Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial.

Objective: Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services.

Methods: In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application.

Boundary spanning and health: invitation to a learning community.

Boundaries, which are essential for the healthy functioning of individuals and organisations, can become problematic when they limit creative thought and action. In this article, we present a framework for promoting health across boundaries and summarise preliminary insights from experience, conversations and reflection on how the process of boundary spanning may affect health. Boundary spanning requires specific individual qualities and skills.

Appreciative Inquiry for quality improvement in primary care practices.

Purpose: To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process.

Methods: Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates.

Measuring practice capacity for change: a tool for guiding quality improvement in primary care settings.

Purpose: Capacity for change, or the ability and willingness to undertake change, is an organizational characteristic with potential to foster quality management in health care. We report on the development and psychometric properties of a quantitative measure of capacity for change for use in primary care settings.

Methods: Following review of previous conceptual and empirical studies, we generated 117 items that assessed organizational structure, climate, and culture.

A systematic approach to practice assessment and quality improvement intervention tailoring.

Background: The ways in which tailored interventions foster sustained improvement in the quality of health care delivery across different practice settings are not well understood. Using the empirically developed Practice Change Model (PCM), we identify and describe assessment and tailoring activities with potential to enhance the fit between proposed interventions and practice settings.

Methods: We obtained quantitative and qualitative data from 2 quality improvement trials conducted in diverse primary care practices in northeast Ohio.

Making sense of primary care practices' capacity for change.

A deeper understanding of the forces that shape the motivation and willingness of primary care practices to adopt and implement new procedures-their "capacity for change"-may better guide development of interventions to foster adoption and implementation of evidence-based care. This study applies and evaluates the utility of a previously described framework for making sense of this complex construct in a diverse sample of primary care practices. A multidisciplinary team of 3 analysts examined ethnographic field notes that describe 15 single-physician or multiphysician practices in different organizational settings.

Correlates of baseline performance do not predict results of an intervention to improve preventive care.

Background: Cross-sectional analyses of baseline performance often inform the development of interventions to improve care. An implicit assumption in these studies is that factors associated with better performance at baseline may also be useful in predicting change in performance over time.

Methods: We analyzed data collected from 1997-2002 at 77 practices in Northeast Ohio participating in an intervention to increase evidence-based preventive services delivery (PSD).

Association of intervention outcomes with practice capacity for change: subgroup analysis from a group randomized trial.

Background: The relationship between health care practices' capacity for change and the results and sustainability of interventions to improve health care delivery is unclear.

Methods: In the setting of an intervention to increase preventive service delivery (PSD), we assessed practice capacity for change by rating motivation to change and instrumental ability to change on a one to four scale. After combining these ratings into a single score, random effects models tested its association with change in PSD rates from baseline to immediately after intervention completion and 12 months later.

An appreciative inquiry approach to practice improvement and transformative change in health care settings.

Amid tremendous changes and widespread dissatisfaction with the current health care system, many approaches to improve practice have emerged; however, their effects on quality of care have been disappointing. This article describes the application of a new approach to promote organizational improvement and transformation that is built upon collective goals and personal motivations, invites participation at all levels of the organization and connected community, and taps into latent creativity and energy. The essential elements of the appreciative inquiry (AI) process include identification of an appreciative topic and acting on this theme through 4 steps: Discovery, Dream, Design, and Destiny.

Facilitating practice change: lessons from the STEP-UP clinical trial.

Background: The Study To Enhance Prevention by Understanding Practice (STEP-UP) clinical trial (1997-2000) resulted in sustainable increases in preventive service delivery in primary care practices. However, the process by which practice change can be facilitated has not been well described.

Methods: Comparative case studies were conducted of eight STEP-UP practices with the largest increases in preventive service delivery rates and compared to seven practices with the lowest increases.

Physician and staff turnover in community primary care practice.

The effect of a rapidly changing healthcare system on personnel turnover in community family practices has not been analyzed. We describe physician and staff turnover and examine its association with practice characteristics and patient outcomes. A cross-sectional evaluation of length of employment of 150 physicians and 762 staff in 77 community family practices in northeast Ohio was conducted.

A practice change model for quality improvement in primary care practice.

Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement.