A key feature of the P&CD study design was an openness to the integration of emerging insights into the data collection protocol. For example, preliminary analyses of the DOPC data13 and other ongoing studies14 led to the discovery that complexity science was valuable for explaining the dynamics of office systems6 and needed to be incorporated into the design. (Complexity science is the study of systems that are characterized by nonlinear dynamics and emergent properties; it emphasizes the need to understand the interrelationships of the whole system and not just collect data about the parts.15) The investigators also developed new ways to display the relationships among physicians and staff in the practices using “practice genograms.”16 The practice genogram is a diagram of the functional and interpersonal relationships among the clinicians, support staff, and other people and organizations interacting with the practice. Throughout the project and consistent with the standards of qualitative research design,17 there were continued modifications and enhancements in the data collection and analysis strategies in response to insights that were emerging from ongoing analyses and interpretation of the data.
An important feature of the project was the development of an advisory committee of consultants and co-investigators that convened annually to provide multidisciplinary input, review results, and provide feedback. The advisory committee included academic representatives with expertise in nursing, health education, women’s health, minority health, and public policy. Two additional members were added to the project to provide expertise into the study of organizations as complex systems. The annual reviews by the advisory committee led to significant changes in the research design while the study was ongoing.
Practice Sample
Beginning in late 1996, we drew from 91 practices in Nebraska that had been randomly selected to participate in an earlier study on tobacco prevention and cessation.18 Initially a sample of 10 practices was purposefully selected19,20 using an iterative process to represent a range in size (small and large), geographic location (urban, suburban, and rural), and rate of delivery of tobacco-related preventive services. Preliminary analyses of these 10 initial practices provided a summary of preventive health delivery strategies in primary care practices and a description of competing demands that enhanced or limited these strategies. To confirm or refute the emerging insights from the original 10 practices, 8 additional practices were selected for further data collection during the second and third years of the study. The sampling strategy in years 2 and 3 ensured that at least 2 practices each from several major regional hospital health systems were included and allowed us to assess emerging hypotheses about the importance of health system context for understanding community practices.
The practices were recruited by contacting one of the physicians to solicit participation; only those in which all family physicians in the practice agreed to participate were included in the study. Twenty-three practices were contacted; all physicians in 18 agreed to participate (78%).
Core Data Collection Methods
Data were collected by trained field researchers who spent 4 weeks or more taking notes at each practice while observing the practice and clinical encounters, conducting informal key informant interviews of staff, collecting office documents, and auditing charts of patients whose encounters were observed. Within each practice, data collection occurred in stages, with a short break after the initial week or 2 of observation to allow preliminary analyses to inform additional data collection.
Observations at the practice level were recorded in a combination of structured observational checklists, unstructured dictated field notes,21-23 and key informant interviews.24 Detailed floor plans of the practice were used to identify where particular activities occurred and where individual practice participants worked. Each day at the practice, the field researcher took short notes or “jottings” and dictated expanded field notes in the evening.23 A template of topics was used periodically to ensure that important aspects of the practice were not being overlooked. The template included lists of features of the community, practice, staff, and patients that the researchers saw as important Figure W1.*13 A 3-page structured practice environment checklist was adapted from earlier work on the DOPC project11 and included a wide range of practice characteristics and functions, including items such as the number and training of staff, counseling options offered, and management of telephone calls and referrals Figure W2a. This checklist also served as a detailed reminder to the research nurse of topics to be included in the field notes. Throughout the time the field researchers were recording field notes and filling in the checklist, they opportunistically asked clinicians or staff informal key informant questions for confirmation or clarification.