Primary care practice organization and preventive services delivery: a qualitative analysis.

BACKGROUND: Rapid developments within the health care environment have led to increased pressures for change among primary care physicians and their practices. Nevertheless, a lack of understanding of practice organization and function has limited the effectiveness of attempts to change practice behaviors. Recent attempts to increase the delivery of preventive health care services illustrate the limitations of current approaches. To assist physicians in their attempts at change, our study looked at the office as a whole system and at the competing demands within the primary care setting. METHODS: Qualitative fieldnotes were recorded by research nurses who observed 138 family physicians in 84 practices in northeast Ohio for 4 days each. These data were content-analyzed to identify features that are important for understanding how practices are organized. RESULTS: These data indicate that primary care practice is much more complex than research and transformation efforts generally acknowledge. The data identified a diverse set of features that describe how primary care practices are organized and function. These included cognitive and behavioral components of physician philosophy and style, and numerous features of the practice organization, such as office efficiency, clarity of staff roles, communication patterns among physicians and staff, and approaches to using office protocols. The data also suggest that some practices are more innovative than others and that some physicians or staff have special motivations that can support or inhibit a particular change. CONCLUSIONS: Physicians who want to change their practice, as well as those persons who want to stimulate change from the outside, need to have a more comprehensive approach than is now commonly used to assess practices that encompass a broad spectrum of variables