J Ambulatory Care Manage

Vol. 33, No. 2, pp. 97–107

Copyright  c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

A Conceptual Model for

Transformational Clinical
Leadership Within Primary
Care Group Practice
Harry A. Taylor, MD, MPH; Barry R. Greene, PhD;
Gary L. Filerman, PhD
Abstract: The patient-centered medical home provides an operational framework for implement-
ing the Institute of Medicine’s 6 quality aims within primary care. Successful implementation of the
patient-centered medical home necessitates transformation at the group practice level. This article
describes a conceptual model for transformational clinical leadership, based on the paradigm of
the care pilot and the tools and training for effective implementation of this role within primary
care group practice. In addition, we propose an innovative academically based system to train and
support the care pilot and practice transformation in primary care and rural practice settings.
Key words: group practice, health service administration, medical education, physician lead-
ership, quality improvement

open scheduling, expanded hours, and new

T HE patient-centered medical home (AAFP,
AAP, ACP, & AOA, 2007) provides an op-
erational framework for implementing the
6 quality aims of the Institute of Medicine
(IOM, 2001) within primary care. There is a
growing body of evidence to support the med-
ical home as an effective approach to pro-
viding quality primary care (Rosenthal, 2008;
Starfield & Shui, 2004). Components include a
relationship with a personal physician, team-
based care, and coordination of care across
the healthcare system and the community.
Hallmarks of the medical home are quality,
safety, and enhanced access to care through
Author Affiliations: Department of Family
Medicine, Oregon Health and Science University,
Portland, OR (Dr Taylor); Department of Health
Management and Policy, College of Public Health,
The University of Iowa, Iowa City (Dr Greene); and
Department of Health Systems Administration,
School of Nursing and Health Studies, Georgetown
University, Washington, District of Columbia
(Dr Filerman).
No funding was received in support of this work.
Corresponding Author: Harry A. Taylor, MD, MPH,
Department of Family Medicine, Oregon Health and
Science University, 3181 SW Sam Jackson Park Rd,
Portland, OR 97239 (Taylorha@ohsu.edu).
options for communication with the primary
care team. However, few primary care prac-
tices include a majority of the components
that together make up a medical home. In
a 2008 American Academy of Family Physi-
cians (AAFP) survey, slightly less than half of
all participating family physicians reported us-
ing an electronic medical record, while only
one-third had extended office hours or used
e-prescribing and less than one-fourth of par-
ticipants reported using a team approach to
care for patients (Backer, 2009).
Tollen (2008) identified 3 key attributes of
physician groups that impact their ability to
provide quality care. The first attribute is co-
hesion defined as the degree to which physi-
cians practice collaboratively within a group.
The second key attribute is “scale,” implying
that there may be a minimum group size re-
quired to support the necessary infrastruc-
ture for quality improvement. The final key
attribute is “affiliation,” which locates the
practice group within a larger context that
might be able to provide infrastructure for
quality improvement. These organizational at-
tributes likely serve as proxies for charac-
teristics within the practice group that are
97
98 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010
more difficult to measure. Leaders of high-
performing integrated healthcare delivery sys-
tems identified (1) strong physician lead-
ership, (2) organizational culture, (3) clear
shared aims, (4) governance, (5) account-
ability and transparency, (6) selection and
workforce planning, and (7) patient-centered
teams as the key characteristics underlying
their success (Tollen, 2008).
A 2003 Commonwealth Fund survey found
that physicians do not routinely use data to
assess their performance and do not rou-
tinely participate in efforts to redesign clin-
ical practice. However, physicians in larger
and salaried groups were more likely than
physicians in solo or group practices of fewer
than 10 clinicians to participate in quality im-
provement (Audet et al., 2005). More recently,
the 2008 AAFP Practice Profile II survey doc-
umented that only 8% of family physicians
in solo practice, 12% in 2-person practices,
and 16% in single specialty group practice re-
ported having quality improvement initiatives
in place in their practice. In that same survey,
only 26% of family physicians in multispecialty
group practices reported having quality im-
provement initiatives in place (written com-
munication between H.A.T. and AAFP on Oc-
tober 3, 2008), with 70% of family physicians
practicing in solo and small single specialty
practices (“Practice profile,” 2007). Closing
the gap between current practice and the
future ideal of the medical home model of
care poses a significant challenge for primary
care.
A national demonstration project on imple-
menting the medical home in family medicine
practices identified several lessons learned.
First, the most successful practices seemed to
have systems of shared leadership rather than
an individual physician leader. Second, de-
spite being highly motivated, some practices
had serious dysfunctional relationship prob-
lems and this became a barrier to success.
Third, a practice’s capacity for change at base-
line was an important determinant for that
practice’s success at transformation. Finally,
integration of technology into a new model of
practice is not easy and in part due to the on-
going challenges of technology, even the most
successful practices experienced change in fa-
tigue (Stewart et al., 2007).
At the end of the national demonstration
project, the evaluation team made these as-
sessments regarding primary care practice
transformation.
Achieving a patient-centered medical home re-
