Meaningful practice change: less "top-down," more "copy-improve"

- Jennifer Middleton, MD, MPH

I recently wrote about the slow uptake in practice changes in response to the Choosing Wisely recommendations. Understanding the potential challenges to implementing change is an important prerequisite for success, and the current issue of Family Practice Management describes these challenges in the article Why Best Practices Fail to Spread. Drs. Toussaint and Elmer discuss 4 common reasons that practice changes fail; although their discussion centers on workflow changes, the obstacles they discuss can certainly pertain to clinical change as well.

1. A top-down approach: organizational leaders mandating how change must happen even though every practice is different
2. A lack of compelling data: physicians won’t buy into making changes unless there is some proof those changes will provide benefit
3. Standard work for everyone but providers: requiring standardization of everyone in an office except the physicians
4. Lack of management: office managers must routinely audit compliance with the change plan

The authors suggest one key solution:

[O]rganizations need to include a bottom-up aspect to their change effort; that is, give clinics a playbook not to simply copy but to “copy-improve.” …. Each clinic took the standard work and adapted it to its own environment and specific needs.

Implementing office workflow changes that support Choosing Wisely could follow a similar pattern. As Dr. Lin and colleagues discussed in an FPM article last year, “Many of the recommendations can become the focus of quality improvement projects, performance metrics, and pay-for-performance measures.” Each office could choose a Choosing Wisely recommendation that is especially pertinent to their patient population’s needs and initiate a quality improvement (QI) cycle. The initial point of change could come from within the office itself. Presenting staff and physicians in the office with the evidence base behind the recommendation may increase buy-in, and standardizing the new process for everyone - including physicians - may increase the likelihood of success. Office managers must then commit to auditing workflows and charts to ensure ongoing compliance with the change plan.

FPM is an excellent source of ideas about how to implement these kinds of changes. Family physicians can also find useful articles there about partnering with insurance companies on quality efforts, using pre-visit planning to your advantage, and conducting meaningful audits. AFP has several useful tools to consider as well, including the Choosing Wisely recommendation search tool and articles such as this review of the evidence consistent with several Choosing Wisely recommendations.