Multistakeholder Perceptions of Priorities in Primary Care as a Source of Local Innovation: Qualitative Descriptive Study

Introduction

Primary care plays a unique and foundational role in the US healthcare system. Care delivered in primary care settings is distinguished by its emphasis on person and family centeredness, continuity, coordination, comprehensiveness, and accessibility. ¹ The 2021 National Academies report on Implementing High Quality Primary Care asserted that a high performing primary care system is essential for promoting health, reducing health inequality, and preventing illness and unnecessary use of emergency room and hospital care. ² For decades, primary care has faced numerous challenges in fulfilling its mission and functions, including inadequate funding, antiquated payment systems, and a declining and maldistributed workforce.^{2 -6} There was significant burnout and turnover in the primary care workforce as a result of COVID.^7,8 According to experts, solving this complex set of problems requires a combination of federal, state, and local, point-of-service solutions.^{2 -4}

To answer this call, several federal and state initiatives were launched to address practice and payment reforms. Demonstrations like Making Care Primary and Accountable Care Organization (ACO) Primary Care Flex seek to transition primary care from traditional fee-for-service to value-based payment and/or hybrid models of both types of payment.^9,10 They incorporate practice elements like coordinated care and integrated behavioral health as vehicles to enhance quality care and cost-savings for populations with complex care needs. Importantly, participants in these initiatives are encouraged to design models that integrate required elements with local context and need. Previous research has shown that engaging stakeholders in practice improvement and innovation improves the relevance of solutions and contributes to greater adoption by patients, clinicians, and community members.^11,12 Further, research demonstrates that local innovation, defined as “the creation of new ways of doing things compared to existing practice within a specific local context,”(p. 1) ¹³ extends stakeholder relationships and system capacity for effective change as well as better solutions.^13,14

Finding effective local solutions and innovations is increasingly challenging as the number and types of local stakeholders in primary care change along with payment, technology, and workforce demands. The traditional patient-provider dyad has expanded to include many other team members and community services as well as learners, preceptors and academic faculty.^2,3 Ideally, each group can be a source of new ideas. They also may be expected to have different and potentially conflicting perspectives on their goals and priorities. The objective of this research was to compare and contrast the needs and priorities of diverse stakeholder groups in one primary care network as a source of local practice innovations. Our hypothesis was that ideas for innovation might be found at the intersection of needs and priorities across the stakeholder groups.

The research questions guiding this study were:

Methods

The study used a qualitative descriptive approach to explore the needs and priorities of key stakeholders and areas of convergence and divergence. The study followed EQUATOR guidelines relevant to qualitative research conducted in primary care. ¹⁵ Qualitative description, one of the most used qualitative methods, allows the researcher to describe everyday experiences and events, like those in primary care practice and education, in practical, commonplace words and images.^16,17 Less abstract and inferential than other qualitative methods, qualitative descriptive allows for flexibility in theoretical orientation and data collection methods while maintaining rigor in analysis and conclusions. ¹⁸

The Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review (CLER 2.0) framework was used to guide this research and initial data analysis. ¹⁹ According to the CLER framework, the clinical setting in which patients and the clinical team, including residents and health professions students, deliver care together is a “shared space” (p. 7) in which all participants are integral and interdependent parts of continuous learning, improvement and innovation. Also consistent with the perspective guiding this research, the CLER framework emphasizes the importance of local context in shaping the strengths and unique opportunities for each clinical learning environment (CLE).^20,21 Biannual evaluations of the framework conducted using interview and survey data from hundreds of site visits to CLEs, including primary care CLEs, support its relevance and contributions to improvements in learning and patient care.^20,22 Key concepts in this framework, patient safety, health care quality, teaming, supervision, well-being, and professionalism, represent foundational aspects of clinical care and education and as such, provided an appropriate starting place to understand the intersections among the needs and priorities of diverse stakeholders in the primary care clinical space.

