In this climate of health care reform efforts, primary care practices (PCP’s) are being urged to redesign their delivery systems1–3
Some of the major themes in the practice transformation discourse revolve around increased “collaboration, coordination and movement of information to maximize patient care.” 4
These types of changes, which are encouraged in the broadly endorsed patient-centered medical home (PCMH) model of practice transformation, require a sweeping re-imagination of entire practice systems and practice roles. 5–7
To achieve such a vision of change, Nutting et al.8
underscore that “creat[ing] a strong communication and relationship infrastructure … is paramount to transformation success.”
Attending to interpersonal relationships in the practice setting is additionally supported by a growing body of research that suggests that the quality of interpersonal office relationships can impact the quality of care provided9–18
. Included in this body of work are studies that specifically link interpersonal factors with a variety of desired organizational or clinical outcomes. For instance, Stevenson et al.19
find an association between the perception of good team work and successful improvement in diabetes care. Hung et al’s20
study associates participatory decision-making with higher productivity and lower staff turnover. Nembhard and Edmondson21
find that a sense of psychological safety mediates an association between inclusive leadership style and greater engagement in quality improvement initiatives in the practice setting. And, Risser et al.22
find that medical errors can be reduced through improved teamwork.
While such research contributes to the evidence that systematically working on interpersonal relationships can be a valuable practice investment, much of this research does not illuminate what is involved in the process of working to improve interpersonal relationships within the practice setting. This may be, in part, because such change processes can require considerable time, longer than most studies allow. As Pettigrew23
argues, much research on organizational change is limited by “snapshot time-series data” which encourage studies to focus on “the intricacies of narrow changes rather than the holistic and dynamic analysis of changing.” He therefore recommends analyses that consider both “temporal and contextual” factors, noting that there are “remarkably few studies of change” that do so in a substantial way. Miller et al.24
similarly argue – in their efforts to study primary care practices as complex adaptive systems – that “[f]uture research needs to include more in-depth case studies of practices over time.” Because they understand practices to be “much more than a set of independent variables influencing some dependent variables,” they suggest methodology that is sensitive to the interdependent parts of the system that evolve in nonlinear ways over time.
Our analysis is able to reap the analytic benefits of this methodological approach by taking advantage of extensive qualitative and longitudinal data on a single PCP that participated in two, back to back QI interventions from 2003–2009. Both of these intervention studies shared the philosophy that the quality of interpersonal relationships can impact the quality of care as well as the practice improvement process. This case study thus offers a nuanced examination of the process involved in one practice’s efforts to address its interpersonal issues in the context of these consecutive interventions and suggests some provisional consequences of these efforts. We conclude by identifying a variety of facilitators and barriers to these interpersonal change efforts and suggest some implications from this case for future quality improvement (QI) research.