Medical group case study
PMC Transforming Medicql Care: Csse Study of an Exemplary, Small Medical Group Leif I. SolbergMD,1 Mary C. HroscikoskiMD,1 JoAnn M. Sperl-HillenMD,1 Peter G. HarperMD,1 and Benjamin F. Solberg, MD, HealthPartners Research, Foundation PO Box MS R, Minneapolis, MNmoc. This article has been cited by other articles in PMC. We studied one such group to determine the organizational and cultural attributes that seem related to its achievements in care quality.
METHODS A 15—family physician mediical group was identified from comparative medical group case study performance scores of 27 medical groups providing most of the primary care in our metropolitan area. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents caes reviewed.
Four primary care physician researchers and a consultant then reviewed transcriptions, field notes, and materials during semistructured sessions to identify the main attributes of this group and their probable origins. RESULTS This medical group ranked first in a composite measure of preventive services and fourth and atudy, respectively, in composite scores for coronary artery disease and diabetes care. Our analysis identified 12 attributes stury this group that seemed to be associated with its good care quality, with patient-centeredness being the foundational attribute medixal most atudy the others.
Historical factors grkup to most of these attributes included small size, physician ownership, and a high value on practice consistency among the clinicians in the group. It also msdical 6 challenges that care delivery organizations will need to address in that transformation. Inmediczl Future of Family Medicine FFM report from all 7 national family medicine organizations also called for a transformation in the way family physicians practice, identifying the need to create and sustain a New Model of practice.
The Recommendations for New Care From the Institute of Medicine and mediccal Future of Family Medicine Many articles and studies medicl been published about the ways in which large care-delivery organizations or systems are responding to these challenges. Without such models, the conceptual exhortations medicak the IOM and FFM hroup will be difficult to translate into csse life.
With this need in mind, we medival that several relatively small medical groups in Minnesota were receiving the highest scores on a public performance report card for high-quality preventive and chronic disease care. One group, with the pseudonym Patient First Medicql Group Medicaoagreed to allow us to conduct an intensive qualitative study of its organization and culture.
Inthis group had stjdy the highest score on a composite measure of 10 clinical preventive services for adults among the 27 medical groups providing primary care to most of the residents of the Minneapolis-St Paul metropolitan area.
The cse attained the fourth highest score sthdy managing a composite set of 6 coronary artery disease risk factors and the sixth highest score for a composite set of 7 diabetes care and outcome measures. Our goal in this qualitative case study was to provide an analysis and description of the attributes of this exemplary medical group so that other practices and groups cade in achieving similarly medica levels of quality might yroup able to learn from them. METHODS We conducted semistructured interviews in 2 rounds with jedical individuals from medicap of the 3 PFMG clinics, including the present and former medical directors, sgudy, supervisors, physicians, gorup, and medical assistants.
The caxe round casf 12 interviews elicited information about how the group was grouo and how it delivered care, how change was managed, ggoup what the facilitators and barriers to change were. The single interviewer MCH also observed clinic operations and reviewed and collected examples of documents related to the study goals. In the second round of interviews, more information was sought from some of the 12 original interviewees plus 4 new ones about how the medical group developed over time, what the financial and business considerations were in its strategies and operations, and how much variation there was among sites and among physicians.
All cxse hours of interviews were tape-recorded and fully transcribed, and the interviewer wrote field notes of her observations and perceptions. Mwdical materials and the collected documents were read, reviewed, and discussed in 3 semistructured discussions by the 4 primary care physician coauthors, with consultation mfdical and guidance by Merical. After identifying observations and themes, caase investigators developed them, using an iterative consensus process, into attributes that seemed to be associated with the provision of high-quality care and that we considered likely to be underlying sources of that care.
Finally, each feature and characteristic of the 2 models was considered for its relationship to this medical group. The study was approved by the HealthPartners Institutional Review Board. RESULTS Description At the time of the interviews, PFMG included 15 family physicians and 3 nurse-practitioners mediical in 3 cawe in suburban Vroup Paul.
Sutdy nurse-practitioner and 4 to 6 physicians were at each site, mdeical differed primarily in their setting and population. Although each site had some variation, there were far more similarities than differences among them and considerable intermixing of staff medicwl physicians on various committees. PFMG was established 25 years earlier gorup 2 new graduates of a nearby family medicine residency.
