Legitimizing new practices in primary health care.

ABSTRACT

BACKGROUND: Finding ways to reinvent primary health care is imperative. One way is to change practices from a physician-focused model to an interdisciplinary team approach where other health professionals (nurses, nurse practitioners, dieticians, rehabilitation therapists, and other qualified primary care providers) collectively take on much stronger roles-often providing services instead of the physician. Health care policy makers and professionals agree that these new practices are a good idea, and yet they have not been widely adopted. PURPOSE: Our goal was to understand how new interdisciplinary practices became legitimized as the new accepted working standards. METHODOLOGY: We conducted a qualitative, longitudinal comparative case study of 8 primary health care innovation sites established to provide services through interdisciplinary teams. We followed changes in practices over a 3-year period by conducting 150 interviews with professionals and managers across the 8 sites. FINDINGS: At the end of 3 years, new practices were adopted in 5 of the sites, but in 3 sites, they were not. We explain the differences by identifying a series of strategies used by managers in the successful sites and compare them with those used in the other 3 sites. Strategies used in the successful sites were (a) gaining full engagement, (b) enticing people to try new practices, (c) encouraging structured disagreement, and (d) staying focused on overall goals. PRACTICE IMPLICATIONS Managers of health care change initiatives must gain buy-in from professionals, but that is not enough. They must also facilitate trying the new practices as soon as possible. Open disagreement should be carefully encouraged, but any concerns must also be successfully addressed. Finally, managers must keep professionals focused on the overall goals of change rather than allowing paralysis in response to external events.