Regular articleTools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery
Introduction
Illness prevention and health promotion represent two major components of U.S. public health initiatives [1]. While a variety of settings provide such services, primary care practices are the major locus for clinical preventive service delivery [2]. Despite the fact that providing preventive care is part of the day-to-day practices of primary care physicians, discrepancies exist between recommended [2], [3] and actual preventive service delivery [4], [5], [6], [7].
A substantial body of literature suggests that office characteristics, such as preventive service materials, availability of technology and personnel, organizational priorities, and office practice structure, are associated with the delivery of preventive services [8], [9], [10], [11], [12], [13], [14], [15]. Nevertheless, a lack of conceptual, theoretically driven research exists in understanding how office characteristics interact in their association with preventive service delivery.
Crabtree et al. [16] argue that primary care practices need to be viewed as whole systems, not just individual parts, in which a variety of factors contribute to the overall practice dynamic and consequently influence preventive care. Drawing from this perspective, the present study constructs and tests a theoretical model of practice-level influences on preventive services, hypothesizing that three categories or factors of office characteristics are associated with preventive service delivery. This model (detailed in Fig. 1) is centered on three primary care office system constructs—Tools, Teamwork, and Tenacity—that have been proposed as being important for preventive service delivery [16], [17], [18]. The terminology “Tools, Teamwork, and Tenacity” is drawn from Carney and colleagues [18], who used it in detailing the results of the Cancer Prevention in Community Practice (CPCP) Project, a primary care office system intervention for cancer prevention. However, while these three concepts are central themes to their work in exploring factors that may promote or impede improvement of preventive service delivery, the present study takes these concepts a step further by developing a theoretical model that operationalizes them in assessing how they are associated with preventive care.
Tools is operationalized as skills, aids, equipment, facilities, and procedures utilized in the provision of preventive services (e.g., prevention checklists, computer monitoring for preventive services, and availability of specific services). Use of a wide range of such tools has been found to play an important role in preventive care delivery [9], [14], [19], [20], [21]; however, increasing the use of tools may not necessarily equate to improved delivery rates [18], [22]. For example, the national program “Put Prevention Into Practice” (PPIP), designed to improve preventive service delivery, packaged and made available a number of office tools (i.e., waiting room posters, wall charts, preventive care flow sheets, and preventive service prescription pads) [23]. McVea and colleagues [22] found that among a sample of practices that obtained PPIP materials, the tools were not being used by sites that provided limited preventive services because they did not possess the organizational skills to independently implement the program. Consequently, there is a need to consider other office system factors in addition to tools.
Teamwork considers the roles of different personnel in the office and how these personnel operate in providing preventive services—in essence, the division of labor of physicians, nurses, and other staff members, and the interactions between these individuals in providing care for patients (e.g., degree of efficiency of staff, office hierarchy, and group functioning of the office staff). As Carney et al. [18] found, teamwork among office staff is a crucial factor in monitoring patients’ preventive services status and providing health habit counseling. Competing with other services, preventive care requires proactivity on the part of not only the physician, but also the entire office staff to share responsibilities and successfully manage [24].
Tenacity refers specifically to the attitudes and ideology that exist in the office regarding preventive services (i.e., importance placed on preventive services by a physician and/or other staff members). As Crabtree and colleagues [16] argue, a “Bee in the Bonnet” attitude toward prevention can greatly affect a practice’s delivery of preventive services (or perhaps a specific preventive service, such as tobacco counseling). For example, in their survey of pediatricians, Cheng et al. [25] found that the importance of a particular health topic predicted physician counseling. Further validating the need to consider Tenacity, Goodson and colleagues [26] found in their study of Texas practices that a philosophy of prevention characterized practices that successfully implemented the PPIP program [23]. Others [27] have found that positive attitudes do not always predict preventive service delivery rates.
