Two heads are better than one, and growing numbers of family physicians are discovering that a “community of practice” is better yet. Defined by organizational theorist Etienne Wenger as “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis,”1 communities of practice hold great promise for practice improvement.
Whether you are practicing in a complex system isolated from your colleagues or a small or solo practice, communities of practice can help you gain a better understanding of how your practice functions as a complex, interconnected, adaptive system in the delivery of care and develop knowledge, innovations and change strategies more quickly.
What is a community of practice?
A fundamental fact often overlooked in our efforts to change and improve how we practice is that what you know depends on who you know. Our knowledge base and practice patterns are, in some measure, the result of our many interactions with colleagues and mentors. When these interactions are ongoing and centered around a specific, shared interest, they are essentially a community of practice.
Communities of practice are “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise on an ongoing basis.”
Family physicians can benefit from communities of practice by learning and working with others to accelerate practice improvements.
Resources are available for finding existing communities of practice and for building your own.
Some examples of communities of practice in family medicine include clubs, committees, associations, academies, study groups, coalitions, e-mail discussion lists, medical staffs of local hospitals and community-oriented primary care groups. Communities of practice can exist in many different forms and professions, but all communities of practice share three key dimensions – a domain of knowledge, a community and a shared practice:2
Domain of knowledge. In a community of practice specific to family medicine, the common domain of knowledge among all of its members may be the specialty of family medicine, a focus on specific populations, performance of specific procedures or a particular need or interest, such as becoming more competitive with other specialties or physicians.
Community. People in a community of practice share a voluntary commitment to relationship building.
Shared practice. In a shared practice, members develop and share knowledge and build expertise by compiling resources, tools and strategies that support future learning for all involved.
Communities of practice organize around one or more of the following functions: peer-to-peer problem-solving, sharing best practices, updating and sharing knowledge for daily practice and generating new ideas and innovations.2
Communities of practice can range in size from several colleagues to a national community of hundreds of individuals. Regardless of their size, successful communities have a number of key functional roles that facilitate the evolution and work of the group. These include a leader or facilitator who keeps dialogue flowing smoothly, experts in the areas around which the community is organized, core members who are active participants in discussions and activities, and “lurkers,” who are members but not regular contributors. Since lurkers often constitute two-thirds or more of the community, they serve as important knowledge resources despite their limited participation.
While communities of practice do have some things in common with teams or committees, communities of practice are distinctly different. Because they are self-organized and self-selected based on expertise or passion for a topic, communities of practice often have fuzzy boundaries and changing membership. In contrast, teams and committees are often created by organizations with a distinct purpose, assigned membership and clear leadership roles. Generally, teams disband when the goal is accomplished, but communities of practice are often sustained for indefinite periods of time.
(See “Meet the community” for an example of what a community of practice in family medicine might look like and how it can benefit its members.)
MEET THE COMMUNITY
To help you better understand what a community of practice might look like and how it can benefit family physicians, here is how one family-medicine-specific community might be described to a new member:
“Welcome to our group! Let us tell you what we do. As you know, we are family physicians from the community who meet here each month to talk about what we are doing in our practices. We discuss common issues and share ideas and approaches to making our practices more efficient and effective. n addition to our monthly meetings, we communicate with each other through an e-mail discussion list that one of our members started. He also started a Web site for the group that allows us to post questions, ideas or practice tools. Our goal is to be more competitive with the large, hospital-owned primary care network in our community by putting our heads together, sharing what we know and sometimes testing new ideas out together. We have recently started pooling data from each of our practices to identify our opportunities for improvement.
"One of the members of our group has been participating in a chronic-disease collaborative where he works with other primary care physicians to find new ways of improving care for patients with diabetes and asthma. At one of our recent meetings, he shared with us some of the tools he had come across in his collaborative work – chart-tracking tools, patient-education materials and disease-registry software.
"Another one of our members is particularly interested in financial-incentive programs for family physicians and recently attended an AAFP seminar on the topic. He will be talking with us today about pay-for-performance pro grams in our community. Also, the medical director for one of our local health plans will be here to explain what his plan’s new physician incentive program is and how we might participate.
“We are pleased that you are joining our community. We look forward to learning from you, working on problems together and improving how we practice family medicine.”
Finding communities of practice
Communities of practice are everywhere. We participate in them at work, at school and in our spare time. The key is to ensure that you find one that best fits your needs. Ask yourself the following questions about your practice before you begin your search:
What do I want to excel in the most?
What am I most passionate about?
What are the most important sources of revenue?
Do I want to interact only with family physicians or also with physicians from mul tiple specialties and health care professionals from different training backgrounds?
Do I want to interact with other family physicians locally, state-wide or nationally?
With your answers to these questions in mind, you should be ready to start locating potential communities of practice. Begin by looking for groups within your own practice or organization that are already meeting regularly to improve specific aspects of practice. You can widen your search by contacting any of the following resources:
Medical societies you belong to may be able to direct you to communities of practice in your area of interest and may also have an e-mail discussion list you can use to post your interest and identify family medicine communities. They may also offer courses or other programs that can bring physicians together into communities of practice. For example, the AAFP offers several e-mail discussion lists for those interested in practice management, EMRs and clinical topics, among others. Academy members can subscribe by accessing https://www.aafp.org/resources.xml and then clicking on “E-mail Discussion Lists.” The AAFP also has sponsored a quality improvement project developed and facilitated by the National Initiative for Children’s Health Care Quality (NICHQ). Participants in the program attended learning sessions and also shared information and questions via conference calls and an e-mail discussion group. See https://www.aafp.org/x3851.xml for information about this and other AAFP quality initiatives.