quires whole practice redesign, and is not merely
the sum of many incremental changes. Achieving
a patient-centered medical home requires more
than 2 years. The journey to the patient-centered
medical home requires both personal and practice-
level transformation. Finally, transformation also
involves learning to be a “learning organization.”
(Stewart et al., 2009)
TRANSFORMATIONAL PHYSICIAN
LEADERSHIP AND QUALITY
IMPROVEMENT
Transformational physician leadership ap-
pears to be a key element in initiating qual-
ity improvement and practice redesign efforts
within the group practice setting. The na-
tional demonstration project noted that suc-
cessful leadership teams invariably included a
visionary physician as well as a clinical and/or
office manager who gets the job done and a fi-
nancial component to ensure fiscal viability of
the organization as it progresses through the
transformation process (Stewart et al., 2007).
Much has been written about leader-
ship and change in the business literature.
Kotter (1999) notes the key distinction
between management and leadership when
he writes, “Management is about coping
with complexity. Leadership, by contrast, is
about coping with change.”(p52–53) Goleman
(2001) found that effective leaders are alike
in their high degree of emotional intelli-
gence that is composed of self-awareness,
self-regulation, motivation, empathy, and
social skills. Drawing on research with more
than 3000 executives, Goleman identified
6 distinctive leadership styles arising from
different components of emotional intel-
ligence: coercive, authoritative, affiliative,
democratic, pacesetting, and coaching.
Goleman’s research indicates that authori-
tative leaders, those who mobilize people
 A Conceptual Model for Transformational Clinical Leadership
toward a vision, have the most positive
impact on the organizational climate
(Goleman, 2001).
Senge (1994) describes a model of leader-
ship on the basis of the learning organiza-
tion. He states that “the organizations that will
truly excel in the future will be the organiza-
tions that discover how to tap people’s com-
mitment and capacity to learn at all levels in
an organization.” He goes on to describe 5
disciplines, personal mastery, mental modals,
building shared vision, team learning, and sys-
tems thinking, that must be mastered to create
a learning organization. In this type of organi-
zation, the leader must see himself or herself
in roles of the designer, steward, and teacher,
and the leader’s primary task is to generate
and manage creative tension within the orga-
nization (Senge, 1994).
If one views practice transformation
through the filter of Senge’s learning orga-
nization and draws on the work of Kotter
and Goleman that a transformational physi-
cian leader should possess a high degree of
emotional intelligence, be able to mobilize
physicians and staff toward a vision and
manage the creative tension within the
practice.
Silversin (2008) identified physician expec-
tations of their physician leaders as a barrier
to practice transformation. In a workshop ti-
tled “Engaging Physicians in Transformation”
at the 2008 Annual Institute for Healthcare Im-
provement (IHI) Forum, he noted that “physi-
cians want their leaders to advocate for them,
to protect them from outside influences, to
effectively communicate with them and for
them to outside organizations and finally to
be first among equals—not one millimeter
higher than the rest.”
Greene and Filerman (2007) coined the
term care pilot to describe an individual
within a group practice who has a clinical
leadership role in guiding the group’s practice
toward the IOM quality aims. In this paradigm,
the “care pilot” is a physician with a pri-
mary responsibility within the group to com-
pare the practice’s performance against the
best available evidence, to effectively influ-
ence the group’s practice and then to analyze
99
the effect of the resultant practice changes on
the quality of care provided.
While originally described as a model
for reinventing continuing medical educa-
tion (CME) to enable practice teams to be-
come learning organizations, H.A.T. found this
paradigm consonant with his 22 years of ex-
perience as a family physician and clinician
leader within Navy Medicine, where he men-
tored other physician teams in clinical pro-
cess improvement at the clinic, hospital, and
health system levels. Because the care pilot
role is modeled on the collaborative relation-
ship between a ship’s captain and a harbor pi-
lot who comes onboard to help the captain
navigate the ship through treacherous waters,
the paradigm of the care pilot is an attractive
model for overcoming the barriers to engag-
ing physicians in practice transformation de-
scribed by Silversin. For these reasons, we hy-
pothesize that the construct of the care pilot
is a model of transformational physician lead-
ership that would be practical to implement
even in smaller, less complex practice groups
where the lowest rates of involvement in qual-
ity improvement and practice redesign were
reported.
CONCEPTUAL MODEL
We propose that the requisite knowledge
and skills needed to become an effective trans-
formational physician leader “care pilot”at the
group practice level aggregate into 3 domains:
(1) systems thinking, (2) envisioning change,
and (3) change management.
In their original article, Greene and Filer-
man (2007) provide an accurate and appro-
priately complex model of the medical group
context that was of great help in conceptual-
izing domains of knowledge and skills needed
by a care pilot at the group practice level.
In Figure 1, taken from the original article
by Greene and Filerman, the group practice
is represented by the central oval with pa-
tients, physicians, nurses, administrator, med-
ical director, and support staff enmeshed by
a variety of organizational factors with the 6
IOM quality aims placed to the far right within
the oval. This group practice is influenced by
100 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010

