Through identification of the core themes, concepts and relationships, the framework was developed. Figure provides an image representing the process of change that was undertaken by the practices. Clear leadership from the practice leaders was seen as an important component of the framework for implementing change in practice 'How to Lead Improvement for PPRNet-TRIP'. The following concepts elaborate the process of how change occurred within these practices:
Figure 1 How to Lead Improvement for PPRNet. The concepts of the model reflect an iterative and interactive process by which additional cycles of change are stimulated through performance feedback and subsequent opportunities to modify vision with clear goals. (more ...)
1. Vision with clear goals
2. Team involvement
3. Enhance communication systems
4. Develop staff knowledge
5. Take small steps
6. Assimilate electronic medical record (EMR) into clinical practice to maximize clinical effectiveness
7. Feedback within a culture of improvement
The concept 'assimilating the EMR into clinical practice to maximize clinical effectiveness' was central to explaining how practices changed within PPRNet-TRIP II. The framework's focus on improvement and guideline implementation through better use and adaptation of processes within the practices' EMR tools is fitting for a group of practices engaged in a practice based research network (PBRN) aligned around a common EMR system. The forthcoming sections illustrate the concepts of the framework. The framework synthesizes the enabling strategies for change, which were present throughout the sample, but not necessarily seen in every practice. Pseudonyms were assigned to those interviewed, whose comments follow as the framework is explained.
Vision with clear goals
Practices were most effective at change when the practice leader set a clear vision. In these practices, staff members discussed the goals for change. A physician in a solo practice who achieved significant change in practice performance benchmarks explained:
'It is defined in the guidelines, my professional responsibility for success. That is my profession: to get from point A to B. I use information that comes from the specialists in the studies that I am following, and that's how I gauge my success.'
Dr. Carl articulated what was important for him in his practice, that being successful in his patient care management was his responsibility as a physician. He established vision by determining which quality benchmarks were necessary for his practice to achieve, so his patients could benefit. His staff members understood the vision for his practice.
In another practice both physicians discussed the importance of vision and goals. The two physicians articulated a high regard for establishing goals and defining what needed to be accomplished.
'We look at the site visits as needs assessments to identify goals. It's important that you explain what the goals are, get buy in to work with people, and to see how you can help them to accomplish those things.'
'Our goal is to be like an old-fashioned family practice, with responsiveness on the same day as needed.'
Involve the team
When staff members were clear about the vision and goals, felt included in decision-making, and were responsible for leading some component of the work plan to achieve results they adapted to make change happen. The nurse who worked with Dr. Glenn demonstrated effective teamwork through this comment.
'Basically to help Dr. Glenn I try to make his life simpler and make him go faster. I do a lot of the recalls, sending out the letters, to get a hold of the patients. When they are here, I make sure that they get everything done that they need, a little bit of everything, really ...Templates. I do a lot more with them now ... I try to get the notes done before he walks in. So he can do more talking with them instead of typing, and when he walks out he just has to put in his recommendations and impressions and then he'll be done with it all.'
A business manager of one practice related how well the team members work together.
'The biggest asset we have is our employees. We are like a well-oiled machine. Everyone knows what they're doing, and things get done. It works.'
This manager's perspective was that staff contributed to improved outcomes in patient care through teamwork. This practice valued clear leadership, working well together, and staff competence to do things the right way. This allowed them to be successful with their patients' care management. Observations in the practice environment revealed a cohesive group of staff who followed through with improvement goals they established.
'It's been a group effort. Everybody has to see the need. It's actually lives that you're saving; it's not just numbers ...just again, empowering the nurses, Dr. Carl has been real clear about use of guidelines, and to get the nurses and patients more involved in their care management. When patients call in for an appointment they are asked to plan for a cholesterol check. Continuing to call if they miss a visit, we stress the importance of these tests. It's leadership but it's also good patient care.'
A clerical staff member in a larger Northwest practice commented on what worked well and what did not regarding the involvement of the team.
'I think having a set of standards is really helpful, and the set criteria as to what needs to get done, and the goals. It still fluctuates some because we do have different personalities that do not necessarily agree. But everybody seems to know what the goals are and that really seems to help. What doesn't help is when one provider feels like they are being singled out because they are not doing it that way. And that kind of happens from time to time. I don't think that's real helpful.'
A physician leader in this practice discussed the new team approach:
'It's important for people to be honest and up front and have a level playing field with individuals talking to each other as professionals and not having a hierarchy where like the medical assistants don't talk to the doctors.'
