Understanding practice from the ground up

Our objective was to understand family practices from the ground up through intensive direct observation of the practice environment and patient care. Eighteen practices were purposefully drawn from a random sample of Nebraska family practices that had earlier participated in a study of preventive service delivery. Each practice was studied intensely over a 4- to 12-week period using a comparative case study design that included extended direct observation of the practice environment and clinical encounters, formal and informal interviews of clinicians and staff, and medical record review. This multimethod assessment process (MAP) provided insights into a wide range of practice activities ranging from descriptions of the organization and patient care activities to quantitative documentation of physician- and practice-level delivery of a wide range of evidence-based preventive services. Initial insights guided subsequent data collection and analysis and led to the integration of complexity science concepts into the design. In response to the needs and wishes of the participants, practice meetings were initiated to provide feedback, resulting in a more collaborative model of practice-based research. Our multimethod assessment process provided rich data for describing multiple aspects of primary care practice, testing a priori hypotheses, discovering new insights grounded in the actual experience of practice participants, and fostering collaborative practice change.