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Implementation and Sequencing of Practice Transformation in Urban Practices with Underserved Patients

Quigley, Denise D. PhD; Predmore, Zachary S. BA; Chen, Alex Y. MD, MS; Hays, Ron D. PhD

Quality Management in Healthcare: January/March 2017 - Volume 26 - Issue 1 - p 7–14
doi: 10.1097/QMH.0000000000000118
Original Articles

Background: Patient-centered medical home (PCMH) has gained momentum as a model for primary-care health services reform.

Methods: We conducted interviews at 14 primary care practices undergoing PCMH transformation in a large urban federally qualified health center in California and used grounded theory to identify common themes and patterns.

Results: We found clinics pursued a common sequence of changes in PCMH transformation: Clinics began with National Committee for Quality Assurance (NCQA) level 3 recognition, adding care coordination staff, reorganizing data flow among teams, and integrating with a centralized quality improvement and accountability infrastructure. Next, they realigned to support continuity of care. Then, clinics improved access by adding urgent care, patient portals, or extending hours. Most then improved planning and management of patient visits. Only a handful worked explicitly on improving access with same day slots, scheduling processes, and test result communication. The clinics' changes align with specific NCQA PCMH standards but also include adding physicians and services, culture changes, and improved communication with patients.

Conclusions: NCQA PCMH level 3 recognition is only the beginning of a continuous improvement process to become patient centered. Full PCMH transformation took time and effort and relied on a sequential approach, with an early focus on foundational changes that included use of a robust quality improvement strategy before changes to delivery of and access to care.

RAND Corporation, Santa Monica, California (Dr Quigley); RAND Corporation, Boston, Massachusetts (Mr Predmore); AltaMed Health Services Corporation, Los Angeles, California (Dr Chen); and UCLA, Division of General Internal Medicine & Health Services Research, Los Angeles, California (Dr Hays).

Correspondence: Denise D. Quigley, PhD, RAND Corporation, 1776 Main St, Santa Monica, CA 90407 (

The authors acknowledge the time and support of the interview participants in this study.

This work was supported by a cooperative agreement from the Agency for Healthcare Research and Quality (AHRQ) (Contract number U18 HS016980).

All authors had a significant role in conceptualizing and writing the article.

The authors have no financial or proprietary interest in the subject matter or materials discussed in the manuscript.

© 2017Wolters Kluwer Health | Lippincott Williams & Wilkins