Stakeholder groups included in this study were selected for their central roles in primary care. These included primary care providers, clinical team members, physician practice administrators/leaders, health professions faculty/preceptors, health professions graduate students, family medicine residents, and community members. Convenience sampling was used. Participants for each focus group were recruited through practice administrators and contacts in academic and community organizations affiliated with a large health system. All primary care providers and team members in 3 local primary care practices were invited to participate. Eligible participants were 18 years of age or older and engaged in current full-time or part-time practice in the 3 clinics as primary care providers, clinical team members or front-office personnel. Faculty and clinical preceptors were recruited through project team contacts at affiliated universities. Eligible participants were 18 years of age or older with current responsibility for precepting graduate students in primary care rotations. Graduate students in programs at 3 affiliated universities were recruited to participate through their academic deans and faculty. Residents in an affiliated family medicine residency program were recruited through their faculty. Eligible graduate students and residents were 18 years of age or older who had at least 1 clinical rotation in a primary care setting. Community members representing the patient voice were recruited through local community affiliates of the health system’s community outreach director. Individuals 18 years of age or older who spoke English and were currently participating in a community affiliate program were eligible for this study.

The study protocol was determined to be exempt by the university and health care organization’s institutional review boards (IRBs). The university IRB was designated as primary IRB by the health care organization’s IRB. Written consents were completed by every participant prior to the focus groups. Eight of the 9 focus groups were conducted virtually due to in-person meeting restrictions during COVID-19. Participants in the final focus group requested an in-person meeting when COVID-19 restrictions were lifted. Team member focus groups were conducted separately from provider focus groups to reduce the potential for status and power differences to affect participation. In focus groups that included members of professions with potential power differences, additional strategies were used to mitigate these differences, such as monitoring for signs of deference between groups and encouraging all participants to speak.

Forty-four individuals participated in a total of 9 focus groups conducted between December 2020 and November 2021. One focus group each was conducted with physician practice administrators/leaders, health professions faculty/preceptors, health professions graduate students, family medicine residents, and community members. Two focus groups were conducted each for primary care providers and primary care team members to allow for clinic coverage during their participation. The number of participants in each focus group ranged from 3 to 10 with an average of 6 participants in each group.

Each focus group was co-facilitated by 2 project team members using semi-structured questions, such as “what is important to you as a provider, a learner, a patient?” “what would your ideal primary care practice or experience look like?” (The Interview Guide is provided in Supplemental Material). Questions were derived from the CLER 2.0 framework to capture each stakeholder’s perspective on key aspects of the CLE. Each focus group was asked the same questions modified according to the roles and composition of the focus group. In contrast to provider questions, for instance, graduate health professions students were asked, “what is important to you about your primary care clinical experience?” “what would your ideal clinical experience look like?” Community members were asked “what is important to you about your primary care visits?” Each of the focus groups was digitally recorded with group member approval. An additional team member served as a recorder for additional notes and as back-up for any recording gaps. Each focus group lasted approximately 1 hour.

Identifying information was removed from all transcripts. A professional transcription company transcribed focus group recordings. Prior to analysis, project team members compared transcripts with recordings for accuracy and completeness. Directed content analysis was carried out using the process described by Colorafi and Evans ¹⁸ and Hsieh and Shannon. ²³ Each transcript was read in its entirety and open-coded by 3 or 4 project team members who had been pre-trained and participated in practice sessions. In open coding, each team member identified meaning units consisting of phrases or sentences with one idea or focal point and assigned them a code—usually a gerund—that incorporated the participant’s words. Codes were reviewed in project team meetings. Three pages of 2 focus group transcripts were selected to evaluate interrater reliability. Reliability was determined according to consistent assignment of codes to meaning units. Four coders achieved a consistent interrater reliability of 85% or higher. Differences in assignment of codes to meaning units were resolved through discussion.

