLD) to further understand the pathways to impact of P4P on delivery and uptake of MCH services in Tanzania. The CLD was developed and validated using qualitative data from a process evaluation of a P4P scheme in Tanzania, with additional stakeholder dialogue sought to strengthen confidence in the diagram. The CLD maps the interacting mechanisms involved in provider achievement of targets, reporting of health information, and population care seeking, and identifies those mechanisms affected by P4P. For example, the availability of drugs and medical commodities impacts not only provider achievement of P4P targets but also demand of services and is impacted by P4P through the availability of additional facility resources and the incentivisation of district managers to reduce drug stock outs. The CLD also identifies mechanisms key to facility achievement of targets but are not within the scope of the programme; the activities of health facility governing committees and community health workers, for example, are key to demand stimulation and effective resource use at the facility level but both groups were omitted from the incentive system. P4P design considerations generated from this work include appropriately incentivising the availability of drugs and staffing in facilities and those responsible for demand creation in communities. Further research using CLDs to study heath systems in LMIC is urgently needed to further our understanding of how systems respond to interventions and how to strengthen systems to deliver better coverage and quality of care.

Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.