title: Facilitators of transforming primary care: a look under the hood at practice leadership.
abstract: OBJECTIVE
  This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care.
  
  
  METHODS
  We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach.
  
  
  RESULTS
  Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff.
  
  
  CONCLUSIONS
  In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.
authors.affiliation: University of North Carolina, Department of Family Medicine, Chapel Hill, North Carolina 27599, USA. kdonahue@med.unc.edu
authors.forename: Katrina E
authors.initials: KE
authors.lastname: Donahue
authors.forename: Jacqueline R
authors.initials: JR
authors.lastname: Halladay
authors.forename: Alison
authors.initials: A
authors.lastname: Wise
authors.forename: Kristin
authors.initials: K
authors.lastname: Reiter
authors.forename: Shoou-Yih Daniel
authors.initials: SY
authors.lastname: Lee
authors.forename: Kimberly
authors.initials: K
authors.lastname: Ward
authors.forename: Madeline
authors.initials: M
authors.lastname: Mitchell
authors.forename: Bahjat
authors.initials: B
authors.lastname: Qaqish
mesh_terms: D001249:Asthma / Q000628:therapy; D003695:Delivery of Health Care / Q000458:organization & administration*; D003920:Diabetes Mellitus / Q000628:therapy; D006801:Humans; D007857:Leadership; D011320:Primary Health Care / Q000458:organization & administration*; D011785:Quality Assurance, Health Care; D058996:Quality Improvement
keywords: change; coaching; innovation; organizational; practice facilitator; practice-based research; primary care; quality improvement