The landscape is a dynamic, fluid system within which the component parts respond to and influence each other. Everyday Primary Care is embedded in such a landscape, acting on and being acted upon by other parts of the system. Unfortunately, like most practices we observed, Everyday tended to ignore or resist the local fitness landscape rather than trying to understand and adapt to it. The physicians felt trapped by environmental constraints and frustrated by the turbulence they observed.
What constraints does Everyday Primary Care face? When we first visited this practice, we could see that the facility was too small for the growing volume of patients. The physician-owners knew the space wasn’t conducive to optimum patient care, but told us they could not afford to pay higher rent for larger quarters. Similarly, they understood the potential of electronic medical records (EMRs), but hadn’t been able to find time or money to support the transition. Rising overhead expenses were outpacing practice productivity, as measured in the number of patients seen per day. What was worse, the need to see so many patients was making it more difficult to address the needs of their aging and medically complex patient population.
Looking outward can help
Despite these constraints, internal conversations generated through RAP sessions led practice staff to reach out to other physicians and physician organizations for information. They compared notes with other practices on questions like how their computerized billing system functions, or how to word a letter to patients announcing a new policy on prescription refills. These external conversations expanded the practice’s notions of what was possible and gave them opportunities to share information and learn of new approaches other practices were developing. The result was a newfound level of energy and hope within the practice and exposure to new ideas from the outside.
Learning from the landscape. Numerous conversations with physician organizations, neighboring practices, and a local hospital system yielded new solutions for recalcitrant problems: How to make better use of existing office space, for example, and where to find support for long-range strategic planning. These contacts exposed Everyday to the experiences of other practices with EMRs, and the practice’s physicians have now selected and implemented their own system. The practice was finally able to address the inevitable retirement of 1 of the physicians and now has a succession plan in place. In sum, Everyday learned how to interact and adjust to the changing environment and no longer worried about survival.
Practices co-evolve with all the other systems in a constantly changing fitness landscape. As practice members navigate the local fitness landscapes, they make decisions among competing demands and priorities to maintain their own financial viability and internal stability. What seems to characterize innovative primary care practices is that they don’t wait to react to the next environmental change. Rather, by paying attention to local relationships, they improve the chances that co-evolution will move the practice in desired ways.
Making much-needed connections
There are a number of ways that practices can engage their fitness landscapes, but perhaps the most powerful is creating the time and space to meet with colleagues—either locally or regionally. The most effective approaches are likely to be those that allow sharing experiences and ideas over time, rather than one-time, opportunistic conversations that occur, say, at national and state academy meetings. Practices can participate in activities of regional Practice-Based Research Networks, local residency programs, or even form their own local support group.34,35 To learn how you can connect with a regional Practice-Based Research Network, go to the AHRQ website (http://pbrn.ahrq.gov/portal/server.pt). FIGURE 2 summarizes 4 strategies for reaching out to your local landscape.
FIGURE 2
4 strategies for reaching out to your local landscape
One size doesn’t fit all: Strategic alternatives
When practices build critical relationships and pay attention to their local fitness landscape, they co-evolve improvements that make sense in the context of their unique characteristics and circumstances. Our research shows that practices use a range of alternative strategies to meet the needs of patients, their communities, and themselves. For example, while we have observed primary care offices using EMRs that have achieved high levels of adherence to diabetes guidelines, we have also found high adherence rates in practices that use paper charts.19 We have seen different, successful approaches to the delivery of preventive health services.11 Some practices involve staff in assuring protocol adherence and others don’t. Some use reminder systems and others don’t. Several practices with higher rates of preventive service delivery use none of these. A recent evaluation of 15 case studies of family practices using teams to implement the chronic care model showed the value of different types of teams in different practices.36