Quality Improvement Organizations (QIOs) are federally funded state organizations, formerly known as peer-review organizations, that provide outreach and support to physicians and medical groups. They organize topic-specific improvement collaboratives and provide a number of well-validated practice tools, such as disease-registry software programs, patient-education tools and disease-management guidelines. QIOs can also provide assistance in assessing and improving your office practice and getting involved with other physicians and health care organizations in system-improvement efforts, such as pay-for-performance, information technology and chronic disease initiatives. Contact information is available for each state’s QIO at http://www.medqic.org/content/qio/qio.jsp?pageid=4.
Collaboratives are self-selected individuals or groups of practices with a common aim who meet to specifically improve a target area in practice (e.g., chronic disease management, access to care, office efficiency). Participants test well-validated, community-shared ideas, tools and interventions for process improvement in their practices. Collaboratives are organized and supported by a number of organizations, such as the QIOs mentioned above, the AAFP, the Institute for Healthcare Improvement (http://www.ihi.org/), the Bureau of Primary Health Care for federally qualified community health centers (http://bphc.hrsa.gov/), the Indian Health Service (http://www.ihs.gov/), the Group Practice Improvement Network (http://www.gpin.org/) and the American Medical Group Association (http://www.amga.org/).
Building your own community of practice
If you can’t find a community of practice that meets your specific needs, consider working with others to build your own community. According to Wenger, the goal of community design is to bring out the community’s “own internal direction, character and energy.”1 In keeping with this goal, he developed a list of core principles for cultivating communities of practice:
Design for evolution. Anticipate changing membership and focus areas. Build as you go, and change as needed.
Open dialogue between inside and outside perspectives. Open the community to others by inviting new members or expert participants. Encourage members to attend outside medical education meetings and share what they learned with the community. Develop ways of bringing new evidence, tools and ideas into the community.
Invite different levels of participation. Allow members to participate as much or as little as they choose based on their available time and interest. Seek to cull the knowledge of lurkers.
Develop public and private community spaces. Communities of practice are more than a calendar of meetings; they are, in essence, networks of relationships that add value to the work of a family physician. Encourage opportunities to work together as a group (e.g., in a collaborative) and to work together as individuals (e.g., using an idea from the community in an individual practice).
Focus on value. Continually assess whether community activities are providing value to the members. Drop what doesn’t add value; try new activities that have the potential for value.
Combine familiarity with excitement. In addition to supporting regular interaction and work, look for opportunities to “stir the pot.” For example, invite a managed care plan’s medical director or an expert outside of family medicine to a meeting.
Create a rhythm for the community. Keep the pace of work within the community at a level that is comfortable to members, recognizing this pace should change with the needs of the membership. For example, you may choose to meet only through e-mail or an online chat room during peak influenza season, or you may choose to meet more frequently when new Medicare regulations have been released so that you can design strategies to manage changing demands.
As you begin building your own community of practice, you may also find it useful to look at specific models other organizations have used for the same purpose. For example, the U.S. Navy is actively building and supporting a diverse array of communities using a seven-stage model. In addition to naming each of the stages in the process and listing the benefits and constraints of each stage, the model also identifies the key questions you need to ask yourself along the way:
Why are we forming?
Who will participate?
What will we share?
How will we interact?
What will we impact?
How will new knowledge be found and used?
How will the community evolve to meet new choices and challenges in practice?
To view and learn more about this model, go to http://openacademy.mindef.gov.sg/openacademy/central/html%20folder/km/bcp and click on Development Model, Model Overview and then CoP Development Model.
Finally, some other tips to keep in mind as you take the first steps toward building your own community include the following:
Write a community charter that clearly describes the group’s aims and process.
Develop a mix of interaction methods by varying the location, frequency and type of meetings. For example, instead of relying solely on face-to-face meetings, consider using technology to hold some meetings by conference calls, e-mail, chat rooms or Web sites.
Plan agendas that emphasize interaction, sharing and learning while also offering occasional didactic elements.
For more information on building and maintaining communities of practice, see “Resources.”
Meeting the challenges
To meet the challenges we face as family physicians in the 21st century, we must acquire the skills and knowledge base to continually improve the way we care for our patients and to demonstrate our outcomes to patients, payers and ourselves. Communities of practice offer opportunities for learning and improving practice processes that we could never achieve working in isolation. Whether you join an existing community or start your own, communities of practice offer a way of learning and working together that can accelerate improvement in your practice and allow you to stay ahead of the pack in the health care marketplace.
To learn more about communities of practice and how you can build your own, check out the following resources:
Cultivating Communities of Practice. Wenger E, McDermott R, Snyder WM. Harvard Business School Press; 2002. A guidebook to developing communities of practice in organizations.
Communities of Practice: Learning, Meaning, and Identity. Wenger E. Cambridge: Cambridge University Press; 1988. A framework for how to foster innovative ways of learning.
CPsquare (http://www.cpsquare.org). An online “community of communities” started by Etienne Wenger, one of the leaders in the field of community of practice, that includes resources and a health-care-specific community page.
Community Intelligence Lab (http://www.co-i-l.com). Articles, models and other electronic resources for groups interested in organizing communities of practice.
Community of Practice Resources (http://home.att.net/~discon/KM/CoPs.htm). Introductory explanations and definitions of communities of practice as well as a helpful start-up kit for those interested in building their own communities.
Community of Practice Practitioner’s Guide (http://knowledge.usaid.gov/documents/cop_practicioners_guide.pdf). A longer, more in-depth manual developed by the U.S. Navy for starting and managing communities of practice.