Enhance communication systems
Communication was enhanced by using the features of the EMR system more efficiently. Patient care needs were communicated within some practices using letter templates that reported results of diagnostic tests with therapeutic goals. Additionally, clinicians and staff used electronic mail within the EMR for internal messaging and reminder systems to help improve internal communication. One of the physicians discussed how patients are informed about when to follow-up regarding their laboratory tests:
'... as part of our result letters we have the reminder put in about when they're supposed to get checked again.'
Clinicians followed-up on the important details of patient care through several embedded (within the EMR) communication systems. Dr. Betty explained the reminder systems for follow up with patients, and illustrated how practice members communicated effectively with each other.
'We communicate through our staff extensively. The facilitators for that communication are internal e-mail, and the EMR is huge in terms of inter-physician and staff ... to get things done... also in future activation we also use the e-mail ...send yourself one so that three weeks from now you remember to go back to X or Y or check on things. Then, we use the letters within Practice Partner to do a whole ton of communications to the patients, and the recall letters in the billing to activate patients to come in. Of course, we talk to each other face to face. And the staff talks to the patient by phone. We talk to the patient by phone. I would say [we use] every known strategy [of] communication, except e-mail. We studiously avoided e-mail ...for communication [with the patients].'
Develop staff knowledge
While involving the team is an important concept, additional effort must be undertaken to develop knowledge (related to the clinical guidelines being implemented) of practice staff. Staff must understand the rationale for the work they are engaged in to be most effective. By providing avenues for staff to ask questions, office and clinical staff can provide critical reinforcement of the ideal plan of care and help the patients understand treatment goals and the importance of follow-up.
Dr. Glenn discussed how development of the staff occurs within his practice, which enabled the nurses to integrate their assessments into the templates that drive the patient care in his practice.
'I have spent time to work closely with the nurses, to make the templates be very clear and effective to our practice... the nurses and I work very close together, and are real clear about what they need to do. The templates are developed together, to make things workable and make sense to the nurses since they do the data collection. It helps to make things work smoothly.'
The nurse in this practice expressed how she learns what is most important for patient care during dedicated time to develop templates and systems.
'We usually go over the templates and what we need for each disease process, what questions we need to ask. ...it cues us on what needs to be done when the patient is here. And [during these meetings we receive] just overall education on what it is we are trying to achieve, to let them [the patients] know where exactly we are trying to get to.'
Take small steps
When making changes in practice, perfection is not needed to embrace a different approach. All of the practices had taken small steps, trying new methods and adjusting to the changes in their practice as they sought to embrace the clinical guidelines. Taking small steps implies motivation is present within the practice, and willingness to test a small change in practice.
Staff from the Northwest family practice discussed the small steps they had been taking in making changes in the practice that related to the guidelines. More was being delegated to the non-clinical staff in this practice to ensure patient communication and follow up was occurring as the practice decided. Clinical staff increased their efforts to use the EMR more actively than previously.
'We're seeing a lot more diabetics that are following up, you know, making sure they get done what they need every three months, every six months.'
'The biggest change I've noticed were the letters going out, and then of course, the huge influx of patients and getting those patients in for their [glycosolated] hemoglobins and blood pressure checks.'
'As far as anything new with this project, the most different thing is that I note in the open chart note for diabetics, especially for lab work.'
Assimilating the EMR into clinical practice to maximize clinical effectiveness
Using the EMR features more robustly assists with embedding evidence-based guidelines into practice. The practices and participants had different levels of expertise and experience with the use of the Practice Partner™ EMR system. Participants modified their approaches and methods to document in the record, search within the record, organize care, and use recalls for disease management.
'Well, I'd have to say that the physicians have definitely had to change the way they practiced. That's probably more in terms of utilization of the medical record. But that is what we probably should be doing anyway ...I can actually come and review my labs from the day before and then process the lab letter, which I can then give the staff and document in the back part of it. Actually it is working very well.'
Feedback within a culture of improvement
Change in the practices was most enhanced by PPRNet-TRIP interventions. This had an impact on the practices' organization and communication. A culture of participation and a competitive spirit emerged among numerous practices within the intervention group, revealing the motivating effect of feedback from the intervention. Practices received performance data on the quality indicators quarterly. Dr. Valerie explained how dedicating time for prioritizing performance improvement within her practice was valuable:
'I think the patients' achievements themselves give you the kind of day-to-day feedback that keeps you going ... I think that what I am doing differently now is what I thought I was doing before. I do a better job of it now. I have an understanding of how I can go about measuring the effectiveness of any particular approach that I am doing. And, it also has to do with the aging of the practice. I could have continued to emphasize care of younger people and health maintenance to a degree that would have eventually succeeded in excluding people who have chronic health problems cause they were going to move on or die...So, I think it just clarified in my mind that this is actually where the most effect is going to be felt.'