Benjamin F. Crabtree, PhD Department of Family Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ crabtrbf@umdnj.edu
William L. Miller, MD, MA Department of Family Medicine, Lehigh Valley Hospital and Health Network, Allentown, Pa
Reuben R. McDaniel, EdD McCombs School of Business, University of Texas at Austin
Kurt C. Stange, MD, PhD Departments of Family Medicine, Epidemiology and Biostatistics, and Sociology, Case Western Reserve University, Cleveland, Ohio
Paul A. Nutting, MD, MSPH Center for Research Strategies, Department of Family Medicine, University of Colorado Health Sciences Center, Denver
Carlos Roberto Jaén, MD, PhD Departments of Family and Community Medicine and Epidemiology and Biostatistics, University of Texas Health Sciences Center, San Antonio
The authors reported no potential conflict of interest relevant to this article.
Practices with improved relationship systems exhibit more resiliance in weathering a hostile environment.
Variability and standardization. The emergence of processes and outcome measures designed to meet the needs of a particular local setting (fitness landscape) appeals to our sense of equity and common sense. Yet variations like these fly in the face of prevailing models and guidelines that emphasize standardized processes. Many health plans and provider organizations insist on evidence-based “best practices” and “optimized models” for delivering primary care.37-39 They assume that if we know the goals, there is a best way to get everyone to achieve them.
A better strategy is to determine when variability and tailoring are more appropriate and then use standardization to help create more time for those processes that require variation. Thus, the practice can use a standardized protocol to turn over immunizations to staff in order to free clinicians to spend more time interacting directly with patients.
Multiple pathways to excellence. Medical practice is full of surprises and complexities. We used to believe that the right tools in the hands of accountable individuals using good management systems would produce best practice outcomes. But we have learned that no single right tool or individual management strategy works consistently in primary care.
FAST TRACK
We hope that the health care reform plans now being debated in Congress will provide space for multiple models of care delivery to emerge.
We now believe that the relationship system within the practice is a critical element in creating an optimal healing environment. Practices with improved relationship systems exhibit more resilience in weathering a hostile environment, while discovering their own unique model of successful primary care. Such practices can thrive, provide improved quality of patient-centered care, and find professional satisfaction and joy in daily work. We hope that the health care reform plans now being debated in Congress will be informed by these insights and provide space for multiple models of care delivery to emerge.
CORRESPONDENCE Benjamin F. Crabtree, PhD, Department of Family Medicine, Robert Wood Johnson Medical school, 1 World’s Fair Drive, First Floor, Somerset, NJ 08873; crabtrbf@umdnj.edu
