Elsevier

Preventive Medicine

Volume 36, Issue 2, February 2003, Pages 131-140
Preventive Medicine

Regular article
Tools, teamwork, and tenacity: an examination of family practice office system influences on preventive service delivery

https://doi.org/10.1016/S0091-7435(02)00024-5Get rights and content

Abstract

Background

Most research examining primary care office characteristics and preventive service delivery (PSD) has evaluated preventive service aids and equipment, while generally overlooking the complex interactions among multiple office systems where multiple factors influence the overall practice. We test a theoretical model of practice influences on PSD that accounts for Tools (preventive service aids/equipment), Teamwork (office organization), and Tenacity (prevention delivery attitudes).

Methods

Office characteristics and 4454 patient visits were observed for 138 family physicians in northeast Ohio. Utilizing U.S. Preventive Services Task Force recommendations, age- and gender-specific PSD summary scores were computed for each patient and then averaged per physician. Multivariate analysis of variance tested office characteristic associations with PSD scores.

Results

Tools were common, but most were not significantly associated with PSD scores. The Teamwork indicators of clear staff role expectations and shared vision among physician and staff existed, respectively, for 80 and 73% of physicians. A high average reported practice focus on prevention existed, despite low staff involvement in PSD (22.2%). Compared with Tools, more Teamwork and Tenacity characteristics were associated with the PSD scores.

Conclusion

Teamwork and Tenacity appear to be more important than Tools in delivering preventive services in primary care practices.

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.

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