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Background: Central to the 'medical home' concept is the premise that the delivery of effective primary care requires a fundamental shift in relationships among practice members and between practice members and patients. Primary care practices can potentially increase their capacity to deliver effective care through knowledge management (KM), a process of sharing and making existing knowledge available or by developing new knowledge among practice members and patients. KM affects performance by influencing work relationships to enhance learning, decision making, and task execution. Purpose: We extend our previous work to further characterize, describe, and contrast how primary care practices exhibit KM and explain why KM deserves attention in medical home redesign initiatives. Methodology: Case studies were conducted, drawn from two higher and lower performing practices, which were purposely selected based on disease management, prevention, and productivity measures from an improvement trial. Observations of operations, clinical encounters, meetings, and interviews with office members and patients were transcribed and coded independently using a KM template developed from a previous secondary analysis. Face-to-face discussions resolved coding differences among research team members. Confirmation of findings was sought from practice participants. Findings: Practices manifested varying degrees of KM effectiveness through six interdependent processes and multiple overlapping tools. Social tools, such as face-to-face-communication for sharing and developing knowledge, were often more effective than were expensive technical tools such as an electronic medical record. Tool use was tailored for specific outcomes, interacted with each other, and leveraged by other organizational capacities. Practices with effective KM were more open to adopting and sustaining new ways of functioning, ways reflecting attributes of a medical home. Practice Implications: Knowledge management differences occur within and between practices and can explain differences in performance. By relying more on social tools rather than costly, high-tech investment, KM leverages primary care's relationship-centered strength, facilitating practice redesign as a medical home. [ABSTRACT FROM AUTHOR]

BACKGROUND: Knowledge management (KM) is the process by which people in organizations find, share, and develop knowledge for action. KM affects performance by influencing work relationships to enhance learning and decision making. PURPOSE: To identify how family medicine practices exhibit KM. METHODOLOGY: A model and a template of KM concepts were derived from a comprehensive organizational literature review. Two higher and two lower performing family medicine practices were purposefully selected from existing comparative case studies based on prevention delivery rates and innovation. Interviews, fieldnotes of operations, and clinical encounters were coded independently using the template. Face-to-face discussions resolved coding differences. FINDINGS: All practices had processes and tools for finding, sharing, and developing knowledge; however, KM overall was limited despite implementation of expensive technologies like an electronic medical record. Where present, KM processes and tools were used by individuals but not integrated throughout the organization. Loss of information was prominent, and finding knowledge was underdeveloped. The use of technical tools and developing knowledge by reconfiguration and measurement were particularly limited. Socially related tools, such as face-to-face-communication for sharing and developing knowledge, were more developed. As in other organizations, tool use was tailored for specific outcomes and leveraged by other organizational capacities. PRACTICE IMPLICATIONS: Differences in KM occur within family practices and between family practices and other organizations and may have implications for improving practice performance. Understanding interaction patterns of work relationships and KM may explain why costly technical or externally imposed 'one size fits all' practice organizational interventions have had mixed results and limited sustainability. [ABSTRACT FROM AUTHOR]

BACKGROUND: Efforts to redesign primary care practices are beginning to address how decisions are made in the practice setting. This study contributes to these efforts by examining associations between staff participation in decision-making, productivity, and turnover in primary care practices. The study is informed by organizational theories of participation that emphasize cognitive and affective influences on employee output and behavior. METHODS: This research used data collected from primary care practices involved in a national initiative sponsored by the Robert Wood Johnson Foundation. Cross-sectional survey data on organizational structures and attributes among 49 practices were analyzed. Regression analysis was used to examine associations among practice productivity, staff participation in decision-making, and formal structures such as staff meetings. Associations between staff turnover and participative decision-making were also examined. RESULTS: Staff participation in decisions regarding quality improvement, practice change, and clinical operations was positively associated with practice productivity, whereas formal structures such as staff meetings were not. In addition, higher levels of participation in decision-making were associated with reduced turnover among nonclinicians and administrative staff. CONCLUSION: Examination of organizational features is increasingly recognized as a key to improving primary care performance. Study findings suggest that one important strategy may be implementation of a participative model emphasizing greater staff involvement in practice decisions. This may enhance information-sharing, work satisfaction, and commitment to organizational decisions, all of which can lead to beneficial outcomes such as increased productivity and stability in primary care practices. [ABSTRACT FROM AUTHOR]