RESUMO
PURPOSE: Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework. METHODS: We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings. RESULTS: Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps. CONCLUSIONS: Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale.