Cultivating Engaged Leadership Through a Learning Collaborative: Lessons From Primary Care Renewal in Oregon Safety Net Clinics

Article Figures & Data

Table 1

Characteristics of Primary Care Renewal Provider Organizations and Data Collected

	Organization

Characteristic	VGMHC	MCHD	OHSU	Legacy Emanuel	Old Town Clinic
Organization characteristics	FQHC	FQHC	FQHC look-alike, rural health clinic family medicine department	2 PCR clinics from a large, nonprofit health system	FQHC; Healthcare for the Homeless site
Clinician FTEs (2011)^a	36.8	56.6	14.9 (Richmond); 8.0 (Scappoose)	3.2 plus residents^b	6.12
Patient characteristics	Many Spanish-speaking patients; migrant workers; diverse cultures and languages; high-volume pediatric care	Diverse cultures and languages; refugees	Family medicine residency training sites; 1 urban, ethnically diverse clinic; 1 rural clinic	Urban; internal medicine residency training site (at 1 clinic)	Homeless individuals with chemical dependencies
Study data
Leaders interviewed, No.	1	2	1	1	1
Learning collaborative^c	Yes	Yes	Yes	Yes	Yes
PCR steering committee	Yes	Yes	Yes	Yes	Yes
Clinic site visit measures, No.				N/A	N/A
Interviews	20	26	23	–	–
Field note pages	181	293	218	–	–
Survey questionnaires	57	51	71	–	–
Researcher days^d	15	23	16	–	–

FQHC=Federally Qualified Health Center; FTE = full-time equivalent; MCHD = Multnomah County Health Department; N/A = not applicable; OHSU = Oregon Health & Science University; PCR = Primary Care Renewal; VGMHC = Virginia Garcia Memorial Health Center.
↵a All but Legacy Emanuel’s data come from 2011 Uniform Data Set reporting to the Health Resources and Services Administration, compiled by the Oregon Primary Care Association. (See also http://bphc.hrsa.gov/uds/view.aspx?q=rlg&year=2011.)
↵b From Legacy Emanuel’s third-quarter 2011 PCR Status Report to CareOregon.
↵c A total of 7 learning collaborative and steering committee observations yielded 58 pages of field notes, which we could not separate by organization because multiple PCR organizations attended these activities.
↵d Researcher days were calculated by number of team members present for each day or half-day of observation. Typically, 3 or 4 team members were present at any given time during a site visit.

Table 2

Description of Interview Participants (N = 9)

Organization	Role	Primary Role Regarding PCR Initiative
CareOregon	Medical director of Clinical Innovations Support	Broker between PCR funding organization and participating PCR clinics
CareOregon	Senior evaluation associate	Resource for data monitoring and measurement of results for PCR-involved clinics
CareOregon	Senior manager of Primary Care Projects	Medical home facilitator: responsible for building “a community of practice” among PCR organizations
Legacy Emanuel	Medical director/outpatient care	Physician champion with a focus on quality improvement and disease management
Old Town Clinic	Medical director	Physician champion with a focus on developing pain management, tobacco cessation, and diabetes management programs
OHSU (Richmond)	Clinician/faculty	Physician champion and clinic lead advocating for PCR within larger organizational system
VGMHC	Chief executive officer	Public administrator with focus on payment reform, public policy, and integration of behavioral health into primary care
MCHD	Medical director	Became medical director during PCR initiative; prior role included EHR champion and assistant medical director
MCHD	Operations director	Prior experience in managing finance and operations in a large private health care organization

EHR = electronic health record; MCHD = Multnomah County Health Department; N/A = not applicable; OHSU = Oregon Health & Science University; PCR = Primary Care Renewal; VGMHC = Virginia Garcia Memorial Health Center.

Table 3

Inspiration Phase: Key Themes According to Leadership Element

Modeling Leadership	Facilitative Leadership	Adaptive Leadership
Before deciding to embark on PCR, regional safety net clinic leaders had similar personal drive and vision for their organizations: a population-based approach to care that enhanced the patient care experience. All PCR participants shared a deep dissatisfaction with the current state of primary care and desire for transformation. All PCR leaders had a strong leadership vision that reflected a desire to put systems and structures in place to foster nonjudgmental, patient-centered care.	Leaders codesigned 5 pillars and the payment method to align resources to allow the model to emerge and function. Leaders saw collaboration, empowerment, and codesign as essential during the piloting phase. All levels of the organization, especially frontline staff, were included as thought partners in the process of pilot testing (and later implementing) the model. Pilot teams were composed of champions.	Steering committee had a combination of closed meetings only for PCR participants and open meetings with other community partners or advisors. Recognizing that external partnerships and payment reform were required for PCR success, CareOregon and steering committee members also advocated for statewide payment and health care reform.

Table 4

Implementation Phase: Key Themes According to Leadership Element

Modeling Leadership	Facilitative Leadership	Adaptive Leadership
Coaching in Lean management pushed leaders to formalize rounding visits to clinic-level leaders. Top leaders noted that these rounds seemed overly structured and not “friendly,” but clinic-level management liked leaders’ interest in the details of their work and what they were expected to present when top leaders visited the clinic.	Leaders purposefully involved key staff—directors, quality managers, physician leaders, frontline medical and allied health professionals, and office personnel— throughout their organizations in learning collaborative training sessions. The leaders and champions viewed themselves from the beginning as advocates of the model, cocreating a change process through inspiration and advice, rather than through a top-down approach of dictating change. Communication structures were organized to avoid a top-down approach and encourage participation of all staff.	Learning collaborative seminars and workshops spread expertise from experts to beginners. Learning collaborative seminars provided dedicated time for organizations to meet by themselves to discuss lessons, and align and set organizational priorities. Participation in Safety Net Medical Home Initiative focused on development of technical expertise. Metrics underlying reimbursement incentives were continually reviewed in steering committee meetings as implementation matured.