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Your practice members have the answers; they just need to be heard.

Fam Pract Manag. 2010;17(2):31-34

Dr. Chase is a medical anthropologist and research analyst in the research division of the Department of Family Medicine, Robert Wood Johnson Medical School in New Brunswick, N.J. Dr. Nutting is director of research at the Center for Research Strategies and a professor in the Department of Family Medicine, University of Colorado Health Sciences Center in Denver. Dr. Crabtree is professor of family medicine at the Robert Wood Johnson Medical School, professor of epidemiology at the University of Medicine and Dentistry of New Jersey School of Public Health, and program leader of quality and outcomes in the cancer care program at the Cancer Institute of New Jersey in New Brunswick, N.J. Author disclosure: nothing to disclose. The authors would like to thank Dr. Bijal Balasubramanian for her contributions to this article.

Finding the time, energy and enthusiasm to hold regular, productive meetings may seem like an insurmountable task for your practice. If so, you're not alone. Our research group has explored the common challenges of hundreds of family medicine practices over the last 15 years, and in our most recent study of 60 practices we found that most do not meet consistently and that, when they do, it's rare for input and discussion to involve the entire practice.1,2 To help practices hold meetings that encourage the kind of communication and collaboration required for teams to identify and resolve challenges, we've developed what we call the reflective adaptive process, or RAP.

What is RAP?

RAP is an approach to meetings that uses representation and facilitation to engage staff members from every part of the practice (physicians, nurses and office staff) in improvement efforts. This process also encourages practice members to think and act like a team rather than a loose collective.

Traditional meetings are often spent with office managers or physicians telling staff about new office procedures3 or what not to do.4 This approach sidesteps reflection and limits discussion, and it encourages practices to rush toward implementing a plan that may not be the right plan. Over time, practice members can become weary of the repeated disappointments that are common with this approach.


Progressive Family Care was inundated for years with patient complaints about excessive wait times. A reflective adaptive process (RAP) team discussion revealed that blood draws were overloading the clinical support staff and causing serious backups in the schedule, frustrating both patients and staff. The physicians tried to help ease the problem by rooming patients themselves, but wait times remained unchanged. RAP team reflection revealed that this “solution” was enabling the problem by allowing it to go unfixed. The team then decided to eliminate Tuesday and Wednesday morning blood draws because only one medical assistant (MA) worked during those times.

At the next RAP meeting, the team agreed that the plan seemed to be working. Communication had improved as the MA began telling the physicians what the backup was like throughout the day. The group decided that the physicians and MAs would work together to inform patients of the wait time at the practice's lab or give them a lab slip that they could take elsewhere. In the end, this plan worked. It lessened patient complaints dramatically and created better conditions for both patients and staff.

RAP requires a shift in mindset. It does not emphasize traditional top-down information-sharing but instead encourages staff to attack problems from multiple viewpoints. Team members talk freely about problems and challenges they are facing at work. The group then examines each problem from every team member's perspective. This inclusive approach can help pinpoint why problem-solving attempts have failed in the past, and it can save promising new plans from failure. The facilitator helps the group use quality improvement, brainstorming and prioritization techniques to create new, stronger problem-solving strategies. For example, this process may help to streamline prescription refill requests, enhance patient flow or improve patient wait times (see “The RAP approach in action”).

Laying the foundation

These steps will help you implement RAP in your practice.

  1. Create a team. The team must consist of at least one representative from every part of the practice. Designate a timekeeper and a recorder, or rotate these roles among team members. (See “Key roles.” ) RAP teams can vary in size as long as all parts of the practice are represented. “Incorporate the ‘six Ps’” includes more guidance for RAP teams.

  2. Choose a facilitator. The facilitator should be someone who can model effective communication and moderate conflict. The facilitator should keep conversations focused by asking questions like, “What was our original intent when we started this discussion?” (See “Key roles” for more examples of facilitator responsibilities.) Keep in mind that facilitators should play a neutral role during meetings. This is often difficult for physicians to do. While you may be used to leading, you may not make the best facilitator.

  3. Establish ground rules. The team, and especially the facilitator, can use ground rules to keep the meeting's topics in focus and avoid counter-productive speech. (See “Sample ground rules.”)

  4. Establish a regular meeting schedule. Practices often start by incorporating RAP into their existing meeting schedule or by holding a new breakfast or lunch meeting once a week. After a consistent meeting pattern is established and the team has learned the process, many RAP teams meet twice a month.



  • Advises group of time relative to the agenda,

  • Keeps discussion moving according to time schedule,

  • Warns group when 15 minutes, 10 minutes and 5 minutes of meeting time remain,

  • Helps to ensure that meeting ends on time.


  • Takes notes,

  • Records who has committed to do what,

  • Records plan-evaluation strategies,

  • Types notes and distributes them,

  • Maintains archive of meeting notes.


  • Ensures all parts of practice are represented,

  • Ensures all key roles are filled,

  • Keeps discussion moving,

  • Moderates discussion and makes sure everyone speaks and is heard,

  • Reminds group of ground rules,

  • Keeps focus on system-level problems,

  • Redirects speech away from territory-policing and blaming,

  • Maintains a comfortable environment for open communication, for example, by prohibiting personal criticism and threatening behavior,

  • Keeps group accountable: Asks who will do what, when?

  • Encourages group by reminding them of past successes,

  • Optional: Records key points on flip chart in front of group.


We've found that six words describe teams that are highly successful with the reflective adaptive process:

  • Passionate – Team members express themselves with enthusiasm and intensity.

  • Participatory – Everyone contributes regularly by sharing their opinions and experience.

  • Playful – Debate can give way to laughs and jokes.

  • Pragmatic – Discussions are based on action and accountability (for example, key questions might include “What would it take to test a new problem-solving strategy?”, “Who will be responsible for implementing each part of it?”, “When will the practice try it out?” and “How will the group know it is working?”).

  • Productive – Small problems are resolved in a single meeting, and more complex problems are resolved over several.

  • Persistent – Teams meet regularly, even if there are absences.

Getting started

The initial meeting should be a brainstorming session that produces a list of clinical and administrative problems in the practice.

When the discussion concludes, the group should identify the top three issues using a process such as multi-voting. For example, once the group compiles a list of problems, each team member assigns three points to his or her top priority, two points to the second, and one point to the third. The votes are then tallied, and the issue with the greatest number of points becomes the group's first focus. In subsequent meetings, the group should examine the top problem and create a plan to solve it. Once a change has been implemented, the team considers whether the plan is working by revisiting it and evaluating the results.


  • Be prompt: Start and end meetings on time.

  • Respect others' opinions.

  • Avoid side conversations.

  • Agree to disagree when necessary.

  • Maintain confidentiality regarding sensitive issues.

  • Focus on system-level problems, not on people.

  • Don't point fingers.

  • Keep an open mind.

  • Stay focused.

  • Participate.

  • Distribute minutes and keep co-workers informed.

Keep in mind that RAP group members should make sure everyone in the practice is apprised of the meeting topics and discussions, and they should seek feedback from co-workers. Some practices may benefit from rotating RAP team members so that everyone can participate in the meetings.

We think RAP's emphasis on communication and collaboration can increase the effectiveness of meetings in family medicine practices of all sizes, and we encourage you to give it a try in your practice today.

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