Figure 1. The real picture of the medical group context. From “The Role of the Care Pilot in the Medical
Group Practice,” by B. R. Greene and G. L. Filerman, 2007, Journal of Ambulatory Care Management,
30(4), 284.

real-world factors including patient demo-
graphics, third party payers, and managed
care organizations, and brushes up against the
swirl of systems thinking and improvement
efforts.
Leaders in a learning organization must see
themselves in roles of the designer, stew-
ard, and teacher, and should view the gen-
eration and management of creative tension
as their primary task within the organization
(Senge, 1994). Figure 1 suggests 3 domains
of knowledge and skills that a successful care
pilot must acquire to be an effective trans-
formational leader. We have identified these
domains in Figure 2 by overlaying 3 purple
ovals that are labeled respectively as (1) sys-
tems thinking, (2) envisioning change, and (3)
change management. In the upper right quad-
rant of Figure 2, we have identified a domain
of “systems thinking,”which encompasses the
intersection of the real-world factors, pro-
cess improvement methodologies, and strate-
gic vision. The domain labeled “envisioning
change” lies along the right side of the fig-
ure encompassing current practice, idealized
practice, and the real-world factors impacting
the group. The middle ground of the diagram
is captured by the domain of “change manage-
ment” and that oval encompasses the group
practice itself.
Our conceptual model links these 3 do-
mains of knowledge and skill with a frame-
work for clinical process improvement that
H.A.T. successfully employed throughout his
22-year career as a Navy family physician
and clinician leader (Fig 3). In Figure 3, the
 A Conceptual Model for Transformational Clinical Leadership 101

Figure 2. Domains of knowledge and skills for care pilots. From “The Role of the Care Pilot in the Medical
Group Practice,” by B. R. Greene and G. L. Filerman, 2007, Journal of Ambulatory Care Management,
30(4), 284.

Environmental Survey
Systems thinking SWOT Analysisa
• Strategic Planning
• Process Improvement Project Selection

Envisioning change
Internal Evidence-based
• Data Management Data Practice
• Evidence-based
Medicine Evidence and Outcomes Tables
• Gap Analysis
• Project Selection
Adapt Practice for Group
Change management

• Rapid Cycle PDSA Implementation

(plan, do, study, and act)
• Physician behavior
change Evaluation
• Organizational change
• Audit and feedback

Figure 3. Educational framework for training care pilots. a Strengths, weaknesses, opportunities, and
threat analysis.
102 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010