“Preventive Service Delivery” is operationalized as all U.S. Preventive Service Task Force recommended screening, counseling, and immunization services [2] appropriate for each patient (based on age and gender) that have been provided within the recommended time frame. Finally, “Practice Context,” is considered because of its potential influence on preventive service delivery. Included in this construct are the type of practice (i.e., solo, single-specialty group, or other arrangement), practice ownership, patient volume, and demographic characteristics of the practice’s patients. Lower income patients, while generally more likely to have riskier health behaviors and lower overall health status than more affluent patients, are also less likely to receive certain forms of health counseling from physicians [28], [29]. Additionally, having insurance that pays for preventive services is an important predictor of many screening tests and tetanus immunization [30].
With the intention of exploring the question of how office system factors are associated with preventive care, this study assesses how these three constructs of primary care office systems (Tools, Teamwork, and Tenacity) are associated with preventive service delivery. We hypothesize that each of these office system constructs is positively associated with preventive service delivery, both independently and when combined with the other constructs, and after controlling for the potentially confounding effects of practice context.
Section snippets
Study design and data collection
The data used for this study were taken from the Direct Observation of Primary Care (DOPC) study, a cross-sectional study of service delivery in community practice. While the design of the DOPC study has been described in detail elsewhere [17], [31], briefly, participating physicians were members of the Research Association of Practicing Physicians (RAPP), a network comprising 138 community-based family physicians from 84 practices in northeast Ohio, who agreed to participate in a study of
Descriptives
Table 1 shows physician and practice characteristics. Overall, participating physicians were demographically similar to active practicing members of the American Academy of Family Physicians in terms of gender (AAFP = 79% male) and age (AAFP mean = 45 years) [35].
Of the 4994 total patients who presented for care during their physicians’ observation days, 4454 (89%) agreed to participate and have their visits observed. Participating patients were more likely to be female and White [31]. Patient
Discussion
This study utilized measures drawn from observation of patient encounters, medical record review, practice environment checklists, physician surveys, and qualitative fieldnotes in studying 4454 outpatient visits from 138 community-based family physicians with the purpose of testing a conceptual model of practice characteristic influences on preventive service delivery. Although the hypothesized effects of the Tools, Teamwork, and Tenacity practice constructs on preventive service delivery, both
Acknowledgements
The authors are grateful to the practices and patients who participated in the study. This study was funded by grants from the National Cancer Institute (1RO1 CA80862, 2R01 CA80862, K24 CA81031, K07 CA86046) and by a Research Center Grant from the American Academy of Family Physicians.
References (38)
- et al.
Direct observation of rates of preventive service delivery in community family practice
Prev Med
(2000) - et al.
Delivery rates for preventive services in 44 midwestern clinics
Mayo Clin Proc
(1997) - et al.
Obstacles to family practitioners’ use of screening testsdeterminants of practice?
Prev Med
(1989) - et al.
Put prevention into practice. Evaluation of program initiation in nine Texas clinical sites
Am J Prev Med
(1999) - U.S. Department of Health and Human Services. Healthy people 2010. 2nd ed. With understanding and improving health and...
Guide to clinical preventive services
(1996)- Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force (USPSTF)....
- et al.
Performance of cancer screening in a university general internal medicine practicecomparison with the 1980 American Cancer Society guidelines
J Gen Intern Med
(1986) - et al.
Screening procedures in the asymptomatic adult. Comparison of physicians’ recommendations, patients’ desires, published guidelines, and actual practice
JAMA
(1985) - et al.
An office systems approach to cancer prevention in primary care
Cancer Pract
(1997)
Primary care physicians’ use of office resources in the provision of preventive care
Arch Fam Med
Implementing the Put Prevention Into Practice program
Nurse Pract
Characteristics of primary care office systems as predictors of mammography utilization
Ann Intern Med
Improving and maintaining preventive servicesPart 1. Applying the patient model
J Fam Pract
Improving and maintaining preventive servicesPart 2. Practical principles for primary care
J Fam Pract
Practical approaches to providing better preventive careare physicians a problem or a solution?
Am J Prev Med
Primary care practice organization and preventive services deliverya qualitative analysis
J Fam Pract
Illuminating the ‘Black Box’a description of 4454 patient visits to 138 family physicians
J Fam Pract
Tools, teamwork, and tenacityan office system for cancer prevention
J Fam Pract
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