Natural History of Practice Transformation: Development and Initial Testing of an Outcomes-Based Model

Abstract

PURPOSE Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation. METHODSWe developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the fi rst group of participating North Carolina Improving Performance In Practice practices to test and further refi ne the model. RESULTSThe resultant model described motivators and supports to transformation. Three emerging practice patterns were identifi ed with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation. CONCLUSIONS Practice transformation is a continuous and long-term process.Internal and external practice motivations and specifi c practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance. 2013;11:212-219. doi:10.1370/afm.1497. Ann Fam Med INTRODUCTIONP ractice transformation on a large scale is a cornerstone of the future of family medicine and health care reform, but little is known about the natural history of the process. It is clear that offi ce systems changes are necessary for quality improvement (QI) [1][2][3][4][5] and implementation of the patient-centered medical home (PCMH). [6][7][8][9] Furthermore, leadership, 10 practice facilitation, 11 and organizational adaptive reserve 12-14 modify a practice's ability to transform. To begin to test large-scale interventions to transform practices, however, a more specifi c description of the process of transformation is necessary.Prior work suggests that the methods for changing offi ce systems for chronic disease 4 18 This program strives to improve clinical outcomes with the use of practice facilitators and other interventions to help practices to improve care delivery through changes in offi ce systems. The assumptions of this program are that practices, rather than individuals, are the key units of delivery of primary care, and that offi ce systems drive much o...

Shifting Implementation Science Theory to Empower Primary Care Practices

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