Table 2.
Descriptions of Nine LEAP Practices Selected
| Practice ID | Setting/Demographics | Leadership Attributes |
|---|---|---|
| Practice 1 | Small clinic, part of large medical system 3 PCP FTE | The practice leader is the medical director who founded Practice 1. He is well respected and well read across sophisticated literature on QI, organizational change, and systems thinking. He has applied his long‐standing learning philosophy to practice, viewing change as constant and believing that systems need to be built to be nimble and constantly responding to change. Notably, he has made extraordinary efforts to level the hierarchy in the practice workforce through prioritizing numerous, regular office meetings that are facilitated to ensure that everybody can contribute. As a result, staff feel comfortable giving and receiving feedback, delegating and negotiating tasks, and dealing with interpersonal conflicts directly. Practice 1's leader has explicitly endeavored to develop a well‐defined culture that is solidified by written principles that are reviewed annually by all practice members. There is a strong sense of teamwork among clinicians and staff, aided by extensive and diverse forms of communication (eg, many formal meetings, one‐on‐one communication and mediation, and informal social conversation). The practice is constantly innovating and reflecting on lessons learned, and they have a history of breaking with convention to implement creative ideas. The leader reaches outside the discipline of medicine for ideas and pushes the boundaries of practice roles. |
| Practice 2 | Large, multispecialty practice 11.5 PCP FTE | Practice 2 is in a transitional phase. The former leader was a highly engaged, dynamic individual, and the practice continues to ride on her legacy. Since she left two years ago, a combination of people have stepped up to fill her shoes; however, they acknowledge that the former leader had many strengths they do not have. As a team, they tend to think a lot about strategies for future funding. The height of Practice 2's transformation efforts occurred approximately a decade ago when the leadership invested a lot into team building and practice redesign in response to financial challenges. Staff are given opportunities to develop and expand their roles and are encouraged to take classes to get more training. There is also evidence that staff feel encouraged to share their opinions and feel safe to do so. The leadership team has a vision for the practice that they try to spread, but there is a sense that it is not shared by the whole practice. This limits the extent to which clinicians and staff deliver care with a sense of teamwork. Although ideas for practice change tend to flow from the top, there are many forms of communication in place to ensure that information is passed to those who need to know, as well as opportunities for feedback to be given to those at the top. Formal processes are abundant, largely around processes for communication, as well as curriculum for trainings and health coaching. There is evidence of learning culture, at least among the leadership team, as leaders articulate with ease the lessons learned from their practice redesign efforts. |
| Practice 3 | Medium‐size FQHC, part of small health system 8 PCP FTE | The practice leadership team has a strong philosophical understanding of practice change and explicitly works to involve people in the process while building excitement about being an innovator in the field. In addition to being person‐centered, leadership is also financially savvy. They have created an extensive process whereby the entire practice is involved in the budget development annually, as well as a strategic planning process every few years. This reflects a general attitude of respect for all, regardless of position. Staff know they can question why things are done the way they are, and in general, people feel they can vent and be heard. Leadership has intentionally worked to instill a “culture of quality” mind‐set, and all staff are taught QI principles. There is evidence that “doing what's best for the patient” is a shared priority for everyone at Practice 3. There is a strong team mentality, facilitated by multiple opportunities for formal and informal communication (eg, monthly team meetings, biannual all‐staff meetings, and regular walks together for discussion and reflection). They seek practice transformation that touches all roles and recognize the value of learning from mistakes in their ongoing process. |
| Practice 4 | Medium‐size clinic within large health system 7‐8 PCP FTE | Practice 4 was founded by a physician who had a vision for a clinic with a social justice mission embedded into the local immigrant community. Along with two other physicians, she worked with the health system to establish this small clinic with staff hired from the community. Although there is constant effort from the lead physician to bring in new ideas and improve care, it is all with the aim of addressing social determinants of health, not anticipating future payment systems. This high‐energy, extroverted leader actively works to create an atmosphere of trust and camaraderie among all practice staff, and she has helped to cultivate a practice culture in which staff are acknowledged for their various skills and contributions. Their knowledge of the local community is especially valued, and they are respected members of the care team. The leader makes explicit efforts to give everyone a voice and to involve them in practice change efforts. There is a lot of evidence of staff coming up with change ideas that get implemented. They have several different types of staff and leadership meetings on a regular basis, as well as daily clinical huddles. They use abundant email to communicate between meetings, and clinicians and staff often have lunch together. Staff work outside their job descriptions, and all are cross‐trained to serve as either MA or receptionist. There is a strong sense of shared vision of community activism and social justice among the whole office, and the practice organizes services around the needs of the community. |
| Practice 5 | Medium‐size FQHC, part of large, national nonprofit health care organization 8 PCP FTE | Practice 5's leadership is a duo of a physician and a spiritually oriented clinical staff member with a mission to care for the underserved. There is strong evidence that this service mission is pervasive throughout the practice, and many report believing that patients can feel that. Leadership supports non‐clinicians to take on a great deal of responsibility and to fill leadership roles. Staff say they feel supported by staff‐level leaders who were promoted to lead daily operations. In addition, some MAs have different areas of expertise (eg, vaccines) that are recognized by the office. Staff and clinicians alike seem empowered to give input on change and to systematically try out new ideas. The model facilitates a workflow in which “everybody … come[s] together and work[s] through issues with the patient.” Practice 5 has various kinds of formal meetings, including monthly all‐staff meetings, meetings by group (eg, front office, back office, clinicians), and meetings of representatives from each role to work on QI. In addition to the many meetings, they have regular training sessions focused on using algorithms. Communication in the office is not just formal, however, as there is also evidence that people connect socially and form relationships with one another. |