Concepts from the CLER framework were used as initial coding categories for the analysis. Exemplars assessed to be components of these categories were grouped into themes. Themes were then compared across stakeholder groups to illuminate similarities and differences in perspectives on the CLER 2.0 concepts. ²⁴

Trustworthiness and authenticity of the findings were addressed by having all project team members engage in discussion of their assumptions and expectations of findings prior to data collection and analysis ²⁵ and using a semi-structured interview guide for consistency. During analysis, all coders were encouraged to stay close to the interview data and attend to context and rich descriptions to support decisions about transferability.^{26 -28}

Results

Forty-four members of 7 stakeholder groups participated in the 9 focus groups. Descriptions of each focus group are shown in Table 1. The 3 practice administrators/leaders interviewed for the study were physicians with direct supervision responsibilities for primary care clinics. Two of the 3 also practiced as primary care providers in the clinics. The 2 primary care provider groups had a total of 6 participants including 4 physicians, a nurse practitioner and a physician assistant. The 2 primary care team groups consisted of 5 medical assistants, a Registered Nurse (RN) and a front office staff member. The health professions faculty and preceptor group had 5 members from medicine, nursing, and physician assistant programs from 4 different universities. The health professions graduate student group included 8 participants from 2 nurse practitioner and physician assistant programs and 1 medical school and 1 behavioral health program. The family medicine resident group had 10 first and second year residents from 1 residency program. And finally, the community member focus group included 5 women who were members of a mothers’ support group at a local community center. All 5 women were experienced users of primary care services for themselves and family members.

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Table 1.

Focus Group Meetings and Composition.

Focus groups	Providers	Team members	Admin	Faculty	Grad students	Residents	Community members
No. Focus groups; (total hours)	2 (2)	2 (2)	1 (1)	1 (1)	1 (1)	1 (1)	1 (1.5)
Number of participants	6	7	3	5	8	10	5
Description	MD (4) NPs (1) PA (1)	RN (1) MA (5) Front office (1)	MD (3). Active caseload (2)	Med (2) NP (2) PA (1)	NP (3) PA (2) Med (1) DBH (1)	Family medicine	Mothers’ support group

Note. MD = physician; NP = nurse practitioner, PA = physician assistant, RN = registered nurse; MA = medical assistant; Med = medical school; DBH = doctor of behavioral health.

Three CLER 2.0 concepts, health care quality, teaming, and well-being were central to an optimal primary care experience for each of the stakeholder groups. Each of these concepts was emphasized across the stakeholder groups with fewer comments about the remaining CLER 2.0 concepts. The following analysis focuses on the 3 dominant concepts in the data. Exemplars are used to illustrate themes throughout the narrative and highlight similarities and differences.

Health Care Quality

The CLER 2.0 framework pivots around the importance of the delivery of high-quality patient care and continuous quality improvement. In this framework, all participants in the CLE share in the common goal of high-quality care and are responsible for identifying and taking action to improve outcomes.

All stakeholders in this study saw health care quality as their top priority. Health care quality had the highest frequency of coded statements among the 3 concepts (Table 2). Major themes comprising health care quality were (1) achieving desired outcomes, (2) having meaningful relationships, and (3) supporting primary care providers.

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Table 2.

Frequency of Health Care Quality Statements: All Stakeholders.

Health care quality themes	Providers	Team members	Admin	Faculty	Graduate students	Residents	Community members
Achieving desired outcomes	7	5	8	6	4	6	14
Having meaningful relationships	8	2	3	7	7	4	10
Supporting providers	20	16	11	2	2	8	0

Desired outcomes were ones commonly associated with the aims of primary care, that is, promoting health, preventing premature onset of illness, and managing chronic illnesses. All groups emphasized the goal of enabling patients to live healthy and active lives.

One of the providers shared: “On a daily basis, I know that I’m making worthwhile contributions to my patients’ lives and changing their trajectory. Changing their health patterns.”

And a health professions graduate student stated: “It’s important to me to have my patients excited and involved and to help them change their health.”

Community members were more granular than providers and learners emphasizing the effects of visits and care on their daily lives. For them quality care included getting information from providers they needed to anticipate potential health problems and address them before they became serious. In addition, they wanted short wait times and accurate diagnoses that required only essential tests and follow-up visits.

