Natural history of practice transformation: development and initial testing of an outcomes-based model

Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation.

We developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the first group of participating North Carolina Improving Performance In Practice practices to test and further refine the model.

The resultant model described motivators and supports to transformation. Three emerging practice patterns were identified with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation.

Practice transformation is a continuous and long-term process. Internal and external practice motivations and specific practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance.