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Ann Fam Med. 2010 Sep-Oct;8(5):425-32. doi: 10.1370/afm.1159.

Using Learning Teams for Reflective Adaptation (ULTRA): insights from a team-based change management strategy in primary care.

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  • 1Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas School of Public, Dallas, Texas 75390, USA.



The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed.


We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach.


Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practice-wide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines.


Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.

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