The Effect of Physician Group
Culture and Structure on
Quality of Care Outcomes
Amy Smalarz, MHA, PhD Candidate
Academy Health Research Meeting
June 26, 2005
Overview
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Background/Theory/Model
Methods
Results
Conclusions
Policy Implications
Study Focus and Goals
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Focus shifting from individual to group
Factors of potential influence:
 Culture
 Structure
Incentives are temporary; we need sustained
change and improvement
(Kralewski et al., 2003; Hammons et al., 2001; Miller and Bougberg, 2002; Wakefield et al.,
2001)
Theoretical View of Culture
Concepts of
“Culture” from
Anthropology
Culture is an
instrument
serving human
biological and
psychological
needs
Malinowski’s
functionalism
Themes in
Organization and
Management
Research
Cross-Cultural or
Comparative
Management
Concepts of
“Organizations”
in Organizational
Theory
Organizations are
social
instruments for
task
accomplishment
Classical
Management
Theory
Model
Culture
Inputs
Work
Outputs
Structure
Environment
Physicians
Adaptation of Nadler et al.’s Congruence Model
Unit (Group)
Individual
(Physician)
Methods
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Culture Survey
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Structure Survey
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Surveyed 1,206 physicians from 57 groups;
received 734 from 45 groups (61% response rate)
Surveyed office administrators/managers from
57 groups; received 45 completed surveys
Quality Data from local Insurer
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Regression Analysis
DEA (aka Frontier) Analysis
Cultural Trait
Description
Collegiality
Reflects the degree to which there is a shared sense of belonging to a close
knit group of physicians who feel responsible for each other and openly
share information.
Information
Emphasis
Focused on the technical side of the enterprise and expresses the
commitment to information-based clinical practices and the use of
information systems to assist clinical decision making.
Quality Emphasis
Captures the commitment of the practice to uncover adverse patient care
events and to take remedial action
Organizational
Identity
Represents the way physicians view themselves as members of the group
practice organization
Cohesiveness
Captures yet another dimension of the degree to which the cultural values
organize level approaches to patient care
Business
Emphasis
Expresses the degree to which bottom line financial performance and profits
dominate the culture of the practice
Organizational
Trust
Relates to the degree to which the culture is characterized by open
organizational communications and a commitment to structures that
support clinical practices
Innovativeness
Captures the cultural traits related to the degree to which the practice values
being on the cutting edge of medical care and is willing to assume some
risk of regret in doing so
Autonomy
Represents the alternate sides of cultures that are oriented toward various
aspects of collegiality, cohesiveness and organizational identity
Structure Variables
 Clinical information system
capacity
Yes/No
 Physician profiling
Yes/No
 Clinical guideline use
Scale 0 to 10
 Benchmarking
Scale 0 to 5
 Physician workload
Total hours per physician per week
 Practice size
Total number of FTE physicians and
support staff
 Nurse Practitioners
Yes/No
Quality of Care Outcome Variables
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Diabetic Care
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Eye Exams
HbA1C control
LDL control
Cholesterol Management
High Blood Pressure Management
Adult Well Visits
Results
Descriptive Statistics for Sample
(n = 45)
Size (in physician
FTEs)
Percentage
Cultural Dimensions Descriptive
Statistics
(n = 45)
Cultural
Dimension
Mean
SD
Collegiality
3.56
0.18
Information
Emphasis
3.17
0.25
6-15
49%
Quality
Emphasis
3.17
0.97
16-30
33%
Organizational
Identity
3.02
0.92
31-49
12%
Cohesiveness
3.19
0.96
2.48
0.57
50 +
6%
Business
Emphasis
Organizational
Trust
2.93
0.86
Innovativeness
2.29
0.48
Autonomy
2.93
0.84
Results*
Dependent Variable = Cholesterol Management
Culture
Structure
Independent Variable
Parameter
Estimate
t
Value
Pr > l t l
Organizational Trust
25.86
3.68
.0009
Autonomy
-27.59
-3.85
.0006
Work
-1.95
-2.62
.0134
Nurse Practitioners
25.99
3.12
.0039
Adj R-Sq = .4168
Dependent Variable = Well Visits for Adults
Structure
Culture
Benchmarking
6.06
1.95
0.057
Quality Emphasis
8.38
2.14
0.037
Innovativeness
-10.89
-2.13
0.039
Adj R-Sq = .1181
* Only significant variables presented
Conclusions
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Variance of culture and structure exists among
physician groups in MA
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Aspects of culture explain some of the quality of
care variations among physician groups in MA
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Aspects of structure explain some of the quality
of care variations among physician groups in MA
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A nationwide study should be conducted to
strengthen these findings and apply them
nationally
Potential Policy Implications
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Physician profiling tools need to include
culture and structure to support…
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Sustained change and improvement
Meaningful incentives
Quality-oriented group processes
Acknowledgements
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My Committee Members
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Stanley Wallack, PhD – Chair
John Kralewski, PhD
Christopher Tompkins, PhD
Jody Hoffer Gittell, PhD
Jon Chilingerian, PhD
AHRQ Fellowship/Training Grant