Understanding Practice from the Ground Up
Consecutive patients for each clinician in a practice were approached with a goal of recruiting 30 patients who would consent to have the field researcher observe their visit. This generally required approaching 35 to 40 patients. Because some clinicians worked part-time or were not consistently in the practice, it was not always possible to observe 30 visits. After explaining the study and gaining signed informed consent from patients who agreed to participate, the field researchers observed the outpatient visit as unobtrusively as possible. A 1-page structured encounter checklist Figure W3 that was also modified from the DOPC study11 provided blanks for noting the reason for the visit, chief complaints, and final diagnoses, and for indicating whether any of approximately 100 preventive services were ordered or delivered. Space was provided at the bottom of the form for recording notes that were later used to dictate a re-creation of the encounter. At a later time, a chart audit was done on each observed patient’s medical record using a structure chart audit form Figure W4.
After the initial observational data were transcribed, a preliminary practice genogram16 was drawn, and an initial practice summary was written. The genogram of practice participants, roles, and relationships was initially diagrammed on a white board by a transdisciplinary research team by interviewing the field researcher about the current and past practice clinicians and staff and about the health system and community. The demographics of individuals were recorded, including age, sex, years with the practice, percentage of work effort, and job responsibilities. Additional details included functional and emotional relationships observed in the practice, such as who worked together and any obvious conflicts among members of the practice or with health system or community affiliations. This process enabled the investigators to identify areas of incomplete data so the field researchers could return to fill in missing details.
In addition to the key informant interviews done as part of the observation activities, more formal semistructured individual depth interviews were arranged with each clinician and many of the office staff.25 These interviews consisted of a 30-minute to 1-hour narrative interview in which the respondent was asked open-ended questions designed to elicit in-depth responses Figure W5. Although the major focus of these interviews was on the delivery of preventive services, more general questions were included to understand perspectives on practice process. For example, respondents were asked: “Could you describe for me a typical day for you in this practice?” and “If you believed a change was needed regarding some specific delivery of a service within this office, could you describe the process you would go through to try to get it implemented?” These interviews were audiotaped and transcribed verbatim.
To supplement the observational and interview data, field researchers gathered existing documents and artifacts from the practice. Items such as blank charts and flow sheets, patient schedules, personnel lists, samples of patient education materials and handouts, mission and vision statements, and annual reports were collected and compiled in binders. In some practices, particularly those affiliated with hospital health systems, materials were also available from Web sites. All transcribed interviews and dictated field notes from the practice and encounter observations were imported into FolioViews 4.11 (NextPage, Provo, Utah), a text-base management software program that facilitates coding, searching, and retrieval of large computerized text files.26
Emerging Design Decisions
Midway through data collection at the first practice, the advisory committee met to review the data and discuss any concerns. The advisory committee identified a number of emerging hypotheses related to complexity science concepts that were used to guide subsequent data collection and management. It was deemed particularly important to identify “attractors”—factors in the practice and in the larger environment that influenced the structure and function of the practice as an organization.6 For example, an attractor might be a particular burning interest of one of the physicians, an expectation of the local hospital systems, or a dominant demographic characteristic of the patients being served.13 An expanded systemic model of primary care Figure 1 was articulated that characterized 6 core areas for data collection: (1) patient perceptions and behavior, (2) physician perceptions and behavior, (3) encounter structures and processes, (4) practice structures and processes, (5) community characteristics, and (6) the larger health system. This model identified the need for additional data on the community context and patient experience. Checklists were revised and field researchers were asked to spend more time gathering data about the community. It was also apparent that accurate calculation of certain preventive service delivery rates would require patient input and a larger sample size. For example, a patient exit card
