Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach.

BACKGROUND: Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market. Doing so involves developing effective clinical teams using approaches like the clinical microsystems framework. However, there has been limited assessment of this approach within United States primary care settings. METHODS: This paper describes the implementation, mixed-methods evaluation results, and lessons learned from instituting a Microsystems approach across 6 years with 58 primary care teams at a large Midwestern academic health care system. The evaluation consisted of a longitudinal survey augmented by interviews and focus groups. Structured facilitated longitudinal discussions with leadership captured ongoing lessons learned. Quantitative analysis employed ordinal logistic regression and compared aggregate responses at 6-months and 12-months to those at the baseline period. Qualitative analysis used an immersion/crystallization approach. RESULTS: Survey results (N = 204) indicated improved perceptions of: organizational support, team effectiveness and cohesion, meeting and quality improvement skills, and team communication. Thematic challenges from the qualitative data included: lack of time and coverage for participation, need for technical/technology support, perceived devaluation of improvement work, difficulty aggregating or spreading learnings, tensions between team and clinic level change, a part-time workforce, team instability and difficulties incorporating a data driven improvement approach. CONCLUSIONS: These findings suggest that a microsystems approach is valuable for building team relationships and quality improvement skills but is challenged in a large, diverse academic primary care context. They additionally suggest that primary care transformation will require purposeful changes implemented across the micro to macro-level including but not only focused on quality improvement training for microsystem teams.

Development and Impact of a Novel Academic Primary Care Compensation Model.

BACKGROUND: Traditional productivity-based compensation models do not align well with newer population-based approaches to primary care. There are few published examples of academic general internal medicine compensation models that explicitly reward population health management, including care for patients between visits. OBJECTIVE: To describe the development and implementation of an academic general internal medicine compensation plan based upon actual work performed, compare satisfaction across primary care specialties, and evaluate work-related outcomes. DESIGN: Observational study. PARTICIPANTS: Forty-seven general internists who practice in affiliated academic and community clinics. MAIN MEASURES: Clinician satisfaction with compensation plan, workforce stability, panel data, and productivity. KEY RESULTS: The compensation plan change was associated with higher provider satisfaction. Sixty-five percent (31/47) of participants within general internal medicine reported being satisfied or very satisfied, as compared to 24 % (22/90 participants) for family medicine and 22 % (5/23 participants) for general pediatrics (p < 0.05). In the first 4 years of the compensation plan change, no general internists left to join other local groups. General internal medicine increased its number of physicians by 19 %. The number of established general internists accepting new patients increased from 17 to 48 %, while the relative value units per full-time equivalent declined by 3 %. CONCLUSIONS: An equitable compensation model that aligns with population management goals and work performed outside the clinical visit can lead to improved satisfaction and retention of faculty in an academic general internal medicine division, along with improved access for the patient population.

A Simple Framework for Weighting Panels Across Primary Care Disciplines: Findings From a Large US Multidisciplinary Group Practice.

BACKGROUND: Health system redesign necessitates understanding patient population characteristics, yet many primary care physicians are unable to identify patients on their panel. Moreover, accounting for differential workload due to patient variation is challenging. We describe development and application of a utilization-based weighting system accounting for patient complexity using sociodemographic factors within primary care at a large multidisciplinary group practice. METHODS: A retrospective observational study was conducted of 27 clinics across primary care serving more than 150 000 patients. Before and after implementation, we measured empanelment by comparing weighted to unweighted panel size and the number of physicians who could accept patients. Perceived access was measured by the number of patients strongly agreed that an appointment was available when needed. RESULTS: After instituting weighting, the percentage of physicians with open panels decreased for family physicians and pediatricians, but increased for general internists; the number of active patients increased by 2%. One year after implementation, perceived access improved significantly in family and general internal medicine clinics (P < .05). There were no significant changes for general pediatric and adolescent medicine patients. CONCLUSIONS: The creation of a weighing system accounting for complexity resulted in changes in practice closure, increased total patients, and improved access.

Across the divide: "Primary care departments working together to redesign care to achieve the Triple Aim".

BACKGROUND: Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim. METHODS: As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing. RESULTS: Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability. CONCLUSIONS: Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes. IMPLICATIONS: The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation.