The Direct Observation of Nurse Practitioner Care study: An overview of the NP/patient visit.

BACKGROUND AND PURPOSE: While there is a preponderance of studies that demonstrate the quality of nurse practitioner (NP) practice, little is known on the practice style of NPs. The Direct Observation of Nurse Practitioner Care study provided the first national direct observation and characterization of patient care delivered by primary care NPs. METHODS: The setting for this study was ambulatory care practices of NPs located throughout the United States. A nested sample was utilized, consisting of 22 NPs during visits with 245 patients. Observational data were collected during each visit using the Davis observation code (DOC). Patient information was collected from chart reviews and postvisit surveys. Each NP filled out a demographic and practice survey. CONCLUSIONS: Visits to NPs were 18 min on average, and were most frequently for new/acute problems (45.1%) or routine chronic problems (30.2%). Overall, NPs spent the most time planning treatment, history taking, and providing health education. Topics that NPs frequently provided health education about included medication action and side effects, disease process education, diet, and nutrition. IMPLICATIONS FOR PRACTICE: Data from this study will allow for detailed characterizations of a patient-NP visit and average length of the visit and the time use based on the DOC.

Appreciative Inquiry for quality improvement in primary care practices.

PURPOSE: To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process. METHODS: Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. RESULTS: The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. CONCLUSIONS: An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.

Characteristics of nurse practitioners interested in participating in a practice-based research network.

PURPOSE: Practice-based Research Networks (PBRNs) have emerged as key laboratories for generating new knowledge that reflects community-based practice; however, the representativeness of nurse practitioners (NPs) interested in PBRN participation is not known. This study describes characteristics of NP members interested in participating in a regional PBRN in comparison with state and national data. DATA SOURCES: All 1016 NPs in northeast (NE) Ohio were surveyed by mail and Internet. The survey captured NP demographics, practice characteristics, and gauged interest in participating in future PBRN studies. Survey respondent's data were compared with Ohio and national data obtained from the 2004 AANP National Nurse Practitioner Sample Survey. CONCLUSIONS: NE Ohio NPs were similar to an Ohio and national sample of NPs. Northeast Ohio NPs practicing in ambulatory settings who were interested in participating in subsequent PBRN studies were not significantly different from non-interested NPs. IMPLICATIONS FOR PRACTICE: NPs interested in participation in a PBRN appear to be representative of the NE Ohio population of ambulatory practice NPs and are similar demographically to a national sample of NPs. Findings from studies conducted in the NE Ohio PBRN may generalize to other NPs practicing in the region and across the country.

Possible unintended consequences of a focus on performance: insights over time from the research association of practices network.

BACKGROUND: New pay-for-performance initiatives and quality improvement efforts over the last decade have focused on evidenced-based process measures of quality of care. The effect on preventive service delivery (PSD) measures and patient satisfaction is not well described. The goals of this study were to describe PSD and patient satisfaction trends over the past decade. METHODS: We evaluated delivery of US Preventive Services Task Force (USPSTF)-recommended clinical preventive services and patient satisfaction in 3 studies conducted in the same health care market in 1995, 2000, and 2006, respectively, using previously validated measures. Trends in these 2 factors were compared using data from cross-sectional samples of 4454, 3462, and 1240 patients seen at 84, 80, and 31 participating primary care practices, respectively. RESULTS: In the 3 time periods, patients' rate of being up to date on USPSTF-recommended preventive services increased from 29% to 33% to 38%. Similar trends were observed in subscores for counseling, screening, and immunization services. However, patient satisfaction decreased to a clinically meaningful extent from 4.26 in 1995 to 3.93 in 2006 (range = 1-5). CONCLUSIONS: Quality improvement efforts focused on evidence-based recommendations appear to be working as intended, but with the possible unintended consequence of reduced patient satisfaction.

Facilitating practice change: lessons from the STEP-UP clinical trial.