The patient-provider relationship emerged as a central component of quality health care. Providers, faculty, residents, and graduate students talked at length about the importance of meaningful relationships with patients as the foundation for effective primary care and ultimately for their own professional and personal satisfaction. Having meaningful relationships entailed getting to know patients and their preferences and having patients feel cared about.

Members of the community focus group described many of the same aspects of meaningful relationships with providers. They valued personal care and shared that they wanted their providers to “know me as a unique individual and not part of an assembly line.” Importantly, they saw themselves as experts in their own and family health needs and expected their providers to listen to them and acknowledge their expertise.

I’m not a doctor, but at the same time, I get discouraged when I go in and say, “I think it’s this” and they say, “no, it’s not.” Then a week later, I go back and it is (what I thought). I know my body, too.

Each of the groups recognized that their ability to achieve desired outcomes and develop and sustain meaningful relationships was associated with time. Providers, residents and graduate students prioritized “having enough time” to deliver quality care and to know their patients. Community members, in turn, wanted their visit time spent being listened to and addressing their needs, not waiting or filling out paperwork they found repetitive and unnecessary.

The third major theme in quality health care, supporting primary care providers, centered around protecting and supporting the provider-patient relationship and optimizing time devoted to it. Providers and residents emphasized their need for adequate staff and efficient technology to enable them to focus on delivering quality care. Administrators and clinical team members saw themselves in critical support roles for providers and learners in creating optimal environments, workflows and experiences for quality care. One administrator talked about his effort to create effective “enabling” systems:

What attracts clinicians and keeps them? It’s certainly the people, but there must be a system that enables people to perform their best and removes barriers that get in the way of delivering care. It’s the inefficiencies in the system that get people bogged down and burnt out.

Providers and clinical team members reinforced the importance of having leaders and administrators who understand the rigors of daily practice and focus on reducing barriers to quality care.

One medical assistant shared, “When leadership understands what a real day-to-day office is like, they’re more likely to understand us and our struggles. They can plan for the stuff that happens.”

Clinical team members talked extensively about the importance of managing daily workflows and keeping the clinic schedule on track. Their emphasis, in contrast to the big picture view of the administrators, was on daily operations and anticipating and reducing disruptions.

A good workflow is a big thing. Makes sure everyone is on the same page. Patients show up on time, check in early because one late patient can throw off the rest of the day. Look for scheduling errors to make sure the providers have appropriate time to spend with a patient. We have patients that are very complex and need more time.

One provider described what it feels like when goals, relationship and time priorities come together:

A great day is when I see patients on time, when I have all the information I need to make decisions. Then, I can have a dialogue with my patients about their current situation and how we can get them where they need to be.

As suggested in the CLER 2.0 framework, the participants in this study perceived quality health care as the pivot for everything that happens in primary care. Each group talked about the centrality of the patient-provider relationship to achieving quality outcomes. Community members brought out the importance of being acknowledged as experts in their own and their families’ health as key to their perception of quality.

Time with patients was perceived as essential to providing and improving high quality primary care by providers, residents and graduate students. Each of these groups talked about optimizing their time in direct patient contact. Administrators, clinical team members and faculty preceptors saw it as an important part of their roles to anticipate and reduce system and operational barriers for this to happen.

Teaming

Teaming in CLER 2.0 is concerned with the processes of working together to achieve high-quality patient care. In introducing teaming as a new concept in the second version of CLER, the ACGME noted “the concept of teaming recognizes the dynamic and fluid nature of the many individuals of the clinical care team that come together in the course of providing patient care to achieve a common vision and goals.” (p. 2). ¹⁰ They go on to say, “this new focus area also expressly recognizes and explores the CLE’s perspective on the patient’s role in teaming.”(p. 2). ¹⁹

Among the provider, team, faculty and learner groups in this study, teaming was seen as an important vehicle for improving quality care by (1) expanding expertise and resources available to patients, (2) focusing on my strengths, (3) saving time, and (4) learning new knowledge and skills. Each of these groups identified the value of having team members like behavioral health specialists or community health workers to address patient needs they could not meet on their own. Being able to rely on team members to do the work needed or answer questions enabled them to focus on their strengths and saved them time. Learning from others was seen as contributing to professional growth and improved quality care.