| Practice 6 | Clinic within a large health system 6 PCP FTE | Innovation at Practice 6 is initiated at the system level, and individual clinics are selected to pilot specific QI projects, which are later spread to the rest of the system. Practice 6 demonstrates an innovative, forward‐looking orientation, as clinic leadership participates in systematic QI training and leadership development courses, which are supported by the system. This training, however, does not appear to be widely shared with front‐line staff. Nevertheless, there is evidence of clinic leadership's enthusiasm for innovative changes and for encouraging staff during times of change. Similarly, there are efforts to level the hierarchy of the practice workforce by allowing clinicians to be called by their first names, for example. While clinic leadership aims to create a safe environment, there is mixed evidence regarding the degree to which staff trust leadership enough to ask questions or express ideas. Although there is a shared vision at the level of system leadership, it has not translated to the clinic level. Despite the weak sense of shared vision, clinic physicians and staff do feel that they have learned to function as a clinical team. The commitment to the team is reflected, for example, in the lead MA's willingness to take on a great deal of responsibility, even serving as backup practice manager if all other leaders are unavailable. Practice 6 leadership is least active in promoting strong communication within the clinic. Meetings are infrequent and tend to be top‐down information‐dissemination events as opposed to forums for rich sharing of ideas. Communication within the system leadership is much stronger. Similarly, there are a plethora of formal processes higher up in the system, but very few trickle down to the clinic. Nevertheless, clinic leadership is invested in creating a learning organization and, consequently, make efforts to instill the message that it is “okay to fail” and to learn from failure. |
| Practice 7 | Medium‐size private practice, part of coalition of several practices 8 PCP FTE | Practice 7 is part of an IPA that formed to create a single organization. While they share a name, tax code, and some common objectives, each practice also has a lot of independence. Leadership exists at both the organizational level and the practice level, but the distinction is not always clear, since some individuals serve as leaders at both levels. One of the IPA founders, for example, regularly attends national conferences to bring ideas back to implement, particularly ideas that will help to position the practice for what they anticipate is coming down the pike in terms of reimbursement. Change at Practice 7 seems to be largely initiated at the central organization level, and leadership makes attempts to systematically spread it to each site. Change occurs through the implementation of new formal processes, not through leaders motivating and encouraging innovation and change. They have a formal QI process, in which staff are actively involved, with two to three “redesign teams” that meet monthly. The focus is on implementation rather than reflection and ongoing learning. The office is run in a traditional medical model, with staff functioning in conventional roles to support clinicians. There is some evidence that staff may not be comfortable giving honest feedback to their superiors. Although there is a fairly limited sense of the whole office sharing a collective vision, there is evidence that the clinical assistants do have a strong unity of purpose, and they go out of their way to help each other “keep patients flowing through the clinic smoothly.” |
| Practice 8 | Small clinic within a small clinic system 3 PCP FTE | The corporate office leadership of shareholders makes many decisions that are then enacted at the practice level. Practice‐level leadership is engaged and effectively motivates staff in QI and continual PDSA cycles. The lead physician brings tremendous passion and a bottom‐up philosophy about practice change. This translates into making efforts to have everybody involved in decision‐making and sending staff, not just the physicians, to corporate‐level meetings. Leadership has respect for office staff and feels it is important to give a consistent message in order to develop trust, as well as to reward staff for their work. They try to make staff feel safe to speak up, and they consider the big table in the lunch room to be an important tool toward this end, as it has become a place where staff and clinicians make it a point to share with one another. There are many different types of meetings that involve clinicians and staff, as well as social occasions for more informal sharing of ideas. The lead physician has had a large hand in helping to instill a shared value in investing in QI for the best patient care. Staff are empowered with standing orders and are able to step into each other's roles. This supports a strong team attitude that is driven by the sentiment that “every patient is everybody's patient.” |
| Practice 9 | Large, independent practice with 6 sites 6 PCP FTE | Practice 9 is widely recognized for practice innovations, especially in the use of technology. Practice changes are ongoing and tend to be implemented in a systematic way. One of the founding physicians at Practice 9 is the primary leader who leans toward a top‐down approach. Innovations generally originate with the leader, and other physicians and staff are engaged to implement them. There are strategies in place for clinicians to give input on change ideas; there is no evidence that other staff members have an opportunity to provide input. Practice staff are largely organized into traditional roles, and the leader regularly recognizes staff with monetary rewards for performance. There is a sense of warmth and friendship among staff, although there is little evidence of a strong sense of teamwork. Communication tends to be “lean,” such as electronic huddles. Practice 9 is not a “learning organization,” as it is not based on a mind‐set of learning through reflection, but the leader has successfully instilled a culture of continuous change. |
Abbreviations: FQHC, federally qualified health center; FTE, full‐time equivalent; IPA, independent practice association; MA, medical assistant; PCP, primary care physician; PDSA, Plan‐Do‐Study‐Act; QI, quality improvement.