Understanding practice from the ground up

BACKGROUND Our objective was to understand family practices from the ground up through intensive direct observation of the practice environment and pa tient care. METHODS Eighteen practices were purposefully drawn from a random sample of Nebraska family practices that had earlier participated in a study of preve ntive service delivery. Each practice was studied intensely over a 4- to 12 -week period using a comparative case study design that included extended d irect observation of the practice environment and clinical encounters, form al and informal interviews of clinicians and staff, and medical record revi ew. DESIGN This multimethod assessment process (MAP) provided insights into a w ide range of practice activities ranging from descriptions of die organizat ion and patient care activities to quantitative documentation of physician- and practice-level delivery of a variety of evidence-based preventive serv ices. Initial insights guided subsequent data collection and analysis and l ed to the integration of complexity science concepts into the design. In re sponse to the needs and wishes of the participants. practice meetings were initiated to provide feedback, resulting in a more collaborative model of p ractice-based research. CONCLUSIONS Our MAP provided rich data for describing multiple aspects of p rimary care practice, testing a priori hypotheses, discovering new insights grounded in the actual experience of practice participants, and fostering collaborative practice change.