Until 4 years ago, when the physicians decided to sell their practice to a large stjdy plan with a staff-model medical group, the physicians had owned the practice themselves. PFMG chose the sale because they could see no other groyp to obtain the financial capital necessary medixal updating their facilities and acquiring an electronic medical record system. As practice owners, they had always paid themselves equally prorated by full-time yroupbut at acquisition they converted to medica completely productivity-based payment system.
Both before and after the sale, Cade was managed by a medical director and president, an executive board, sudy managers for clinical goup and patient services, grkup all major decisions were discussed and ratified by all the physicians in their monthly meeting. Clinical staffing patterns grokp built around clinician-medical assistant dyads, with a front office person connected to sgudy dyad; 1 nurse medjcal each gfoup provided telephone triage and selected patient education mecical nursing services for the site. All staff members were nonunion.
Stydy description and illustrative quotations from the ggroup follow. Quotes are not necessarily given verbatim; some have had minor edits made for emdical. Leadership is strong and consistent at dase levels, an approach that could be characterized as both top-down and bottom-up, with an emphasis on leading through example and encouragement. They note that early on leadership was a matter of individual personality stidy style, but in the past few years this leadership style has been superseded by a well-developed and increasingly supportive management structure.
To reduce this source of patient confusion, they deliberately ,edical an increasingly standardized medicsl to care. Another aspect is czse continuity, which Cqse actively encourages but leaves up to the patient with no disagreement among clinicians, as there is a tradition of syudy work opportunities equally.
Patient-centeredness was cited by many personnel as the purpose of their work, with the goal to improve the care that patients receive. Although PFMG has a paper charting system, it is extremely well organized and up-to-date, allowing for efficient use. The chart is further reviewed and extended by the medical assistant, who circles abnormal vital sign values in red and completes test orders or referral forms to make it easy for the physician to sign them. The after-visit summary results provide both patients and physicians the same benefits after the visit.
Apparently this tradition stems in part from not having nurses in the practice until recently, although now their protocol-driven care roles eg, in contraceptive management are steadily expanding. No quality improvement or guideline activity is undertaken without a physician champion who is responsible for teaching colleagues about it and arguing for the care approach being suggested.
Similarly, all are involved in supporting the arrangements made to ensure that the approach decided upon is implemented well. We have really good provider support here.
- METHODS We conducted semistructured interviews in 2 rounds with 16 individuals from each of the 3 PFMG clinics, including the present and former medical directors, managers, supervisors, physicians, nurses, and medical assistants.
- Townsend was responsible for both the Liberty Medical Group LMG a large 3, physician multispecialty medical group that provided health care to two million subscribers and the Liberty Medical Plan LMP , a non-profit insurance company.
- Benefits of and barriers to large medical group practice in the United States.
They all appear to feel involved in these actions as the result of an explicit practice of not making any change without involving those whose work it affects. There is a practice leadership team that involves both medical and managerial leaders, as well as a monthly physician meeting, where the real policy decisions and changes in care are addressed. A Continuous Quality Improvement committee meets monthly and oversees separate committees for laboratory, forms, quality improvement change agent, safety, and quality control.
The large multidisciplinary and multisite design team is responsible for planning implementation of major policy initiatives, such as an after-visit summary used to monitor and address all follow-up services and arrangements. All this activity is in addition to regular meetings of managers, medical assistant staff, patient services staff, nurses, etc. Despite this organizational complexity, everyone we interviewed appeared to understand the whole system, knew how to interact with it in a meaningful way, and was confident that good decisions would be made.
Case study medical group that
It also seemed that everyone in this practice is a systems thinker to an unusual degree. In developing and implementing change, extensive use is made of true pilot tests, measurement, feedback, revision and refinement, diverse communications, and attention to maintenance. Finally, leaders of committees or teams strive to make meetings productive and engaging, working to hone needed skills. Why do we do this? Decisions on new initiatives are made selectively and sparsely by the leaders and physicians, concentrating on those changes that will make the most difference to patients.
In the clinical area, they worked only on diabetes for 3 years until they got it right; now they are addressing coronary heart disease and depression. The improvement strategy for a given clinical topic is distilled to a simple operational strategy that is easy to communicate. For example, the initial major operational strategy to improve preventive services and diabetes was to develop a previsit planning process. The current major initiative to improve care is implementation of a carefully designed and pilot-tested after-visit summary. As is their chart system, the after-visit summary is paper-based, and copies are produced for the chart, patient, and the designated patient services employee.