domain of systems thinking links to the first
2 steps in the clinical process improvement
framework and intersects with the domain of
envisioning change at the node of project se-
lection. The middle section of the flow dia-
gram represents an iterative process wherein
the care pilot guides the group in querying
their internal practice data and the best avail-
able evidence to create estimates of the im-
pact and costs of a proposed change that then
get factored back into the selection of clini-
cal process improvement projects. The lower
third of the framework is a classic PDSA (plan,
do, study, and act) cycle with additional focus
on the art and science of changing physician
behaviors in the adaptation and implementa-
tion nodes.
Table 1 outlines the knowledge and skills
required in the domain of systems thinking.
Remembering that physicians in training are
busy learning the tools of their profession and
practicing physicians are busy caring for pa-
tients, it is important to note that this con-
ceptual model envisions care pilots applying
very basic tools of systems thinking in their
practice setting. To that end, a care pilot in a
small practice group (<10 physicians) needs
at least a basic understanding of environmen-
tal scanning and the use of SWOT (strengths,
weaknesses, opportunities, and threats) anal-
ysis such as could be gained by conducting a
Google search, using the terms environmen-
tal scanning and SWOT analysis.
To conceptualize the group practice as a
system of interrelated processes that can be
improved over time, a care pilot should pos-
sess a basic understanding of LEAN, Six Sigma,
and the theory of constraints. Fortunately, the
IHI Web site (http://www.IHI.org) contains a
wealth of information necessary for a budding
care pilot in this area. The IHI Quality Im-
provement courses, available at the IHI Open
School Web site (“IHI Open,” 2009) http://
www.ihi.org/IHI/Programs/IHIOpenSchool,
provide an excellent overview of quality
improvement. Finally, an IHI white paper
(Institute for Healthcare Improvement, 2005)
describes the application of LEAN manu-
facturing theory in healthcare and a Web
page (“Improve Work,” 2009) on improving
workflow and removing waste provides an
adequate knowledge base for success as a
care pilot in a small practice group.
Table 2 describes the minimum knowledge
and skills required by a care pilot in the
domain of envisioning change. Fortunately,
successful transformational physician lead-
ers rarely operate outside a leadership team
(“Practice profile,”2007; Stewart et al., 2007).
Within a practice group, the skills of data min-
ing and data analysis may reside with the prac-
tice manager or the clinic nurse. A successful

Table 1. Systems thinking domain of knowledge and skills

Strategic planning Goal—Develop strategic understanding of the group practice,

Environment scanning
SWOT analysis
Process improvement
LEAN
Six Sigma variation
Theory of constraints
the practice setting, and the healthcare environment and gain
expertise using basic tools to:
identify factors in the external and internal environment of the
group with potential to influence strategic objectives
use a 2 × 2 matrix to analyze organizational strengths and
weaknesses against environmental opportunities and threats
Goal—understand the group practice as a series of interrelated
processes making up a system and gain experience using basic
LEAN Six Sigma tools to:
reduce inefficiencies within in the group practice
reduce variation in processes
reduce waits and delays
 A Conceptual Model for Transformational Clinical Leadership 103

Table 2. Envisioning change domain of knowledge and skills

Data management Goal—use (internal) group practice data to identify gaps in

Data mining
Data analysis
Evidence-based medicine (EBM)
Efficiently find the best evidence
for clinical practice
Identifying threats to validity
Become informed consumer of
EBM products
Gap analysis
Modeling change from current
to ideal practice
Balance sheet development
Project selection
performance and opportunities for improvement by
gaining experience:
Extracting data from practice databases, record reviews, and
real-time process measurement
Gaining knowledge about group practice from simple
analysis of practice data
Goal—use (external) best available evidence to guide group
practice by gaining experience using basic tools to:
Efficiently search literature to identify patient-oriented
(POEM) evidence that should change group practice
Effectively analyze studies to identify threats to validity
Effectively identify high-quality clinical practice guidelines,
reports, and recommendations for use in changing group
practice
Goal—use EBM evidence in conjunction with practice data
to identify gaps and to project impact of proposed changes
by gaining experience with basic tools to:
Compare current practice (internal data) with optimal
practice (from summary of the literature)
Estimate impact of practice change on relevant outcome for
population and organization such as:
Health status
Patient satisfaction
Provider satisfaction
Cost/utilization of resources
Organizational impact
Goal—use an iterative process to winnow out competing
options to select process improvement projects with high
likelihood of successful implementation

