Key Elements Distinguishing Higher- and Lower-Performing Practices
| Element | Higher-Performing Practices | Lower-Performing Practices |
|---|---|---|
| Managing competing demands to medical home implementation | ||
| Technology | Most had existing EHRs | Most installed new EHRs during medical home implementation |
| Finances | Had stable financial systems and processes | Had less stable financial systems and processes |
| Leadership and vision | ||
| Shared vision and buy-in | Champions emphasized the need for all practice members to be on board with the initiative Careful articulation and reinforcement of how the medical home will help patients and the practice and the need for changes | Little to no dissemination of information about the motivations for joining the initiative Confusion about changing roles, uncertainty about processes and expected outcomes |
| Deliberate planning and testing of changes | Careful, deliberate plan of action, starting slowly with diabetic patients only and with 1 clinician and 1 office staff trying out novel methods and working out the kinks before implementing across the practice | Inconsistent roll-out of methods |
| Building teams and resource capacity | ||
| Sense of team | Collective problem solving and shared decision making High levels of trust, respect, and collaboration Regular multidisciplinary meetings and communication | Top-down approach to decision making Less clarity on roles and responsibilities Noninclusive approach to meetings and communication |
| Cultivating human resources | Strategic development of team in terms of composition and education/training Expansion of the role of the medical assistant Relatively stable staffing | Less effort to form an integrated team and insufficient education/training for staff Role of the medical assistant remains more limited Moderate to high staff turnover |
| Monitoring progress and obtaining feedback | ||
| Feedback systems | Systematic ongoing processes to solicit and share feedback | Feedback was not systemic; lack of opportunity to provide feedback; little dissemination of feedback |
| Benchmarking | Data shared across practice regularly; stimulates changes and healthy competition among clinicians | Data not shared regularly or widely |
| Planning and implementation of changes | Shared planning and decision making regarding changes | Unclear processes in terms of who is involved and what procedures in place to implement changes |
EHR=electronic health record.
Source: Site visit observations and semistructured interviews.