Table 1

Themes and Examples of Contextual Factors

Level specific
PracticeCharacteristics that describe the clinic or practice setting and that are directly related to experiences of patients and staffEmployee mix (eg, number of physicians and midlevel professionals of certain specialties; part time/full time; residents; staffing mix)
Clinician demographics, attitude, and training (eg, family medicine)
Patient panel size and characteristics (eg, SES, ethnic minority composition, payer mix: uninsured, Medicaid, private, etc)
Recognition type (eg, NCQA, other, none)
Ownership of practices (eg, physician owned, independent, group practice) Structural capabilities (eg, EHRs, financial management system, QI system with ability to provide feedback, linkage to hospital)
Leadership style (eg, visionary, strong personality, facilitative)
Larger organizationFactors related to the larger organization (if any) with which an individual practice is associatedOwnership, structural capabilities, and leadership style also may relate to this level
Competing priorities: what else was going on in the organization, and when? (eg, EHR implementation midway, financial crisis, financial health of practices, applying for recognition)
Degree of integration (eg, insurance, hospital system, specialty care, primary care, and AMC)
Contractual arrangements (eg, public payers, private payers, payment model such as extent of capitation)
External environmentThe health care system, policy, and community milieu relevant to the projectMarket environment (eg, competition)
Community characteristics (eg, SES, level of urbanization, availability of transport)
Political authority
Grant or other external financial support
Level of coordination/involvement with community (eg, statewide project, multipayer project, collaborative, advocacy)
Payment model(s) available (eg, fee for service, capitated, pay for performance, care management payment)
Cross-cutting theme
Implementation pathwayThe specific elements and processes of an intervention, including operational changes and feedback loopsWhat elements of the PCMH were implemented; when, and over what period of time?
What were the specific operational changes? (eg, expanded medical assistant role, building team communication, new employees hired; use of specific QI method, involvement of staff and patients in QI, feedback on performance to clinicians)
Formal program identity (eg, demonstration project; pilot project; organizational transformation)
History (eg, experience with transformation, burnout, adaptive reserve)
Provision of a safe place to experiment and even fail
Patient involvement in development
Intervention group (eg, specific disease; specific demographic subpopulation)
Assistance received (eg, external consultants, internal practice coaches; employee site visits; collaborative participation)
Main intervention objectives and outcomes (eg, health status, patient satisfaction, financial stability)
Motivation for implementationKey personal, organizational, and cultural drivers of change at multiple levelsPatient experience, quality, cost of care
Incentives, NCQA/other recognition, marketing
  • AMC = academic medical center; EHR = electronic health record; NCQA = National Committee for Quality Assurance; PCMH = patient-centered medical home; QI=quality improvement; SES=socioeconomic status.