title: Implementing quality improvement in small, autonomous primary care practices: implications for the patient-centred medical home.
abstract: BACKGROUND
  Implementing improvement programmes to enhance quality of care in primary care clinics is complex. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient centred medical homes (PCMH). This study examined practice members' perceptions of the opportunities and challenges associated with implementing changes in their practice.
  
  
  METHODS
  Semi-structured interviews were conducted with a sample of 56 individuals working in 16 small, community based primary care practices. The interviews consisted of open-ended questions focused on participants' perceptions of: (1) practice vision, (2) perceived need for practice improvement and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analysed.
  
  
  RESULTS
  Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients' involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking and follow-up, standardisation of processes of care and overall clinic documentation. Changes related to patients' involvement in their care included improving (a) health education, and (b) self-care management. Among the internal barriers were: staff readiness for change, poor communication and relationship difficulties among team members. External barriers were insurance regulations, finances and patient health literacy.
  
  
  CONCLUSIONS
  Transforming practices to more patient-centred models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programmes. Successful strategies for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members' perceived needs and planned improvement efforts.
authors.affiliation: Department of Veterans Affairs, South Texas Veterans Health Care System, San Antonio, Texas, USA. ararn@uthscsa.edu
authors.forename: Nedal H
authors.initials: NH
authors.lastname: Arar
authors.forename: Polly H
authors.initials: PH
authors.lastname: Noel
authors.forename: Luci
authors.initials: L
authors.lastname: Leykum
authors.forename: John E
authors.initials: JE
authors.lastname: Zeber
authors.forename: Raquel
authors.initials: R
authors.lastname: Romero
authors.forename: Michael L
authors.initials: ML
authors.lastname: Parchman
mesh_terms: D000554:Ambulatory Care Facilities / Q000592:standards*; D048909:Diabetes Complications / Q000517:prevention & control; D006801:Humans; D007407:Interviews as Topic; D018802:Patient-Centered Care / Q000592:standards*; D011320:Primary Health Care / Q000592:standards*; D058996:Quality Improvement; D016032:Randomized Controlled Trials as Topic; D013781:Texas