BACKGROUND: The Study To Enhance Prevention by Understanding Practice (STEP-UP) clinical trial (1997-2000) resulted in sustainable increases in preventive service delivery in primary care practices. However, the process by which practice change can be facilitated has not been well described. METHODS: Comparative case studies were conducted of eight STEP-UP practices with the largest increases in preventive service delivery rates and compared to seven practices with the lowest increases. A multidisciplinary team (research nurse, nurse facilitator, physician principal investigator) used an editing analysis approach to create individual case studies. Then, using an immersion-crystallization approach, the team identified pragmatic lessons for people working to improve primary care practice, and validated these lessons with a participating practice and an additional facilitator. RESULTS: It is not always possible to predict which practices will change based on understanding initial practice conditions. "Malleable moments" can be identified during which practices become open to change. It is important to tie change strategies with existing motivations, or to develop new motivation among potential change agents. Motivation can be developed by discrepant information that challenges self-image, aligning change plans with existing values, or identifying feasible ways of responding to outside pressures or internal demands. Instrumental interventions (such as office systems, tools, new processes) are useful when motivation to change exists, and can build motivation when they meet a perceived need. Disruption in previously workable approaches, either by purposeful information seeking or unanticipated changes, promotes openness to change. CONCLUSIONS: Despite limited ability to predict which practices will change and when, understanding practices' initial conditions and evolution can identify opportunities to craft individualized approaches to positive change.

Features of medical records in community practices and their association with preventive service delivery.

BACKGROUND: Medical records are important for facilitating the process and quality of care. However, little is known about their current state in primary care practices. This article describes features of medical record systems in diverse practices and examines their association with preventive service delivery rates. METHODS: Medical records were reviewed from a consecutive sample of outpatients seen by 198 family physicians in 79 community-based practices in Northeast Ohio. The physicians were participants in a clinical trial designed to increase preventive service delivery. Research nurses performed baseline medical record reviews and used ethnographic field notes and a practice environment checklist to provide global assessments of features of medical records. RESULTS: In 79 practices, 3462 medical records were reviewed. Medical records were rated as highly easy to use in 52% of practices; outpatient visit notes were dictated in 54%. Nine percent of practices grouped individual charts by family. Patient notes were computerized in 1% of practices, although several practices had previously tried and abandoned computerized systems. Flow sheets for immunization, screening, and counseling were present on 71%, 63%, and 16% of charts and were used on 34%, 33%, and 3% of charts, respectively. The presence and use of flow sheets were associated with higher preventive service delivery rates. CONCLUSION: Medical record organization, completeness, and use vary widely, and computerized records remain rare. The association of flow sheet presence and use with preventive service delivery rates shows the potential importance of medical records for enhancing the process and outcome of patient care.

A practice change model for quality improvement in primary care practice.

Faced with a rapidly changing healthcare environment, primary care practices often have to change how they practice medicine. Yet change is difficult, and the process by which practice improvement can be understood and facilitated has not been well elucidated. Therefore, we developed a model of practice change using data from a quality improvement intervention that was successful in creating a sustainable practice improvement. A multidisciplinary team evaluated data from the Study To Enhance Prevention by Understanding Practice (STEP-UP), a randomized clinical trial conducted to improve the delivery of evidence-based preventive services in 79 northeastern Ohio practices. The team conducted comparative case-study analyses of high- and low-improvement practices to identify variables that are critical to the change process and to create a conceptual model for the change. The model depicts the critical elements for understanding and guiding practice change and emphasizes the importance of these elements' evolving interrelationships. These elements are (1) motivation of key stakeholders to achieve the target for change; (2) instrumental, personal, and interactive resources for change; (3) motivators outside the practice, including the larger healthcare environment and community; and (4) opportunities for change--that is, how key stakeholders understand the change options. Change is influenced by the complex interaction of factors inside and outside the practice. Interventions that are based on understanding the four key elements and their interrelationships can yield sustainable quality improvements in primary care practice.

A look into the Amish culture: what should we learn?

It is important to understand the Amish culture in order to provide appropriate, acceptable, and accessible health care to this culturally diverse group. A case study pertaining to the care of a dying elderly Amish woman living in a rural Amish community is examined. This allows for exploration into the world of the Amish community in greater detail. Their overall beliefs, values, and behavior are discussed as well as how their lifestyle affects their health care decisions, access to health care, and reimbursement of services. Nurse practitioners can offer culturally sensitive and appropriate health care to the Amish population by recognizing important cultural values that have survived for more than three hundred years.