Table 4.

Comparison of Change Facilitators and Barriers

Level	Facilitators (Where Present)	Barriers (Where Present)
Clinic	Strong clinic leadership Chief physicians as role models for chronic care and doing change Supervisor support of this work Development of teams Enhancement of trust and communication Promotion of stable work relationships Strong RN leadership of PPT teams and their work Physicians’ passive assent to change Previsit work by nurses and clerical staff, making life easier for physicians Staff unwilling to change leave clinic Natural changes (clinic remodeling, EMR implementation) that force changes in work relationships and flows	Physician, staff, and clinic cultures not supportive of the desired changes Chief physicians relatively uninterested in or uncommitted to chronic care and the CCM Variable, often limited, leadership guidance of PPT development Few systematic change skills, strategies, or structures No standardization of PPT work flows (within and across clinics) No agreement on need for care standardization Physicians generally not engaged in the change process; change is built around them Large medical group size that filters and buffers external change motivators, eg, business competition Demands of simultaneous EMR implementation Union rules inhibit role changes Clinic staff are accountable to supervisors, not to physicians Change fatigue and apathy resulting from recent scope and pace of changes
Organization leaders	Clear articulation of a new conceptualization of the care cycle (previsit, visit, postvisit, between visit) Awareness of clinic attitudes and actions Clear, shared, and long-term commitment to need for change Flexible strategies for change Realistic expectations for minimal early measurable results Recognized need to change the foundation before building the house	Organizational culture not supportive of the desired changes Lack of specific details and examples of desired care changes Broad scale of change required, encompassing multiple organizational facets Too many simultaneous priorities and changes Change goals and outcomes unclear Change process fuzzy and uncoordinated Lack of useful measures of change with periodic measurement Added complexities of grant funder expectations and distractions Leaders face multiple uncertainties and distractions, leading to limited change prototypes and measures, limited push, and accountability

RN = registered nurse; PPT = prepared practice team; EMR = electronic medical record; CCM = Chronic Care Model.