Jenna Howard

The Role of the Champion in Primary Care Change Efforts: From the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP)

Background: Change champions are important for moving new innovations through the phases of initiation, development, and implementation. Although research attributes positive health care changes to the help of champions, little work provides details about the champion role. Methods: Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data, which included field notes of team meetings, interviews, and transcripts of facilitator meetings, from a sample of 8 practices. Results: Our analysis yielded insights into the value of having 2 discrete types of change champions: (1) those associated with a specific project (project champions) and (2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes care processes. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing. Conclusions: Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions—both project and organizational change champions—are critical players in supporting both innovation-specific and transformative change efforts.

Electronic Health Record Impact on Work Burden in Small, Unaffiliated, Community-Based Primary Care Practices

ABSTRACTBACKGROUNDThe use of electronic health records (EHR) is widely recommended as a means to improve the quality, safety and efficiency of US healthcare. Relatively little is known, however, about how implementation and use of this technology affects the work of clinicians and support staff who provide primary health care in small, independent practices.OBJECTIVETo study the impact of EHR use on clinician and staff work burden in small, community-based primary care practices.DESIGNWe conducted in-depth field research in seven community-based primary care practices. A team of field researchers spent 9–14 days over a 4–8 week period observing work in each practice, following patients through the practices, conducting interviews with key informants, and collecting documents and photographs. Field research data were coded and analyzed by a multidisciplinary research team, using a grounded theory approach.PARTICIPANTSAll practice members and selected patients in seven community-based primary care practices in the Northeastern US.KEY RESULTSThe impact of EHR use on work burden differed for clinicians compared to support staff. EHR use reduced both clerical and clinical staff work burden by improving how they check in and room patients, how they chart their work, and how they communicate with both patients and providers. In contrast, EHR use reduced some clinician work (i.e., prescribing, some lab-related tasks, and communication within the office), while increasing other work (i.e., charting, chronic disease and preventive care tasks, and some lab-related tasks). Thoughtful implementation and strategic workflow redesign can mitigate the disproportionate EHR-related work burden for clinicians, as well as facilitate population-based care.CONCLUSIONSThe complex needs of the primary care clinician should be understood and considered as the next iteration of EHR systems are developed and implemented.

Decision-Making Processes of Patients Who Use the Emergency Department for Primary Care Needs

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients’ decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients’ decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients’ health care, which are also a prominent part of their decision-making process.

More Black Box to Explore: How Quality Improvement Collaboratives Shape Practice Change

Background: Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to “open up the black box” to better understand how and why such collaboratives work. Methods: We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings. Results: Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts. Conclusion: QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.

How team-based reflection affects quality improvement implementation: A qualitative study

Quality improvement (QI) interventions in health care organizations have produced mixed results with significant questions remaining about how QI interventions are implemented. Team-based reflection may be an important element for understanding QI implementation. Extensive research has focused on individual benefits of reflection including links between reflection, learning, and change. There are currently no published studies that explore how team-based reflection impact QI interventions. We selected 4 primary care practices participating in a QI trial that used a facilitated, team-based approach to improve colorectal cancer screening rates. Trained facilitators met with a team of practice members for up to eleven 1-hour meetings. Data include audio-recorded team meetings and associated fieldnotes. We used a template approach to code transcribed data and an immersion/crystallization technique to identify patterns and themes. Three types of team-based reflection and how each mattered for QI implementation were identified: organizational reflection promoted buy-in, motivation, and feelings of inspiration; process reflection enhanced team problem solving and change management; and relational reflection enhanced discussions of relational dynamics necessary to implement desired QI changes. If QI interventions seek to make changes where collaboration and coordination of care is required, then deliberately integrating team-based reflection into interventions can provide opportunities to facilitate change processes.

Physicians as inclusive leaders: insights from a participatory quality improvement intervention.

The patient-centered medical home model of primary care requires increased collaboration in care delivery. Recent studies suggest that such a collaborative model of care is aided by physician leaders who practice an inclusive approach to leadership; however, they do not empirically demonstrate what such strategies look like in primary care settings, nor do they provide insights to help physician leaders capitalize on the benefits of such an approach. Our analysis offers extended case illustrations of 3 physician leadership behaviors that exemplify leadership inclusiveness (explicitly soliciting team input; engaging in participatory decision making; and facilitating the inclusion of non–team members) as well as 3 behaviors that are counter to inclusiveness. These 6 cases emerged from our analysis of 8 primary care practices that participated in a 3-month facilitated, team-based quality improvement intervention that encouraged leadership inclusiveness. Qualitative data include observational field notes, interviews, and audio-recorded quality improvement meetings. Through these exemplar and nonexemplar cases, we highlight successes and challenges physicians experienced in their collaborative attempts. Such insights may prove important to physicians, researchers, and policy makers alike as they determine how best to aid physician leaders who are being challenged to recreate themselves as facilitators of collaboration.

Learning the landscape: implementation challenges of primary care innovators around cancer survivorship care

PurposeThis study describes the experiences of early implementers of primary care-focused cancer survivorship delivery models.MethodsSnowball sampling was used to identify innovators. Twelve participants (five cancer survivorship primary care innovators and seven content experts) attended a working conference focused on cancer survivorship population strategies and primary care transformation. Data included meeting discussion transcripts/field notes, transcribed in-depth innovator interviews, and innovators’ summaries of care models. We used a multistep immersion/crystallization analytic approach, guided by a primary care organizational change model.ResultsInnovative practice models included: (1) a consultative model in a primary care setting; (2) a primary care physician (PCP)-led, blended consultative/panel-based model in an oncology setting; (3) an oncology nurse navigator in a primary care practice; and (4) two subspecialty models where PCPs in a general medical practice dedicated part of their patient panel to cancer survivors. Implementation challenges included (1) lack of key stakeholder buy-in; (2) practice resources allocated to competing (non-survivorship) change efforts; and (3) competition with higher priority initiatives incentivized by payers.ConclusionsCancer survivorship delivery models are potentially feasible in primary care; however, significant barriers to widespread implementation exist. Implementation efforts would benefit from increasing the awareness and potential value-add of primary care-focused strategies to address survivors’ needs.Implications for Cancer SurvivorsCurrent models of primary care-based cancer survivorship care may not be sustainable. Innovative strategies to provide quality care to this growing population of survivors need to be developed and integrated into primary care settings.

Up close and (inter)personal: insights from a primary care practice's efforts to improve office relationships over time, 2003-2009.

A growing body of literature suggests that interpersonal relationships between personnel in health care organizations can have an impact on the quality of care provided. Some research recommends that the fundamental practice transformation that is being urged in this current climate of health care reform may be aided by strong interpersonal practice relationships and communication. There is much to be learned, however, about what is involved in the process of addressing and improving interpersonal relationships in primary care practices. This case study offers insights into this process by examining 1 primary care practices efforts to address interpersonal office issues over the course of its participation in 2 back-to-back quality improvement (QI) intervention studies. Our analysis is based on extensive qualitative data on this practice (observational data, interviews, and audio-recorded QI meetings) from 2003 to 2009. By tracing common themes and patterns of interaction over an extended period of time, we identify a variety of facilitators of and barriers to addressing interpersonal issues in the practice setting. We conclude by suggesting some implications from this case for future QI research.

Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities

Importance Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors. Objective To explain why primary care has not begun to integrate comprehensive cancer survivorship services. Design, Setting, and Participants Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes. Main Outcomes and Measures Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care. Results The 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care. Conclusions and Relevance To increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.

Lessons Learned Designing and Using an Online Discussion Forum for Care Coordinators in Primary Care

While an increasing number of researchers are using online discussion forums for qualitative research, few authors have documented their experiences and lessons learned to demonstrate this method’s viability and validity in health services research. We comprehensively describe our experiences, from start to finish, of designing and using an asynchronous online discussion forum for collecting and analyzing information elicited from care coordinators in Patient-Centered Medical Homes across the United States. Our lessons learned from each phase, including planning, designing, implementing, using, and ending this private online discussion forum, provide some recommendations for other health services researchers considering this method. An asynchronous online discussion forum is a feasible, efficient, and effective method to conduct a qualitative study, particularly when subjects are health professionals.