Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership

Abstract

PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODSWe used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTSOf the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the fi rst year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no signifi cant associations were seen for the intermediate outcome measures of hemoglobin A 1c , blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONSIn the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

Minnesota’s Early Experience with Medical Home Implementation: Viewpoints from the Front Lines

“…This unsustainable business model should be addressed by payment reform legislation or health system policies. 26,27 Similar to findings from other studies, 14,15,18 clinical and administrative leadership proved a crucial facilitator at the clinic level and higher. Our interviewees universally endorsed the need for leaders who were 1) inspiring and 2) able to effect fundamental operational changes.…”

“…[12][13][14][15][16][17] To date, significant challenges have been identified; specifically, the investment of resources for infrastructure changes and the leadership skills needed to guide an organization through paradigm-shifting cultural change. 5,14,18 Common facilitators have included valuing innovation, quality improvement, and patient-centeredness. 12,13,16 We sought to augment the literature on motivations, barriers, and facilitators to PCMH implementation by describing a large-scale initiative with some unique features.…”

The Cost to Successfully Apply for Level 3 Medical Home Recognition

“…Following an approach developed in a previous study, 18 we consulted with practice coaches from the North Carolina Area Health Education Center's Practice Support Program to identify primary care practices that had achieved level 3 PCMH recognition, defined as a score of 85 to 100 points and receiving credit for all 6 must-pass elements. We asked coaches to recommend 5 exemplar practices that used internal clinical and administrative staff members to complete the majority of the work required to apply for PCMH recognition (vs relying on the work of people external to the practice).…”

Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study

“…Two intangible practice-level attributes have been shown in previous research to be particularly important: flexibility and resilience in time of change and primary care leadership that promotes inclusiveness and creates a culture of open communication. [3][4][5][6] The practice adaptive reserve (PAR) scale is a commonly used assessment that quantifies successful work relationships that lead to flexibility and resilience within a practice. 3 Conceptually, high PAR correlates with facilitative leadership and an organizational culture that values teamwork, improvisation, and sensemaking.…”