While each group identified each of these major reasons for teaming, they tended to prioritize them in terms of their own goals in the clinical learning environment. For instance, providers spoke most frequently in the focus groups about the benefit of team members for saving them time so they could focus on the work they felt most qualified to do and wanted to do (Table 3). They talked about shifting activities they felt did not require their expertise to others. One provider shared,

One of my priorities is to have behavioral health or social work specialists. That requires a lot of time and resources for me to dedicate to help get patients things they need. Having somebody to take that on, frees me up to do a lot of the other things I need to do.

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Table 3.

Frequency of Teaming Statements: All Stakeholders.

Teaming themes	Providers	Team members	Admin	Faculty	Graduate students	Residents	Community members
Expanding expertise available for patients	4	4	7	8	4	5	1
Focusing on my strengths	4	4	6	2	2	4	0
Saving time	8	8	1	1	0	7	4
Learning new knowledge	3	3	6	3	5	3	2

Residents mirrored this perspective and emphasized the value of teaming for access to people who could answer their questions immediately to allow them to focus on patient needs and keep them on time:

You want to work with people who know the answers to your questions. You don’t want to spend 15 minutes trying to find out simple solutions.

Clinical team members, like the providers and residents, emphasized the value of teaming for saving time and keeping clinic workflows on schedule. They particularly valued having team members who would step in and help them when they got busy.

Community members also looked to teaming to save them time. They recognized they would likely be seeing different team members during their care and expected them to communicate with each other, so they did not need to repeat the same information multiple times.

There was this point that I saw two or three different people and I have to tell my whole story exactly the same. Communicating is an important piece. Let them meet before they see the patient. What did they say? What are they going through?

All the provider/learner groups talked about the importance of learning new knowledge and skills from team members. Providers and their clinical team members talked about the value of integrating students on their teams to sharpen and expand their knowledge. Clinical team members shared students “allowed you to see new things, with fresh eyes.” However, both groups were clear that when the value of learning clashed with their time for patients, patients would remain the priority. At the time of the focus groups, none of the providers currently were precepting students due to time constraints and their unwillingness to provide what they viewed as less than an optimal learning experience.

In contrast to the providers and clinical team members, graduate students and faculty talked at length about the value of teaming for clinical learning. Students relied on team experiences for practicing skills and learning how to collaborate effectively and efficiently.

I learn from sitting next to other students, listening to what they do and having the chance to observe every team member.

When asked about their perspective on their clinical teams, community members focused on their relationship and expectations of their primary care providers, most often their physicians. While they did not frame their role in terms of being a member of the team, community members implicitly described themselves as the expert who knew their and their families’ needs better than any other team member.

As in the CLER 2.0 framework, providers and learners in the focus groups, viewed themselves as members of teams devoted to providing quality health care with the provider-patient relationship at the core. Community members described themselves as active participants with the most expertise about their own bodies and needs.

All participants viewed teaming as a way of saving time. Specific goals for saving time, such as having more time to spend with patients, keeping the clinic on schedule, or having shorter clinic visits, varied by group. We did not explore whether or how these differences were discussed or negotiated. The emphasis on teaming to learn new knowledge and skills, not unexpectedly, came mostly from students and faculty. For providers and team members, having team members and students as a source of new knowledge was seen as desirable but optional.

Well-being

According to the CLER 2.0 framework, physical and emotional well-being of patients and the clinical care team is foundational to achieving high-quality patient care. Well-being includes individual comfort and satisfaction as well as the presence of a supportive care community.

Each of the provider, team, administrator and learner groups talked about important aspects of professional and personal well-being (Table 4). For those on the delivery side of primary care, professional well-being was closely tied to their ability to meet their own and others’ expectations for quality care and feeling they are engaged in meaningful activities.

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Table 4.

Frequency of Well-Being Statements: All Stakeholders.

