Title: Leading Improvement in Primary Care Practices
Author: Lynne S. Nemeth
Setting up the project
A large randomized cluster trial was underway within a primary care practice-based research network (PBRN) of electronic medical record (EMR) users to implement clinical guidelines for primary and secondary prevention of cardiovascular disease. Practices developed plans for improvement for several indicators being measured on a quarterly basis during the trial. We could not clearly explain what led to the improvements in these practices, and initiated a sub-project within this research to explain: "What was the process of change used by practices to implement these guidelines?" seeking to develop a conceptual framework to guide future quality improvement interventions.
Using observation at practice site visits to create field notes, and interviews with a wide range of practice staff members, I sought explanations of how improvement was undertaken at practices within the intervention group of this trial. I based my inquiry on a previously developed framework used for improving quality: Microsystems which had at the time been recently published by the Institute of Medicine. [More...]
Using Microsystems as a starting point I developed an interview tool that homed in on leadership, investment in improvement, roles and processes that characterized each practice. Relationships, performance improvement culture and how they used their information systems were probed to better understand how they made changes in practice. I used a grounded theory approach to the data analysis process, as I sought new explanations to practice change that were not available elsewhere. In-depth semi-structured interviews were conducted to develop rich context about each practice setting, including characteristics about its leadership and organizational structure. Data collection and analysis proceeded in alternating sequences, with analysis of the previous interviews informing the subsequent interviews. For this study, it was important to learn how individual participants perceived the changes made in their practice, and the process of change within their setting during this quality improvement intervention. Participants were probed regarding what changed, and how change occurred within the practice. This helped me to understand each participant within the context of their unique Microsystem. In this study, the conceptual framework of Microsystems provided the initial direction for structuring a dialogue to learn from the participants their views of leadership in the practice, investment in improvement, and infrastructure for information system management. Grounded theorists often start out with few preconceived notions, and allow a theory to evolve from the data. By using inductive and deductive methods to conceptualize the important findings new perspectives were generated to create the conceptual framework evolving within the specific context of primary care practices implementing change while using their EMRs.
I collected demographic data from the interview participants so I could characterize my sample. I recorded the interviews with a digital voice recorder and had them transcribed verbatim so that I could code and analyze the transcripts. I added all field notes and any documents I had regarding the practices to the NVivo dataset I created for understanding the materials. [More...]
Working with data
Using the literature on barriers to implementing clinical guidelines, and Kotter's concepts on leading change, I developed a series of tree nodes to start the coding process. Adding free nodes when none of the established codes fit, I developed a long list of codes. I started the analysis process with the first 9 of 28 interview transcripts to test the process of analysis. Eventually, codes were condensed, and a preliminary draft framework explaining concepts of change within the first nine interviews was created. [More...]
I was a novice qualitative researcher and I relied on mentors to guide my process. A faculty advisor reviewed all of my initial nine transcripts and codes, and together we made some initial interpretations about what we observed as patterns within the data or themes that were emerging. Through the process of setting up a preliminary model for the concepts of change in these practices I tried to remain very open to the possibility that the remainder of my data would not fit the preliminary model. The project evaluator for the larger research project worked with me, reviewing the transcripts and adding any additional observations that should be considered. I looked within the practices and across the practices for any evidence that would fit the proposed concepts. I continued to explore the emerging hunches I was developing until I reached a point of saturation, when I believed that I had what I needed to explain the process of change undertaken by these practice.
I looked at high performing practices and those that had greater challenges to improvement. I brought in the assistance of primary care qualitative thought leaders to assist me in looking completely and accurately in my data for deeper meanings than initially. Beyond my initial "grounded theory" approach, I used immersion and crystallization with two dissertation committee members. Ultimately the initial model was revised to provide a more complete explanation of the process of change used within practices. [More...]
Reporting the project
Getting this project into the literature was a nearly three year challenge. The first one was inertia due to completion of the dissertation! Then, when the first draft manuscript was developed, I had to remain open to critical review from other than a supportive dissertation committee. Through the process of eighteen months, I completed a series of revisions and finally published the project in 2008. Delays meant other reports started to appear in the literature sooner than mine. Finally, the paper available on Implementation Science open access journal is one of the highest accessed papers for 2008. [More...]
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