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

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. METHODS We 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. RESULTS Of 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 first 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 significant associations were seen for the intermediate outcome measures of hemoglobin A1c, 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. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

[1]  J. LaFountain.  Inc. , 2013, American Art.

[2]  Mindy E. Flanagan,et al.  Open Access Implementation Science the Effect of Provider-and Workflow-focused Strategies for Guideline Implementation on Provider Acceptance , 2022 .

[3]  S. Chreim,et al.  Change agency in a primary health care context: The case of distributed leadership , 2010, Health care management review.

[4]  Jeffrey Pfeffer,et al.  Administrative Succession and Organizational Performance: How Administrator Experience Mediates the Succession Effect , 1986 .

[5]  D Blumenthal,et al.  A report card on continuous quality improvement. , 1998, The Milbank quarterly.

[6]  D. Nease,et al.  It Takes Two: Using Coleaders to Champion Improvements in Small Primary Care Practices , 2010, The Journal of the American Board of Family Medicine.

[7]  W. Levinson,et al.  Patient-physician communication as organizational innovation in the managed care setting. , 2002, The American journal of managed care.

[8]  D. Berwick.  About the Institute for Healthcare Improvement , 1993 .

[9]  N. Hoffart.  Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory , 2000 .

[10]  L. Solberg,et al.  The failure of a controlled trial to improve depression care: a qualitative study. , 2001, The Joint Commission journal on quality improvement.

[11]  G. Christiaens,et al.  Leading change , 2018, Leadership Transitions in Universities.

[12]  C. Homer,et al.  How to Scale Up Primary Care Transformation: What We Know and What We Need to Know? , 2010, Journal of General Internal Medicine.

[13]  Paul D. Allison,et al.  Logistic regression using sas®: theory and application , 1999 .

[14]  L. Palinkas,et al.  An ethnographic study of implementation of evidence-based treatments in child mental health: first steps. , 2008, Psychiatric services.

[15]  Matthew B. Miles,et al.  Qualitative Data Analysis: An Expanded Sourcebook , 1994 .

[16]  A. Dietrich,et al.  Implementing a Depression Improvement Intervention in Five Health Care Organizations: Experience from the RESPECT-Depression Trial , 2007, Administration and Policy in Mental Health and Mental Health Services Research.

[17]  J. Hackman,et al.  Leading Teams: Setting the Stage for Great Performances , 2002 .

[18]  Rebecca S. Etz,et al.  Bridging primary care practices and communities to promote healthy behaviors. , 2008, American journal of preventive medicine.

[19]  B. Weiner,et al.  Uncovering middle managers' role in healthcare innovation implementation , 2012, Implementation Science.

[20]  P. Drucker,et al.  Leading teams: setting the stage for great performances [Book Review] , 2003, IEEE Engineering Management Review.

[21]  D. A. Williams,et al.  Extra‐Binomial Variation in Logistic Linear Models , 1982 .

[22]  D. Cummings,et al.  After the collaborative is over: what sustains quality improvement initiatives in primary care practices? , 2009, Joint Commission journal on quality and patient safety.

[23]  A. Dobson,et al.  Infrastructure for large‐scale quality‐improvement projects: Early lessons from North Carolina improving performance in practice , 2010, The Journal of continuing education in the health professions.

[24]  Joel Podolny,et al.  Revisiting the Meaning of Leadership , 2004 .

[25]  Jody Hoffer Gittell,et al.  Coordinating Mechanisms in Care Provider Groups: Relational Coordination as a Mediator and Input Uncertainty as a Moderator of Performance Effects , 2002 .

[26]  M. Parchman,et al.  How inclusive leadership can help your practice adapt to change. , 2012, Family practice management.