Well-being themes	Providers	Team members	Admin	Faculty	Graduate students	Residents	Community members
Meeting own and others’ expectations for quality care	3	2	3	2	2	3	2
Engaging in meaningful activities	6	1	6	3	3	5	2
Having input into decisions	6	7	4	2	5	3	5
Giving and receiving positive feedback	3	4	0	2	4	2	2
Having work-life balance	6	0	4	3	1	3	0

Clinical team members, more so than other groups, talked about the importance of the clinic culture to their well-being. It was important to them to have input into decisions that affected clinic operations and to voice their opinions “without judgement” and “without it being used against you.” Getting positive feedback also was important: “Getting kudos for all the patients that went well, hearing about patients in which we went beyond, not just about patients that were upset.”

Residents and graduate students wanted full participation in the primary care experience with the opportunity to do everything themselves and be a real part of patient care:

When I think about primary care experiences I’ve had, in the ones that were really good, I was taken seriously as a student. My preceptor would say, “this is your patient, what do you want to do for your patient? I felt strongly like I was responsible and able to do things that would make a difference.

Personal well-being was concerned with work-life balance and being able to leave work at work. Many of the providers described taking work home and spending considerable additional hours on documentation and follow-up. As one provider shared:

By the end of the day, if you’re done with your notes, your task box is at zero, that makes for a fabulous day. It would be so nice to go home without 20 more hours of work.

Residents envisioned future positions that allowed for balance:

I want a position with flexibility. I want to be able to take a day off without a lot of paperwork.

Across groups, there was a shared sense that well-being was tied to accomplishing professional and personal goals. As with teaming, sources of well-being reflected roles and priorities for each stakeholder group in the CLE.

Discussion

Common wisdom encourages us to “think globally and act locally.” Attention to local context and needs sets parameters for what is meaningful and feasible for individuals and groups who will be directly involved and affected by proposed changes. Local context, including community, organizational, provider, and academic characteristics and priorities, plays a key role in practice improvement and innovation.^13,20 This is especially true for primary care practices engaging in new opportunities to experiment with alternative payment and delivery models. As a practice setting historically grounded in local communities, primary care needs to balance priorities and needs of community members with a growing number of other groups with vested interest in its performance and outcomes. Emerging federal and state initiatives and policies to improve primary care provide flexibility for participants to operationalize required program elements around local context and need. In the following section, we discuss results from this study and propose pilot interventions aligned with our participant stakeholders’ priorities and needs. Following this, we discuss implications for refining model development and interventions for local primary care innovation and the limitations of this study.

Results from this study indicate that multistakeholder perspectives of their needs and priorities are an important source of ideas and strategies for local innovation in primary care. Identification of both similarities and differences in perspectives illuminates significant opportunities for programmatic innovation and provides rapid immersion in continuous improvement across diverse stakeholder groups. Understanding differences, in particular, may provide critical parameters to challenge traditional assumptions operating in primary care and lead to better solutions.

As expected, the stakeholder groups in this study agreed on some priorities and differed on others. Each of the stakeholder groups prioritized 3 concepts in the CLER 2.0 model, quality health care, wellbeing, and teamwork. All groups identified each of these concepts as important to their primary care experience. The groups shared a common perspective on the major components of quality health care focused on meaningful relationships and healthy outcomes. They differed on the major components of wellbeing and teaming, their perspectives reflective of their different roles in primary care, their perceived accountabilities as well as unique personal situations. Comparison of qualitative and quantitative data showed alignment in these similarities and differences.

The finding of shared perceptions of quality health care and its components is an important one. Shared goals are a foundational aspect of effective teams and organizations.^{29 -31} Participants in team-based and group initiatives need a common objective to organize their efforts and aim them in a common direction. In creative problem-solving, shared priorities like healthy outcomes and meaningful relationships can be used to balance differences and negotiate areas of conflict.

