Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites

Common Features

Case practices shared several traits that are likely to have contributed to their high performance. The practices were older and well established and were in no apparent financial distress. The newest practice was started by a physician who had a successful history of opening and expanding medical offices. Additionally, a leader prioritized performance in each practice at baseline, and regardless of whether individuals had reservations about improvements, they were able to work together as a practice to support their leader’s vision of excellence. To guide their efforts, most practices used the A-TRIP practice performance reports, as well as corresponding patient-level reports that function as a registry. The practices were realistic about performance measurement in the understanding that the ultimate goal was providing the best care for each individual patient. The practices also worked in close partnership with their patients. They used care plans and patient education to ensure that patients played an active role in guideline adherence.

Variations in adoption of PPRNet’s improvement model are depicted in Table 2⇓. Technophiles used a smaller variety of strategies than the other archetypes. As a group, the case practices adopted more strategies than their A-TRIP peers.

The Technophiles Archetype

All practices in the A-TRIP study used an EMR. Five of the high-performing case practices were distinguished by their quick adoption and consistent use of EMR tools.

The practices in this archetype developed problem-based templates that guide clinicians and staff to perform and document routine tasks consistently. A template might guide a nurse to record blood pressure and prompt a screening assessment of alcohol use. A template could also guide a clinician through routine management of a particular chronic condition. The template could import the patient’s last laboratory results or blood pressure, temperature, pulse rate, and respiratory rate, and include reminders about care recommended in new guidelines, as well as links to patient education. Improvements were seen in all 5 Technophile practices in both process and control measures: after 36 months, for example, the mean percentage of patients with diabetes who had a glycosylated hemoglobin (HbA_1c) test in the past 6 months increased from 66.1% (SD 8.1) to 78.6% (SD 4.7), and the mean percentage of patients whose low-density lipoprotein cholesterol was <100 mg/dL increased from to 43.3% (SD 6.0) to 65.0% (SD 5.9). The mean percentage of patients with hypertension whose last blood pressure measurement was <140/90 mm Hg increased from 57.2% (SD 12.2) to 72.2% (SD 4.8).

The Technophiles used interfaces that electronically load laboratory results into the EMR. They took advantage of features that automate the physicians’ review of test results. They developed personalized patient letters that provided tests results and education. They established protocols and assigned responsibility to run regular recalls for care, notifying patients that visits or tests were needed, and they used their scheduling software and reminders to make sure patients got follow-up care when they needed it for conditions such as diabetes.

The clinicians in this archetype made good use of internal messaging features in the EMR. Messages were sent by physicians to themselves to remind them to do follow-up items. Messages sent between staff and clinicians made care coordination more efficient. The best practices in this archetype also used consistent diagnostic nomenclature, which made it easier for them to query their EMR data using the built-in EMR query functions to identify subgroups of patients needing follow-up care.

At the core of each of the practices in this archetype was a physician who was driven to achieve both good care and efficiency. This physician was dedicated to finding new ways to use the EMR, and tended to speak in terms of the time it takes to get things done. Some have described themselves, and have been described, as compulsive. These physicians were innovators and could modify the EMR quickly and easily to include reminders and links that automate care decisions, coordination, and documentation. These physicians also stimulated practicewide improvement by their role as a change champion. One physician explained at a network meeting that when she wants to implement a change in her practice, she sets up a tool in the EMR so that there is no faster or easier way to do the job. Her innovation made it easy to convince other clinicians and staff to adopt the change. An innovator in another practice customized all the encounter templates for medical conditions that might require aspirin prophylaxis. She was able to design this customization during a practice meeting as others were discussing ways to increase aspirin prescribing. She then explained to her practice team how to use the new codes. The practice saw how it worked and decided to adopt this strategy. Their solution to low prescribing rates for aspirin therapy was implemented in a matter of minutes.

The Motivated Team Archetype

All high-performing case practices described in this article participated in biannual site visits and/or annual network meetings to assist them with their change efforts. Two high-performing case practices are distinguished by the additional effort they put into motivating and enabling their staff to play important roles in their improvement efforts. In the larger practice, this focus on engagement extended to clinicians as well. Multiple clinicians frequently deliver care in different ways and may need to be convinced to make changes to conform to practicewide efforts for quality improvement. The motivation in this practice was enhanced by bonuses from a local pay-for-performance program.

The practices in this archetype used multiple strategies to get everyone involved. A lead physician promoted the importance of new activities in conversations and behavior, which staff feedback indicated was a critical first step. Further, because the doctors are usually viewed as the person in charge, this step gave staff employees permission to move forward. The practice leaders in this archetype shared the A-TRIP performance feedback with their staff and ensured that staff members had training about guidelines so that they were aware of the goals behind new tasks. The leaders held practice meetings, in addition to site visits, to check progress and make plans.

The practice staff worked with the clinicians to select indicators they wish to improve and designed activities to achieve improvement. As an example, nursing staff in one practice checked to determine whether health maintenance items were up-to-date and scheduled patients for services, if needed. Mammography rates in the past 2 years for women aged 40 years and older rose from 77.2% to 88.4% in 12 months and remained high, at 89.5%, after another 2 years. Staff in these practices set the tone for visits and saved their doctors some time by providing information about routine care that was due. One licensed vocational nurse said, “By bringing up health maintenance goals before the doctor comes in, patients are prepared for services or discussion.”

The higher-performing practice in this archetype devoted an additional half-day each quarter to making improvements. The office was closed, and all practice employees gathered for meetings and concentrated activity, such as reviewing patient-level reports (a form of registry generated by the A-TRIP project). The physician-owners of the practice emphasized that improving quality is as important as anything they do. Among their experiments was testing a staff incentive plan using graduated individual retirement account contributions based on varying levels of improvement in the practice’s quality indicators.

