Overview The Effect of Physician Group Culture and Structure on
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The Effect of Physician Group Culture and Structure on Quality of Care Outcomes Overview Amy Smalarz, MHA, PhD Candidate Academy Health Research Meeting June 26, 2005 Theoretical View of Culture Study Focus and Goals Background/Theory/Model Methods Results Conclusions Policy Implications Concepts of “Culture” from Anthropology Focus shifting from individual to group Factors of potential influence: Culture Structure Culture is an instrument serving human biological and psychological needs Incentives are temporary; we need sustained change and improvement 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 Malinowski’s functionalism (Kralewski et al., 2003; Hammons et al., 2001; Miller and Bougberg, Bougberg, 2002; Wakefield et al., 2001) Model Methods Culture Inputs Work Outputs Structure Environment Physicians Unit (Group) Individual (Physician) Culture Survey Structure Survey Surveyed office administrators/managers from 57 groups; received 45 completed surveys Quality Data from local Insurer Adaptation of Nadler et al.’s Congruence Model Surveyed 1,206 physicians from 57 groups; received 734 from 45 groups (61% response rate) Regression Analysis DEA (aka (aka Frontier) Analysis 1 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 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 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 Practice size 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 Total number of FTE physicians and support staff Nurse Practitioners Yes/No Autonomy Represents the alternate sides of cultures that are oriented toward various aspects of collegiality, cohesiveness and organizational identity Quality of Care Outcome Variables Descriptive Statistics for Sample (n = 45) Diabetic Care Size (in physician FTEs) Eye Exams HbA1C control LDL control Cholesterol Management High Blood Pressure Management Adult Well Visits Mean SD Collegiality 3.56 0.18 Information Emphasis 3.17 0.25 49% Quality Emphasis 3.17 0.97 16-30 33% Organizational Identity 3.02 0.92 Cohesiveness 3.19 0.96 Business Emphasis 2.48 0.57 Organizational Trust 2.93 0.86 Innovativeness 2.29 0.48 Autonomy 2.93 0.84 31-49 12% 50 + 6% Conclusions Dependent Variable = Cholesterol Management Structure Percentage Cultural Dimension 6-15 Results* Culture Cultural Dimensions Descriptive Statistics (n = 45) Results 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 Variance of culture and structure exists among physician groups in MA Aspects of culture explain some of the quality of care variations among physician groups in MA Aspects of structure explain some of the quality of care variations among physician groups in MA 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 A nationwide study should be conducted to strengthen these findings and apply them nationally * Only significant variables presented 2 Potential Policy Implications Physician profiling tools need to include culture and structure to support… support… Acknowledgements My Committee Members Sustained change and improvement Meaningful incentives QualityQuality-oriented group processes Stanley Wallack, Wallack, PhD – Chair John Kralewski, Kralewski, PhD Christopher Tompkins, PhD Jody Hoffer Gittell, Gittell, PhD Jon Chilingerian, Chilingerian, PhD AHRQ Fellowship/Training Grant 3
