title: Key issues in transforming health care organizations for quality: the case of advanced access.
abstract: BACKGROUND
  The 2001 Institute of Medicine (IOM) report highlighted the need for transformation of the U.S. health care system. This rigorous qualitative evaluation of transformational change for patient access in one large multispecialty group practice identifies the major issues facing organizations addressing the IOM challenge.
  
  
  METHODS
  Semistructured depth interviews were conducted with the medical and administrative leaders at all levels, physicians, and nurses from 17 primary care clinics in one integrated medical group two years after they began to transform their approach to primary care patient appointment access.
  
  
  RESULTS
  The mean time to third-next-available appointment was reduced by 76% during one year, from 17.8 days to 4.2 days. Nine important issues related to the change process were identified from clinic interviews. When combined with issues identified by central leaders, 13 themes stood out as lessons in transformational change. A major issue is the tension between physician autonomy and both effective organizational function and putting patients first. Physician autonomy is also diminished by the need to standardize and systematize care.
  
  
  CONCLUSIONS
  Transformational change in care delivery is possible in large and complex group practices. Changes that directly affect care delivery and physician autonomy present particular challenges to physicians that need to be attended to if the changes are to be successful.
authors.affiliation: HealthPartners Research Foundation, Minneapolis, USA. Leif.I.Solberg@HealthPartners.com
authors.forename: Leif I
authors.initials: LI
authors.lastname: Solberg
authors.forename: Mary C
authors.initials: MC
authors.lastname: Hroscikoski
authors.forename: JoAnn M
authors.initials: JM
authors.lastname: Sperl-Hillen
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: O'Connor
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Crabtree
mesh_terms: D000555:Ambulatory Care Information Systems; D001071:Appointments and Schedules; D001291:Attitude of Health Personnel; D006123:Group Practice / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000458:organization & administration*; D006801:Humans; D007407:Interviews as Topic; D008511:Medicine / Q000458:organization & administration*; D008910:Minnesota; D019982:Organizational Case Studies; D009936:Organizational Innovation; D010344:Patient Advocacy; D017060:Patient Satisfaction; D018802:Patient-Centered Care; D017009:Professional Autonomy; D013038:Specialization; D017748:Time Management