care pilot will make full use of the other mem-
bers of the leadership team. He or she will
not confuse the issue of measurement for pro-
cess improvement versus measurement for re-
search (“Measures,” 2009) and he or she will
be able to use data from a variety of sources
to identify gaps in performance.
Care pilots will need to be skilled in access-
ing, appraising, and using evidence as they
will likely be the best qualified person on the
leadership team to perform these functions.
At a minimum they need to be able to
1. formulate key questions in the PICO
(“PICO questions,” 2009) (patient, in-
tervention, comparison, and outcome)
model to identify opportunities for im-
provement;
2. efficiently and systematically search for
high-quality clinical practice guidelines
and then systematic reviews and ran-
domized controlled trials before accept-
ing lower-level evidence to guide their
practice change;
3. appraise the evidence, calculate the
number needed to treat (NNT) or num-
ber needed to harm (NNH), and grade
(Ebell et al., 2004) the recommendations
developed from their search; and
4. document and catalog these critically ap-
praised topics for use in developing a bal-
ance sheet estimate of the impact of a
proposed change on current practice.
Transformational clinical leaders need to be
good stewards of their practice’s resources.
104 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010

Table 3. Evidence-based medicine resources

Search engines SumSearch. Available at: http://sumsearch.uthscsa.edu

Clinical practice guidelines
Systematic reviews
EBM education and tools
Evidence grading
Project selection
PubMed Clinical Queries. Available at: http://www.ncbi.nlm.nih.
gov/corehtml/query/static/clinical.shtml
National Guideline Clearinghouse. Available at: http://www.
guideline.gov
Cochrane Reviews. Available at: http://www.cochrane.org/reviews
Centre for Evidence-based Medicine and CATmaker critical
appraisal software. Available at: http://www.cebm.net
DelfiniTM Group. Available at: http://www.delfini.org
Strength of Evidence Taxonomy (SORT). Available at:
http://www.aafp.org/afp/20040201/548.html
Evidence & Value-based Secondary Source Appraisal Tool. Available
at: http://www.delfini.org

Baseline practice data and estimates of clini-
cal effectiveness are used to create a balance
sheet (Braddick et al., 1999) in order to esti-
mate the impact of a proposed clinical pro-
cess improvement initiative on outcomes of
interest to the organization such as health
status, patient satisfaction, provider satisfac-
tion, cost/utilization of resources, and the im-
pact on the practice. Clinical improvement
projects identified through this iterative pro-
cess allow the leadership team to evaluate the
effectiveness of these proposed changes be-
fore resources are devoted to implementation
(“DelfiniTM approach,” 2009).
Table 3 identifies resources that we be-
lieve provide the appropriate level of EBM
knowledge for a care pilot in a small group
practice. A combination of useful tools for
the novice care pilot might include the SUM-
search search engine (SUMSearch, 2009), the
CATmaker critical appraisal software (Cen-
tre for Evidence-Based Medicine, 2009), and
the SORT recommendation grading methodol-
ogy (“Strength of evidence taxonomy,” 2009),
along with spreadsheet software to create
a balance sheet and worksheets (Stuart &
Strite, 2009a, 2009b) to aid in project se-
lection. Other useful resources are available
from Delfini Group, an evidence- and values-
based healthcare consulting group that of-
fers several useful free tools at www.Delfini.
org.
Effective visionary physician leaders need
to understand the value and limitations of
various interventions that might be used to
influence the behavior of other physicians
in the group. Passive interventions such as
the distribution of printed material (Farmer
et al., 2008) or lecture format teaching
(Forsetlund et al., 2009) are unlikely to change
physician behavior. More active interventions
such as participatory small group education
(Forsetlund et al., 2009), audit and feedback
(Jamtvedt et al., 2006), automated reminders
(Renders et al., 2000), clinical opinion lead-
ers (Doumit et al., 2007), and academic detail-
ing (O’Brien et al., 2007) are effective in some
conditions but none is effective in all condi-
tions. Multifaceted approaches targeting dif-
ferent barriers to change are more likely to be
effective than a single intervention in chang-
ing clinician behaviors (Hulscher et al., 2006).
Table 4 indicates that care pilots must be
skilled in audit and feedback, interactive small
group education, the effective use of clini-
cal opinion leaders, and academic detailing
to change clinician behaviors in order to im-
prove quality of care. Transformational physi-
cian leaders must understand enough about
organizational change to aid and support the
practice manager in sustaining the transforma-
tion effort over time by providing a clear vi-
sion of the future and encouragement of any
change in culture.
 A Conceptual Model for Transformational Clinical Leadership 105

