TABLE 2.
Results of Taxonomic Analysis for PCMH Implementation Best Practices (n = 51 staff interviewed)
| Best Practice | Description/Examples | Key Ingredients | Latent Function(s) | By-products (+/−) | Evidence as a Perceived Best Practice |
|---|---|---|---|---|---|
| Soft (Domain)a | |||||
| Knowing the patient | Relational/interpersonal: Having an established relationship with patient; knowing their personal situation well | Time, provider interest, staff interest, history with patient, EMR capability | Enhances a strategic approach to individual patient care (personalized care); builds trust in patient-practice relationship | Positive: Improves diagnostic accuracy, patient compliance, and patient satisfaction; can improve scheduling and transactional aspects of practice work.Negative: Can be inefficient and a “time sink,” especially for providers; can place heavier burden on select support staff | Very Strong |
| Negative: Can be inefficient and a “time sink,” especially for providers; can place heavier burden on select support staff | |||||
| Empathy and compassion when dealing with patients | Relational/interpersonal: Identifying with patient's situation and using patient situation on a case-by-case basis when deciding how to approach care/interaction | Time, provider interest, staff interest, history with patient | Builds trust in patient-practice relationship; enhances personalized care | Positive: Improves care management, patients’ compliance, information flow from patient | Strong |
| Negative: Can be inefficient and a “time sink” for practice; can place heavier burden on select support staff who “know” patients | |||||
| Using family | Relational/interpersonal: Practice staff and providers making a concerted effort to involve family members in care when deemed necessary, e.g., informed consent, patient decision making, care transitions | Time, provider interest, staff interest, history with patient and family, family interest, EMR capability | Provides independent verification of patients’ needs and behaviors; enhances personalized care | Positive: Improves care management, patient compliance, diagnostic accuracy | Strong |
| Negative: Can hinder care management if too many family members involved; can be inefficient and a “time sink” | |||||
| Tailored communication approaches | Relational/interpersonal: Relying on personal knowledge of patients and relational elements to tailor communications with them in ways to which they will respond positively | Provider interest, staff interest, history with patient, well-trained staff | Enhances personalized care; makes staff feel better about getting through to patients about orders, etc. | Positive: Improves care management, patients’ compliance; can make visits more efficient and predictable | Moderate |
| Negative: Can be inefficient and a “time sink”; can undermine use of EMRs and e-portals; heavier burden on select support staff who “know” patients | |||||
| Hard (Domain)b | |||||
| Use of formal work protocols | Focused on work flow: Standardized improvements to work flow characterized by routine process implementation, e.g., medication reconciliation, discharge planning, orders tracking, clinical visit summaries | Motivated practice leadership, EMR capability, integration and relationships with other providers | Gets practice staff “on same page” regarding how to move through various primary care transactions; allows lower-level staff to do higher-level work | Positive: Can make visits more efficient and predictable; increases certainty and information about a patient's situation | Strong |
| Negative: Can overemphasize standardization in situations in which contingencies are needed; can undermine relational aspects of care | |||||
| Work redistribution | Focused on human capital: Moving work from one staff person to another, e.g., nurses doing formal triage and medication reconciliation; front-desk staff doing orders tracking and care coordination | Time, history with patient, relational bond between doctor and patient, well-trained staff, EMR capability, adequate staffing | Can increase overall capacity for serving patients in practice; uses full range of staff skills/training, increasing practice's collective knowledge | Positive: Can make visits more efficient; increases certainty and information about a patient's situation | Moderate |
| Negative: Can distance the provider from the patient; potential “voltage” drop of patient information across staff; potentially lower quality in task completion | |||||
| Triage | Focused on work flow: Having in place a formal or informal system of assessing patients’ situations, e.g., staff conducting phone triage with patients, staff contacting patients after hospital discharge to discuss care needs | Time, history with patient, well-trained staff, EMR capability, relational bond between triage staff and patient | Enhances a strategic approach to individual patient care (personalized care); can increase overall capacity for serving patients in the practice | Positive: Produces more cost-effective care delivery; makes better use of provider's time | Moderate |
| Negative: Can distance the provider from the patient; may undermine patient's trust in practice | |||||
Notes
a
“Soft” implementation best practices are those that involve heavy relational aspects of care, that are less easily measured or assessed (e.g., quantified), that derive specifically from ongoing social interactions between staff and patient, and that produce intangible by-products or benefits that are best understood directly by those workers actually delivering the care.
b
“Hard” implementation best practices are those that involve more easily measured or assessed (e.g., quantified) activities, that are geared explicitly to focused outcomes such as improved efficiency, that tend toward standardized changes in work flow and job improvement, that are more easily generalizable or reproduced across settings, and whose focus is task oriented and transactional.