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

Nancy Pandhi,Stephanie Berkson,Sarah Davis,William Caplan,Steven Koslov,Sally Kraft,Elizabeth Trowbridge,Sandra Kamnetz

doi:10.1186/s12913-018-3650-4

Abstract

BackgroundHealth 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.MethodsThis 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.ResultsSurvey 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.ConclusionsThese 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.

Highlights

Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market
In the United States, health systems are increasingly required to become leaders in quality improvement (QI) in order to compete successfully in a value-conscious purchasing market [1,2,3] Effective clinical teams are considered essential to the production of high-value systems of care within primary care
The clinical microsystems framework [4] is one approach to training primary care teams how to engage in QI activities

Summary

Introduction

Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market. Despite widespread use of the Microsystems approach across multiple countries and hospital and ambulatory care settings [7,8,9,10,11], published evaluations of its implementation within United States primary care settings are limited in number and scope This gap is surprising given an international emphasis on re-engineering primary care [12,13,14,15,16], and this approach being considered as one of the first few comprehensive models, besides the Chronic Care Model [17], the and the Idealized Design of Clinical Office Practices [18], that address team-based primary care redesign [19]. A single U.S.-based article briefly describes inclusion of microsystems training as part of a collaborative primary care faculty development initiative, and suggests that it would do best when there is “shared accountability for relationship service and reliability across the three [primary care] disciplines.” [22] Given the unique characteristics of primary care in an academic setting (e.g., providers who perform clinical care part-time among other responsibilities and the presence of trainees), further understanding of the strengths and limitations of the Microsystems approach is needed

Methods

Results

Discussion

Conclusion