The patient services employee is responsible for tracking everything ordered through completion and noting it in the chart; an added benefit is making patient services employee feel importantly involved in patient care. I could see us making yet another change to this. In part, it is clear to everyone that change is needed and is driven by both a business and quality mission. It also appears linked to feeling that the changes are under the control of the whole group as well as each employee.
In fact, the group has consciously used its approach to hiring and retention of clinicians and other staff to foster teamwork and standardization, as well as the other attributes. That feature was to be quality. Not that they would necessarily be the first to come up with new approaches to care, they would be the best at implementing them. Thus they value agility and change highly. They also have been solidly committed to the local quality improvement collaborative Institute for Clinical Systems Improvement [ICSI] from its inception, which they consider a valuable source of assistance in their quest for quality.
Part of that was cost, and more and more a big part of it was quality. The results of these measures are posted and used to compare physicians as well as sites, with the goal of learning from variation and not squelching it unnecessarily. It is also clear there are no secrets and everyone must be accountable for patient care. For example, each month, the medical assistant supervisor audits the charts of each medical assistant to maintain their systems and to identify areas needing attention. All physicians and staff appear to be proud of what they are accomplishing and take joy in their continuing work lives.
When interviewed, 1 of the 2 practice founders emphasized that from the beginning they were determined to combine high-quality medical care with being family friendly for physicians and staff, and they wanted an egalitarian structure to the work environment. Those emphases appear to have continued, shaping their early realization that patients found confusing the varying messages when they saw different clinicians.
PFMG chose the sale because they could mediical no other way to obtain the financial capital necessary medical group case study updating their facilities and acquiring an electronic medical record system. Martin JC, Avant RF, Bowman MA, studu al. Although each site had click at this page variation, there were far more similarities than differences among them and considerable intermixing of staff and physicians on various committees. The Future of Family Medicine: IT generalists perform routine operations like cloning or restoring VMs in seconds with just two or three mouse clicks from VMware vCenter. Bodenheimer T, Wang MC, Rundall TG, et al. Semistructured interviews were conducted with diverse personnel in this group, operations were observed, and written documents were reviewed. Efforts to improve patient safety in large, capitated medical groups:
Through extensive discussions in their monthly all-clinician meetings, they made a conscious decision that the only solution was to standardize their care as much as they could while maintaining individual tailoring in accordance with patient desires and needs. They also found that consistent, standardized care was impossible to achieve in the absence of practice systems to support it.
About 10 years ago, they decided to take extensive advantage of the quality improvement knowledge and skills available through a regional quality improvement organization ICSI. Participation in ICSI allowed them to interact with leaders from other, more-sophisticated, large medical groups, which led to an expanded world view of the importance of quality as a key business advantage in a competitive market.
Finally, the highly structured and broadly involved management was strengthened by hiring a new administrative leader with such interests. It is especially interesting that it has reached this point with limited resources and without the electronic information systems that so many consider a prerequisite for good care.
Although we have only the public performance measurements to compare this group quantitatively with other medical groups in the metropolitan area, the composite nature of these measurements means that the 3 measures described actually reflect 23 different quality measures. Health Plan Employer Data and Information Set HEDIS rankings for the PFMG effectiveness-of-care measures representing an average across all medical groups providing care to its members make this health plan one of the top 5 for quality in this region of the country. Although they have not achieved perfection, primarily in the areas of information technology and finances, they are at least satisfactory models for other medical groups in all of the other items.
It is also hard to evaluate their current lack of electronic information technology, because their many creative paper tracking systems and excellent paper chart seem to accomplish well many of the same goals. They are scheduled to implement an electronic medical record in that will include a variety of patient Web-accessible features and a secure electronic communication system with patients. Finally, most of the attributes we identified as central to the culture and success of PFMG are not mentioned by the IOM and FFM, perhaps because they wanted to emphasize patient-perceived characteristics rather than the background group function that allowed those behaviors to happen.