Table 4. Change management domain of knowledge and skills

Rapid cycle PDCA (plan, do,
check, and act)
Clinician behavior change
Organizational change
Audit and feedback
Goal—learn to pilot, refine, and implement process changes by
gaining experience using the Institute of Healthcare
Improvement (IHI) rapid cycle PCDA methodology and tools
Goal—understand the literature regarding changing clinician
behaviors and gain experience in the use of most effective tools
including:
Interactive small group teaching
Academic detailing
Use of clinical opinion leaders
Goal—develop a basic understanding of organizational change to
ensure that changes to group practice persist after
implementation
Goal—learn to provide ongoing regular audit and feedback at the
appropriate level within the group to monitor and guide future
practice after a change

DISCUSSION within small group practices are imperative

A majority of small group practices cur-
rently lack the necessary attributes and/or
resources to fully participate in quality im-
provement and practice redesign (Audet et al.,
2005; Backer, 2009; “Practice profile,” 2007;
Tollen, 2008). We believe that the care pilot
is a model of practice transformation that is
ideally suited for small independent primary
care practices and rural practice settings. The
ideal transformational physician leader who
possesses a high degree of emotional intel-
ligence, who is able to mobilize physicians
and staff toward a shared vision, and who can
manage the creative tension within a practice
is the visionary physician leader identified in
the patient-centered medical home national
demonstration project.
Because the majority of family physicians
practice in small, single specialty groups
(Audet et al., 2005), our conceptual model
of the care pilot as transformational physician
leadership should be of particular interest to
those striving to transform primary care prac-
tice (Martin et al., 2004) and to educators
engaged in training the next generations
of primary care physicians (Green et al.,
2007). For this reason we propose that iden-
tifying, training, and supporting care pilots
for transforming primary care in the United
States.
One approach to identifying and training
transformational physician leaders is to pro-
vide CME opportunities for practicing physi-
cians. Facilitated Web-based CME, like the
IHI Open School, might be one method for
training care pilots already in practice. An-
other option would be to provide team-based,
action-oriented CME options for practice
improvement.
It seems practical to train internal medicine
and pediatric and family medicine residents
to become care pilots over the course of
their 3-year residency experience. Many of the
elements outlined in our conceptual model
are Accreditation Council for Graduate Med-
ical Education (ACGME) required curriculum
components for family medicine residencies.
Implementation of transformational clinical
leadership training in this setting might be a
matter of creating a coherent whole in bring-
ing together disparate ACGME requirements.
Residency also allows training to span multi-
ple years so that learners can gain experience
as team members before assuming a leader-
ship role in practice transformation.
Equipping physician leaders for primary
care practice transformation may not be
106 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010
sufficient to overcome the barriers to im-
proving quality in smaller practices. Recall-
ing Tollen’s work, cohesion, scale, and affil-
iation are key attributes of physician groups
that impact their ability to provide quality
care. Strong physician leadership is only one
of several underlying characteristics identi-
fied with high-performing physician groups.
Larger practices and healthcare organizations
are able to mobilize greater resources toward
strategic quality improvement goals and inher-
ently possess scale and affiliation lacking in
small private practices.
If academic medical centers assumed the re-
sponsibility for training transformational clin-
ical leaders during residency, it is feasible to
envision the formation of regional practice
transformation centers within the academic
medical centers. Regional practice transfor-
mation centers could provide sufficient scale
and affiliation to support transformational
physician leaders in overcoming the barriers
to quality improvement in small disparate pri-
mary care practices. Such a regional trans-
formation center could be sponsored by the