This group of local stakeholders differed in their priorities and needs for wellbeing and teaming. Priorities for wellbeing were diverse, including work-life balance for providers who were bringing time-consuming work home with them at night; psychological safety for members of the clinical team who wanted their opinions respected and their contributions to care acknowledged; and effective hands-on experiences with a balance of autonomy and mentoring for residents and graduate students who wanted to be well prepared for career opportunities. Each of these priorities for wellbeing are well documented in the research on primary care. Lack of work-life balance is one of the most commonly cited reasons for primary care provider turnover and burnout as well as the decline in the number of medical students choosing family practice residencies.^7,8,32 Similarly, research on psychological safety on teams has grown exponentially in the last decade with greater understanding of its impact on team performance and patient outcomes.^33,34 Student satisfaction also has been closely linked to the quality of clinical experiences. ¹⁹

Similar to wellbeing, each of the stakeholder groups in this study held differing expectations for teaming. Their agreement with the importance of teaming at the CLER 2.0 category level masked substantive differences at the thematic level in both the qualitative and quantitative results. The provider group, mostly physicians, prioritized teaming as a vehicle to save time and delegate tasks to others that they felt did not require their level of skill. This view has also been consistently found in the literature especially in comparison of physician and nurse perspectives on teamwork. Studies of physician and nurse perspectives find that physicians tend to be more positive about teams than nurses who report underutilization of their professional knowledge and skills and perceive lower levels of collaboration than physicians.^35,36 The views of residents in this study were similar to physicians suggesting perceptions of teaming may be a part of professional socialization, a finding also supported in the literature.^36,37 Other stakeholders prioritized aspects of teaming related to expanding services for patients or professional learning. Importantly, comments from all of the stakeholder groups appeared to make teaming conditional on its ability to contribute to quality health care and wellbeing goals and to save time, suggesting inherent conflicts in how various stakeholders balance their priorities for quality health care and the perceived costs of teaming. There were few statements that supported a perception of “we team for the sake of teaming.” This aspect of weighing the benefits and costs of teaming prior to engaging is rarely called out in the teaming literature and has significant implications for team effectiveness and sustainability as well as workforce development. None of the clinical teams interviewed for this study had students practicing with them although they expressed considerable value for precepting and learning from students.

Findings suggest opportunities for local innovation in creative integration of common priorities and differences. Both may play different roles in new solutions with common priorities establishing the required foundation of shared goals as a fulcrum for balancing differences. Working with the stakeholders in this study, for example, local innovations would need to bring together different priorities for wellbeing and teaming. Acceptable solutions would need to (1) contribute to meaningful improvements in quality care according to the priorities of each group, (2) promote provider and learner relationships with patients and families, (3) save time, (4) provide patients with information they want and acknowledge their expertise about themselves, and (5) allow learners to apply knowledge and skills consistent with their level of preparation. Using the data from this study, for instance, a new pilot initiative might embed nursing and social work students in primary care teams for brief follow-up visits with interested patients. During these visits, lifestyle modifications and medication management might be prioritized as 2 areas that primary care providers wanted strengthened. Such an intervention would address a significant quality concern, allow providers and learners to have meaningful exchanges with patients, be built into the visit workflow, engage patients, and capitalize on the competencies of nursing and social work students, thus aligning the priorities and needs of each stakeholder group. A similar process of alignment might be used to generate new ways to solve other issues raised in the focus groups, like expanding the use of telehealth or refining the patient portal.

Finding new solutions that integrate diverse stakeholder needs and priorities requires identification and acknowledgment of both similarities and differences. Our results indicate that glossing over differences misses opportunities to enhance stakeholder alignment and problem-solving capacity. It also reduces the likelihood that participants will be willing to challenge their assumptions about their priorities. Areas of difference we found in this study also have the potential to undermine processes key to success of new primary care demonstrations and initiatives. The guidelines for participation in Making Care Primary, a Center for Medicare and Medicaid Innovation Project, for instance, emphasize the importance of incorporating team-based models in value-based care. Differences in priorities and goals for teaming as found here may reduce team effectiveness and impact necessary for programmatic success and sustainability.