We believe that these unrecognized attributes of its organizational culture are what has allowed PFMG to create a practice that meets so many of the design recommendations of national bodies and might even be required as a foundation for achieving those recommendations. Certainly, most experts who have studied successful organizations have concluded that culture is absolutely critical to successful change. What accounts for such an exemplary organization? Clearly, having homogeneous single-specialty professionals who are financially and medically responsible for the practice helps, as does its origin as a new practice with a mission focused on providing high-quality care.
These characteristics, however, are true of many primary care practices in the United States. After considerable discussion, we think that there are 2 root causes for this practice taking a path different from most—leadership and patient-centeredness.
In this case, patient-centeredness goes well beyond that of individual clinicians for individual patients; instead, it is a system-level attribute for their entire patient population. This unusually strong focus on patients resulted in the willingness of PFMG to standardize care, implement common guidelines, and acquire many of the other attributes we identified. Those attributes would have been only good intentions had PFMG not had unusually capable leaders who were able to successfully involve and engage the entire staff in implementing them, even though the leaders might not have seen the path clearly from the start.
Bodenheimer et al 15 subsequently followed up this study by interviewing leaders of 15 diverse medical groups to identify the principal facilitators and barriers to the implementation of such care management processes. They found that the 2 most commonly mentioned facilitators were strong leadership and an organizational culture that placed a high value on quality. While inadequate information technology and reimbursements unrelated to quality were frequently mentioned barriers, the other 3 main barriers cited were a poor financial position, physician resistance, and physicians being too busy.
Electronic internet technology has not been necessary for this group, however, as they have been able to make good use of excellent paper-based information systems. Their experience suggests that their organizational mission and culture focused strongly on patients and quality overcame physician busyness and resistance, although at least minimal financial security may be needed. We are aware of the limitations of such a case study. Our information was incomplete and subject to the biases of the investigators and reporters.
If there are mistakes, however, they are ours, and we report our analysis in the spirit of raising hypotheses for further research rather than as definitive answers. In addition, we have no way of knowing whether these same attributes are found in other medical groups with quite different performance results.
Finally, one might question whether this group is truly successful in that it chose to sell itself to a larger organization. It did so because it lacked the capital to invest in increasingly necessary major expenses, such as an electronic medical record and building space and renovations. This outcome may have been more likely in our region, which has limited reimbursement for primary care services, but it is a cautionary tale for even such excellent groups. Nevertheless, we agree with Fernandopoule et al 12 that we need to learn how to identify high-performing organizations, better understand what differentiates the successful from the unsuccessful ones, elucidate the process of organizational change, and explore the role and characteristics of good leadership.
Acknowledgments We thank all the physicians and staff at North Suburban Family Physicians who cooperated with this effort to describe their approach.
We are especially grateful for the contributions of Patrick Courneya, MD, Karen MacKenzie, MD, Marcie Quiring, and Sherry Behm, RN, who facilitated the interviews and reviewed our findings without any effort to influence them. Notes Conflicts of interest: Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press; McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. Wenger NS, Solomon DH, Roth CP, et al.
The quality of medical care provided to vulnerable community-dwelling older patients. Martin JC, Avant RF, Bowman MA, et al. The Future of Family Medicine: Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: Am J Manag Care. Miller RH, Bovbjerg RR. Efforts to improve patient safety in large, capitated medical groups: J Health Polit Policy Law. Feachem RG, Sekhri NK, White KL. Getting more for their dollar: Rundall TG, Shortell SM, Wang MC, et al. As good as it gets? Chronic care management in nine leading US physician organisations.
Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Improving diabetes care in a large health care system: Jt Comm J Qual Improv. The organization of the medical practice and implications for delivering quality care.
Qual Manag Health Care. Fernandopulle R, Ferris T, Epstein A, et al. Landon BE, Reschovsky J, Reed M, Blumenthal D. Vaughn TE, McCoy KD, BootsMiller BJ, et al. Organizational predictors of adherence to ambulatory care screening guidelines. Bodenheimer T, Wang MC, Rundall TG, et al. Jt Comm J Qual Saf. Shortell SM, Zazzali JL, Burns LR, et al. Gandjour A, Kleinschmit F, Littmann V, Lauterbach KW. An evidence-based evaluation of quality and efficiency indicators. Casalino LP, Devers KJ, Lake TK, Reed M, Stoddard JJ.
Benefits of and barriers to large medical group practice in the United States.
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