Evaluation data indicated that the staff in these practices responded to their leaders’ efforts to include and motivate them. Staff feedback to their leaders, as well as anonymous surveys for the project, confirmed that the staff valued quality, recognized the importance of their expanded role to their practice, and appreciated the additional training and tools. For example, a medical assistant explained that her motivation to take on extra work to deliver higher-quality care comes from the knowledge that her effort was in the best interest of the patients. Another practice’s medical assistant said that from her participation in the A-TRIP project, she learned she can be more helpful. A receptionist said, “I like education and being informed … checklists, specific goals, and deadlines motivate me.”

In comparison with the Technophiles, the practices in this archetype were more likely to express mixed feelings about their EMR software. In the beginning, individuals were pessimistic about adopting particular EMR tools, and many needed EMR skill development.

The Care Enterprise Archetype

As part of their solution to improving care, 2 high-performing practices took a business approach that was influenced by customer service and risk management. They organized special service lines in the form of focused care management clinics, hiring corresponding staff as needed (eg, certified diabetes educators or nurse-practitioners focusing on women’s health). The problem-focused clinics were designed to provide comprehensive, competitive, guideline-adherent care that was convenient for the patient and that ensured the doctor has done everything possible to manage care appropriately. One physician explained the personal value of his approach: “The ability to reduce risk of harm to my patients and simultaneously reduce risk of litigation is an important benefit.”

The care enterprises could be considered a special form of motivated teams. The leading physicians in these practices delegated care management responsibilities to their staff and provided regular supervision, such as weekly care coordination meetings between nurses and physicians. They excelled in redesigning delivery systems to support their special service lines and their general practice. The practices conducted point-of-care tests and used an in-house laboratory so that test results were available during the visit. Standing orders for routine monitoring tests and immunizations for designated populations were used to delegate components of the care management process. One practice abandoned annual physical visits with patients, instead scheduling intake visits with nurses alone and shorter follow-up visits with the physician. The practice arranged additional follow-up in nurse blood pressure or anticoagulation clinics, and in nurse-practitioner women’s health or diabetes foot clinics, as well as physician medical follow-up based on practice protocols. Staff tracked and enforced the condition-specific schedules.

The practices in this archetype also incorporated a population approach to quality management. In one practice, staff were delegated to use EMR queries to identify patients with specific needs. They conducted outreach to patients when guidelines were not met. These efforts contributed to improvements; for instance, the percentage of patients aged 65 years and older or with conditions requiring pneumococcal vaccines who were immunized in the past year rose from 36.9% to 62.5% in the first year and continued to rise to 87.6% after 3 years.

The 2 practices in this archetype implemented changes in their settings quickly. They did not appear to need to negotiate for investment within their team. The practices’ improvement efforts had a greater focus on A-TRIP indicators related to diabetes and heart disease than other areas.

An Organizational Culture Perspective

Although this study provides insights regarding practice behavior from a qualitative perspective, recent interest in identifying organizational culture characteristics as factors influencing the quality and cost of care have prompted evaluation of several quantitative tools for potential use in health care settings.^34,35 The competing values framework (CVF) has measured organizational culture in various settings outside health care.³⁶ CVF identifies 4 organizational archetypes derived from Jungian influence³⁷: Clan (focused on teams), hierarchy (invested in coordination and control), adhocracy (concerned with value innovation), and market-driven (motivated by competition). The organization’s dominant characteristics influence its members’ values and assumptions, the way they think, and how they process information. The archetypes of high performance that we found in our study have features in common with the CVF types.

The Technophiles archetype fits with CVFs adhocracy culture. This archetype values innovation and flexibility and develops electronic solutions to the demands of a quality-driven practice. The Motivated Team archetype fits a clan culture. These practices share a passion for cohesion, employee involvement, and commitment to team development. We observed a high degree of semiautonomous behavior in the practices that engaged their staff in cycles of improvement. By empowering the staff to come up with relevant solutions to identified problems, the Motivated Team practices were successful with change. The Care Enterprise archetype has additional features similar to the market-driven and hierarchical cultures. This archetype has strong leadership, organizes itself well, studies the community, and defines and packages services that are needed. Care Enterprise practices valued productivity and arranged for comprehensive convenient care for patients.

There are limitations to case study research. The findings are subjective; they are not meant to be representative or externally valid. In this study, only the best cases were observed, so controls for poor performance are lacking. The analysis is open to additional bias from the selection of data, confounding, and the researchers’ interpretations. The study implies that archetype features have led these case practices to their high achievement, but we need additional study comparing these practices with lower-performing practices to verify whether this finding is indeed true.

Another limitation is that case studies are meant to provide illustrations to which a reader can relate. One might feel we are lacking important details about the practices. It is already known that variations in health care quality cannot be explained on the basis of fee-for-service or managed care, size of the community, or type of insurance.^38,39 The problem is believed to reside in how medicine is practiced, and we may have missed or misinterpreted key components. One strength of case study research is that results can be used to generate new hypotheses or insights. We highlight rare observations, such as the high performers, and consider their context.²⁷ The analysis investigates how high performers approached improvements, and why their performance might be high—questions not easily answered in a large-scale outcome experiment.⁴⁰ We encourage others to test the ideas generated here.

In conclusion, high-performing practices in the A-TRIP study adopted variations of the PPRNet TRIP improvement model. There were many common strategies among them, but they organized change using different approaches. No single approach dictated superior performance. Additional study is needed to assess whether better outcomes are caused by the approach of these archetypes and whether adoption of these approaches would translate to high achievement in other practices.