The study results also have implications for theory-building and refining models to improve primary care innovation. The CLER 2.0 framework used in this study emphasizes local context and the importance of attending to the many participants interacting in the clinical learning environment as a source of learning and innovation. ¹⁹ Its learning perspective combined with a broad view of stakeholders contributes to uncovering similarities and differences in priorities that, as shown here, may drive or undermine acceptance and implementation of new ideas. CLER 2.0′s broad conceptualization of the practice environment and its participants should provide a useful adjunct to the strong practice focus inherent in primary care specific models. Integrating the contextual and stakeholder features of the CLER 2.0 model with foundational primary care concepts, like continuity and coordination, found in the Patient Centered Medical Home (PCMH) model^38,39 and other models specific to primary care may offer a stronger explanatory model for primary care outcomes, including innovation.

Frameworks for implementation research ⁴⁰ and local innovation ¹³ also offer a rich source of new ideas for understanding and improving adoption and sustainability of innovation in primary care. Like CLER 2.0, the Consolidated Framework for Implementation Research (CFIR), one of the most commonly used models in implementation research, emphasizes the importance of local context in achieving sustainable change noting that “contextual factors can be powerful forces working against implementation in the real world.” (p. 1). ⁴⁰ . The extensive set of contextual concepts, like local conditions, partnerships, and connections, incorporated in CFIR may provide new insights into key antecedents to successful implementation of change strategies in primary care. In concert with CFIR, local innovation models also build on themes of local context and specifically add concepts related to adoption of change and capacity building in resource-limited settings, like primary care. ¹³ Future efforts at model building and testing will be important for guiding change and innovation initiatives in primary care.

Limitations in this study may have influenced the results. Project team members came from several different professions and backgrounds perhaps limiting their common understandings but adding rich diversity to consideration of the problems of primary care. Most were experienced primary care providers and educators. Although we encouraged reflection and discussion of personal and professional beliefs throughout the study as a strategy to reduce bias, it is likely they influenced data analysis and interpretation. Other safeguards were put in place to balance this, including relying on and returning to the participants’ words for guidance in interpretation and discussing interpretations that were more likely to incorporate bias, such as themes related to teaming, with project members from different professions. On the other hand, differences in disciplines and perspectives may have added depth to the study.

In addition, participants were recruited from one large integrated health system and their local academic and community networks. Reliance on convenience sampling, while acceptable in the qualitative descriptive approach,^18,24 may have limited the range of perceptions captured within and across groups. Individuals who assisted in recruiting participants for the focus groups also may have introduced bias into sample selection. Recruiting from several clinics and academic programs may have mitigated this. Although we did not include the complete range of disciplines who may practice as members of primary care teams, we did look across information-rich clinicians, administrators, educators, and students, comparing their views in the context of patient perspectives. Views of primary care team members in areas like behavioral health or social work would be an important addition in future studies. Another limitation was the lack of pilot testing of the interview questions. While there may have been potential confusion about the questions, each of the questions in the interview guide were brief and stated simply, for example, “what is important to you?” Members of the research team facilitated all of the focus groups were available to clarify any of the questions.

Finally, the COVID-19 pandemic necessitated shifting from an in-person format to virtual focus groups. There may have been greater reluctance to speak or build on each other’s comments in the virtual environment although field notes of the facilitators showed that almost all participants in each of the groups spoke during the 1-h sessions. Virtual groups also make attending to non-verbal cues more challenging. On the positive side, participants noted their appreciation for convenience as well as attention to safety, advantages found in reports of qualitative studies with virtual focus groups.^{41 -43}

Conclusions

With the introduction of several new federal and state initiatives, primary care practices now have a significant opportunity to address the problems that have limited their growth and impact for decades. Local innovation plays an important role in assuring that these initiatives and others are operationalized in ways that are meaningful and successful in diverse communities and settings. Findings from this study suggest early identification and comparison of the needs and priorities of multiple local stakeholders provide important insights for practice innovation, including how medical residents and other learners can be successfully integrated into primary care practices. Understanding differences in how multiple stakeholder groups perceive key aspects of their primary care experience, as found here with wellbeing and teamwork, can be used to generate changes that meet the needs and goals of diverse groups while improving critical clinical processes and outcomes.

Supplemental Material

Supplemental Material