Author: Lynne S. Nemeth

Setting up the project

This project was a sub-project of a larger cluster randomized trial (Primary and Secondary Prevention of Cardiovascular Disease and Stroke-Translating Research into Practice [PPRNet-TRIP-II], funded by the Agency for Healthcare Research and Quality. The project was underway within 20 primary care practices (Ornstein, 2001) that were part of a practice based research network http://www.musc.edu/PPRNet/ (Practice Partner Research Network-PPRNet ) This network was comprised of users of a common electronic medical record (EMR) http://www.practicepartner.com/ (Practice Partner, McKesson, Inc.). The practices sent quarterly data extracts to the network for benchmarking and quality improvement research. The PPRNet-TRIP-II study design included site visits, network meetings and practice performance reports as the intervention being tested. Practice performance on 21 quality indicators (related to cardiovascular and stroke prevention) would be measured to evaluate the impact of the intervention. A process evaluation was needed to learn what practices did as a result of their involvement with this project. This quality improvement model had not previously been tested, thus there was a significant opportunity for qualitative research to learn how and what practices did.

I was a student in a nursing PhD program at the time, and within this project posed the question: How do practices make changes in practice to adopt clinical guidelines for cardiovascular disease and stroke prevention? The quantitative data that demonstrated changes in practice from the baseline of the project did not explain what processes the practices used to implement quality improvements for these conditions. I worked with the investigators to propose this subproject as part of the evaluation of the research, and was granted entrée into this research team. My previous experience was within hospitals, not primary care, but largely focused on quality improvement and outcomes management. I had comfort in the world of hospitals but had biased opinions of how things worked in these settings due to my previous experience. This was not the same in primary care, where I did not previously practice. I was open to seeing things with fresh eyes, and was not tainted in knowing how things should be. I was also not an everyday user of the electronic medical record that was being used in these settings, nor had I participated in the work of a research network before.

I worked closely with the project evaluator for the PPRNet-TRIP-II research study to delineate the scope of this specific project and conducted a literature review on the process of change and quality improvement in practice settings. Within this review, the Institute of Medicine's study on Microsystems http://books.nap.edu/openbook.php?record_id=10096&page=1 provided a useful framework to begin an exploration of the implementation of change in health care practices. This study provided a great starting point to evaluating selected aspects related to the process of change, and an interview tool was adapted to frame my interview. (Donaldson & Mohr, 2000) There was a body of literature on barriers to using clinical guidelines (Cabana et al., 2000; Cabana et al., 1999) that helped me frame my semi-structured interview with a diverse group of practice staff (physicians, nurse, medical assistants, office staff and practice managers). Additionally, research from a business perspective regarding leading change (Kotter, 1996) provided a useful set of concepts to consider as I reviewed the data within my interviews.

I was a novice qualitative researcher at this point, so I consulted with Ben Crabtree, a leading qualitative researcher in the field of primary care medicine (Crabtree & Miller, 1999) who reviewed my initial proposal and agreed to participate with me in the dissertation process. I was surprised at the collaboration and cooperation I was receiving in my scholarly endeavor, and I set off armed with an Olympus DS-330 digital voice recorder, a brand new software package NVivo 2.0 and tremendous enthusiasm for the project I was beginning.

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