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Organizational Change

Over the past decade, our Research Division and its national collaborators have undertaken a series of studies to better understand organizational change in primary care practices and design interventions to enhance quality of care.  Much of this organizational change effort has been described in a Medical Care article summarizing this 15-year developmental program of research (Crabtree, et al. in press).  An early discovery in this program of research was the advantages of viewing practices and practice change from a complexity framework (Miller et al, 1998; Miller et al 2001).  This framework has helped in the formulation of organizational change models that can guide intervention efforts (Cohen et al, 2004; Miller et al, 2010).  It has also been instrumental in the evaluation of the National Demonstration Project (Nutting, et al, 2009; Nutting, et al 2010; Crabtree, et al 2010).

Based on these practice change models, our collaborative team has developed intervention strategies for facilitating organizational change, with a particular emphasis on enhancing the quality of relationships among practice members (Stroebel, et al 2005; Lanham, et al 2009).  This relationship-building facilitation strategy is referred to as the Reflective Adaptive Process or RAP.  We have used RAP facilitation in the recently completed NHLBI-funded ULTRA study (Balasubraminian, et al, in press) and the ongoing NCI-funded SCOPE study.  Additional effort has been placed on understanding the role of relationships (Lanham, et al, 2009) and knowledge management in practices (Orzano, Ohman-Strickland, and Patel, 2008; Orzano, et al, 2008). 

Analyses of data from across our organizational change portfolio have identified critical challenges to practice change and transformation.  For example, there are considerable challenges to the successful implementation of electronic medical records (Crosson, et al 2005; Crosson, et al 2007) and E-Prescribing (Crosson, et al, 2008), as well as the delivery of clinical preventive services (Cohen, et al, 2005; Crabtree, et al, 2005).  To overcome these challenges, the research team has identified practical strategies that practices can use to enhance their quality of care (Crabtree, et al 2009; Chase, et al, 2010; Orzano, et al, 2007).


  • Balasubramanian BA, Chase SM, Nutting PA, Cohen DJ, Ohman-Strickland PA, Crosson JC, Miller WL, Crabtree BF, and ULTRA Study Team. Using learning teams for reflective adaptation (ULTRA) – Insights from a team-based change management strategy in primary care. Ann Fam Med, (in press).
  • Chase S, Nutting PA, Crabtree BF. How to solve problems in your practice with a new meeting approach. Family Practice Management, 2010; March/April 17(2): 31-34.
  • Cohen D, McDaniel RR Jr, Crabtree BF, Ruhe MC, Weyer SM, Tallia A, Miller WL, Goodwin MA, Nutting P, Solberg LI, Zyzanski SJ, Jaen CR, Gilchrist V, Stange KC. A practice change model for quality improvement in primary care practice.  J Healthc Manag. 2004 May-Jun;49(3):155-68.
  • Cohen DJ, Crabtree BF, Tallia AF, Young D. Implementing health behavior change in primary care: Lessons from Prescription for Health.  Ann Fam Med. 2005; 3(Suppl 2):S12-S19.
  • Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR.  Delivery of Clinical Preventive Services in Family Medicine Offices. Ann Fam Med. 2005; 3(5): 430-435.
  • Crabtree BF, McDaniel RR, Nutting PA, Lanham HJ, Looney AJ, Miller WL. Closing the physician-staff divide: a step toward creating the medical home. Fam Pract Manag. 2008 15(4):20-4.
  • Crabtree BF, Miller WL, McDaniel RR, Stange KC, Nutting PA, Jaén CR. A Survivors Guide for Primary Care Physicians. Journal of Family Practice, 2009; 58(8): E1-E7.
  • Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaen CR. Summary of the National Demonstration Project and Recommendations for the Patient Centered Medical Home. Ann Fam Med, 2010; 8(supplement 1)
  • Crabtree BF, Nutting PA, Miller WL, McDaniel RR, Stange KC, Jaen CR, Stewart EE. Primary care practice transformation is hard work: Insights from a 15 year developmental program of research. Medical Care (in press).
  • Crosson JC, Stroebel C, Scott J, Stello B, Crabtree BF.  Implementing an electronic medical record in a family medicine practice: Communication, decision-making, and conflict.  Ann Fam Med. 2005; 3(4):307-311.
  • Crosson JC, Ohman-Strickland PA, Hahn KA, DiCicco-Bloom B, Shaw E, Orzano AJ, Crabtree BF. Electronic medical records and diabetes quality of care: results from a sample of family medicine practices. Ann Fam Med 2007 May-June; 5(3): 209-15.
  • Crosson JC, Isaacson N, Lancaster D, McDonald EA, Schueth AJ, DiCicco-Bloom B, Newman JL, Wang CJ, Bell DS. Variation in electronic prescribing implementation among twelve ambulatory practices. J Gen Intern Med, 2008; 23(4): 364-71.
  • Lanham HJ, McDaniel RR, Crabtree BF, Miller WL, Stange KC, Tallia AF, Nutting PA. How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care. Joint Commission Journal on Quality and Patient Safety, 2009; 35(9): 457-466.
  • Miller WL, Crabtree BF, McDaniel RR, Stange KC.  Understanding Primary Care Practice: A Complexity Model of Change.  J Fam Pract, 1998 46(5):369-376.
  • Miller WL, McDaniel RR, Jr., Crabtree BF, Stange, K. Practice Jazz: Understanding variation in family practice using complexity science. J Fam Pract 2001; 50(10):872-878.
  • Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaen CR. Primary care practice development: a relationship-centered approach. Ann Fam Med, 2010; 8(supplement 1).
  • Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first National Demonstration Project on practice transformation to a Patient-Centered Medical Home. Ann Fam Med 2009; 7(3):254-60.
  • Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaen KC. The journey to the Patient-Centered Medical Home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med, 2010; 8(supplement 1).
  • Orzano AJ, Tallia AF, McInerney CR, McDaniel RR, Crabtree BF. Strategies for developing a knowledge-driven culture in your practice. Fam Pract Manag 2007; 14(4): 32-4.
  • Orzano AJ, Ohman-Strickland P, Patel M. What can family practices do to facilitate knowledge management. Health Care Manage Rev 2008; 33(3): 216-24.
  • Orzano AJ, McInerney CR, Tallia AF, Scharf D, Crabtree BF. Family medicine practice performance and knowledge management. Health Care Manage Rev 2008; 33(1):21-28.
  • Stroebel CK, McDaniel RR, Crabtree BF, Miller WL, Nutting PA, Stange KC. How complexity science can inform a reflective practice improvement process.  Joint Comm J Qual and Patient Safety. 2005; 31(8):438-446.