Area Health Education Center or the Depart-
ment of Family and Community Medicine and
might provide (1) data mining, analysis, audit,
and feedback support to participating group
REFERENCES
AAFP, AAP, ACP, & AOA. (2007, February). Joint principles
of the patient-centered medical home. Retrieved July
13, 2009, from http://www.pcpcc.net/joint-principles
Audet, A. J., Doty, M. M., Shamasdin, J., & Shoenbaum,
S. C. (2005, May/June). Measure, learn, and improve:
physicians’ involvement in quality improvement. Evi-
dence that quality improvement still has not perme-
ated the professional culture of medicine, although
progress is evident. Health Affairs, 24(3), 843–853.
Backer, L. A. (2009, January/February). Building the case
for the patient-centered medical home. Family Prac-
tice Management, 16(1), 14–18.
Braddick, M., Stuart, M., & Hrachovec, J. (1999, March–
April). The use of balance sheets in developing clini-
cal guidelines. Journal of the American Board Fam-
ily Practice, 12(1), 48–54. Erratum in: Journal of the
American Board Family Practice, 12(2), 187.
Institute of Medicine. (2001). Crossing the quality
chasm: A new health system for the 21st century.
practices; (2) practice transformation consul-
tation; (3) ongoing clinical process improve-
ment training; and (4) assistance in commu-
nity residency programs in clinical process im-
provement and leadership curriculum design
and implementation. In addition, a regional
practice transformation center could facili-
tate such regional collaborative initiatives by
bringing together organizations with shared
interests and pushing out “change packages”
to collaborative teams.
While physician leadership is the key to
changing physician behaviors within a group
practice, there is a need to train nurses and
clinic managers to become that leadership
team in support of office practice transforma-
tion. Efforts should be made to collaborate
with the local nursing and healthcare admin-
istrator programs to integrate clinical process
improvement training into their curriculum in
order to produce nurses and administrators
who would be highly sought after by prac-
tices in the process of transformation. Finally,
there is a need to develop and maintain a clin-
ical process improvement knowledge center
that can collect, catalog, and distribute knowl-
edge regarding better practices to interested
groups within the sphere of the regional prac-
tice transformation center.
Committee on Quality of Health Care in America.
Washington, DC: National Academies Press.
Centre for Evidence-Based Medicine. (2009). Retrieved
July 25, 2009, from http://www.cebm.net
DelfiniTM approach to clinical quality Improvement
& value. (2009). Retrieved July 25, 2009, from
http://www.delfini.org/delfiniQI.htm
Doumit, G., Gattellari, M., Grimshaw, J., & O’Brien, M.
A. (2007). Local opinion leaders: Effects on profes-
sional practice and health care outcomes. Cochrane
Database of Systematic Reviews, Issue 1. Art No.:
CD000125. DOI: 10.1002/14651858.CD000125.pub3.
Ebell, M. H., Siwek, J., Weiss, B. D., & Woolf, S. H. (2004).
Strength of recommendation taxonomy (SORT): a
patient-centered approach to grading evidence in the
medical literature. American of the Family Physician,
69, 548–556.
Farmer, A. P., Légaré, F., Turcot, L., Grimshaw, J.,
Harvey, E., McGowan, J. L., et al. (2008). Printed
 A Conceptual Model for Transformational Clinical Leadership
educational materials: Effects on professional prac-
tice and health care outcomes. Cochrane Database of
Systematic Reviews, Issue 3. Art. No.: CD004398. DOI:
10.1002/14651858. CD004398.pub2.
Forsetlund, L., Bjørndal, A., Rashidian, A., Jamtvedt,
G., O’Brien, M. A., Wolf, F., et al. (2009). Con-
tinuing education meetings and workshops: Ef-
fects on professional practice and health care out-
comes. Cochrane Database of Systematic Reviews, Is-
sue 2. Art. No.: CD003030. DOI: 10.1002/14651858.
CD003030.pub2.
Goleman, D. (2001). What makes a leader? Harvard Busi-
ness review on what makes a leader. Boston, MA:
Harvard Business School Press.
Greene, B. R., & Filerman, G. L. (2007, October–
December). Reinventing CME. The role of the care pi-
lot in the medical group practice. Journal of Ambula-
tory Care Management, 30(4), 283–290.
Institute for Healthcare Improvement. (2005). Going lean
in health care. IHI Innovation Series white paper. Re-
trieved July 25, 2009, from http://www.IHI.org
Green, L. A., Jones, S. M., Fetter, G., & Pugno, P. A. (2007,
