Readiness and Implementation of Quality Improvement Strategies Among Small- and Medium-Sized Primary Care Practices: an Observational Study

Abstract

Background: Little is known about what determines strategy implementation around quality improvement (QI) in small- and medium-sized practices. Key questions are whether QI strategies are associated with practice readiness and practice characteristics.

Objective: Grounded in organizational readiness theory, we examined how readiness and practice characteristics affect QI strategy implementation. The study was a component of a larger practice-level intervention, Heart of Virginia Healthcare, which sought to transform primary care while improving cardiovascular care.

Design: This observational study analyzed practice correlates of QI strategy implementation in primary care at 3 and 12 months. Data were derived from surveys completed by clinicians and staff and from assessments by practice coaches.

Participants: A total of 175 small- and medium-sized primary care practices were included.

Main measures: Outcome was QI strategy implementation in three domains: (1) aspirin, blood pressure, cholesterol, and smoking cessation (ABCS); (2) care coordination; and (3) organizational-level improvement. Coaches assessed implementation at 3 and 12 months. Readiness was measured by baseline member surveys, 1831 responses from 175 practices, a response rate of 73%. Practice survey assessed practice characteristics, a response rate of 93%. We used multivariate regression.

Key results: QI strategy implementation increased from 3 to 12 months: the mean for ABCS from 1.20 to 1.59, care coordination from 2.15 to 2.75, organizational improvement from 1.37 to 1.78 (95% CI). There was no statistically significant association between readiness and QI strategy implementation across domains. Independent practice implementation was statistically significantly higher than hospital-owned practices at 3 months for ABCS (95% CI, P = 0.01) and care coordination (95% CI, P = 0.03), and at 12 months for care coordination (95% CI, P = 0.04).

Conclusion: QI strategy implementation varies by practice ownership. Independent practices focus on patient care-related activities. FQHCs may need additional time to adopt and implement QI activities. Practice readiness may require more structural and organizational changes before starting a QI effort.

Keywords: hospital-owned practice; independent practice; organizational readiness; primary care; quality improvement; strategic activity; strategy implementation.

Fig. 1

Heart of Virginia Healthcare (HVH) QI strategy implementation. The graph provides information on QI strategy implementation by percentages at 3-month and 12-month intervention (N = 165). QI strategies included 15 QI strategy items by three domains (ABCS preparations, care coordination, and organizational improvement). Each strategy item was assessed by practice coaches on a scale from 1 to 0: 1 = “practice has implemented the QI strategy,” and 0 = “practice has not implemented the QI strategy.” The differences between the strategy domains were statistically significant when comparing the average of ABCS with that of care coordination and of organizational improvement (P = 0.001).

Fig. 2

Practice readiness (N = 175). Adapted from Weiner et al. Self-reported 5-point Likert scale (5 = strongly agree, and 1 = strongly disagree). The graph displays an aggregated mean readiness score for each readiness item across 11 questions. The overall aggregated mean readiness score was 3.83 (SD = 0.3). The survey was conducted at baseline. The response rate was 73%.