December). Preparing the personal physician for prac-
tice: Changing family medicine residency training
to enable new model practice. Academic Medicine,
82(12), 1220–1227.
Hulscher, M., Wensing, M., van der Weijden, T., &
Grol, R. (2006). Interventions to implement preven-
tion in primary care. Cochrane Database of Sys-
tematic Reviews, Issue 1. Art. No.: CD000362. DOI:
10.1002/14651858.CD000362.pub2.
IHI open school courses. (2009). Retrieved July
25, 2009, from http://www.ihi.org/IHI/Programs/
IHIOpenSchool
Improve work flow and remove waste. (2009). Re-
trieved July 25, 2009, from http://www.ihi.org/IHI/
Topics/OfficePractices/Access/Changes/ImproveWork
FlowandRemoveWaste.htm
Jamtvedt, G., Young, J. M., Kristoffersen, D. T., O’Brien,
M. A., & Oxman, A. D. (2006). Audit and feedback:
Effects on professional practice and health care out-
comes. Cochrane Database of Systematic Reviews, Is-
sue 2. Art. No.: CD000259. DOI: 10.1002/14651858.
CD000259.pub2.
Kotter, J. P. (1999). On what leaders really do. Boston,
MA: Harvard Press Review.
Measures. (2009). Retrieved July 25, 2009, from http://
www.ihi.org/IHI/Topics/Improvement/Improvement
Methods/Measures.
Martin, J. C., Avant, R. F., Bowman, M. A., et al. (2004,
March–April). Future of family medicine project lead-
ership committee. The future of family medicine: A
collaborative project of the family medicine commu-
nity. Annals of Family Medicine, 2(Suppl. 1), S3–S32.
O’Brien, M. A., Rogers, S., Jamtvedt, G., Oxman, A.
D., Odgaard-Jensen, J., Kristoffersen, D. T., et al.
(2007). Educational outreach visits: Effects on
professional practice and health care outcomes.
Cochrane Database of Systematic Reviews, Issue
4. Art. No.: CD000409. DOI: 10.1002/14651858.
CD000409.pub2.
107
Practice profile of family physicians by family medicine
residency completion. (2007, December 31). Re-
trieved July 13, 2009, from http://www.aafp.org/
online/en/home/aboutus/specialty/facts/4.html
PICO questions in depth. (2009). Retrieved July 25,
2009, from http://ebling.library.wisc.edu/portals/
ebhc/pico.cfm
Rosenthal, T. C. (2008). The medical home: Growing ev-
idence to support a new approach to primary care.
Journal of the American Board Family Medicine, 21,
427–440.
Renders, C. M., Valk, G. D., Griffin, S. J., Wagner, E.,
van Eijk, J. T., Assendelft, W. J. J. (2000). Interven-
tions to improve the management of diabetes mel-
litus in primary care, outpatient and community
settings. Cochrane Database of Systematic Reviews,
Issue 4. Art. No.: CD001481. DOI: 10.1002/14651858.
CD001481.
Silverstin, J. (2008, December 9). Engaging Physicians
in Transforming Care. In: IHI 20th Annual Na-
tional Forum on Quality Improvement in Health Care,
Nashville, TN.
Starfield, B., & Shui, L. (2004). The medical home, ac-
cess to care and insurance: A review of evidence. Pe-
diatrics, 113, 1493–1498.
Stewart, E. E., Jaén, C. R., Crabtree, B. F., Nutting, P. A.,
Miller, W. F., & Stange, K. C. (2007, June 4). Evaluators
report on the national demonstration project (NDP)
to the board of directors of Transformed #3 dated. Re-
trieved July 13, 2009, from http://www.transformed.
com/evaluatorsReports/report3.cfm
Stewart, E. E., Jaén, C. R., Crabtree, B. F., Nutting, P. A.,
Miller, W. F., & Stange, K. C. (2009, winter). Evaluators
report on the national demonstration project (NDP)
to the board of directors of Transformed #6 dated. Re-
trieved July 13, 2009, from http://www.transformed.
com/evaluatorsReports/report6.cfm
Senge, P. M. (1994). The fifth discipline. The art and prac-
tice of the learning organization. New York: Double-
day.
SUMSearch. Retrieved July 25, 2009, from http://
sumsearch.uthscsa.edu
Strength of evidence taxonomy (SORT). (2009).
Retrieved July 25, 2009, from http://www.aafp.
org/afp/20040201/548.html
Stuart, M., & Strite, S. (2009a). Evidence & value-
based secondary source appraisal tool. Retrieved July
25, 2009, from http://www.delfini.org/delfiniTools.
htm
Stuart, M., & Strite, S. (2009b). Evidence-based qual-
ity improvement project implementation tool. Re-
trieved July 25, 2009, from http://www.delfini.org/
delfiniTools.htm
Tollen, L. (2008, April 17). Physician organization in
relation to quality and efficiency of care; a synthesis
of recent literature. Commonwealth Fund Pub. No.
1121. Retrieved August 5, 2009, from http://www.
commonwealthfund.org/Content/Publications/Fund-
Reports/2008/Apr/Physician-Organization-in-Relation-
to-Quality-and-Efficiency-of-Care–A-Synthesis-of-
Recent-Literatu.aspx