Perceptions of Specific Clinician
Behaviors Linked to Health Care Quality
Karen Shore, PhD
Roger Levine, PhD
Julia Mitchell, MS
Margarita Hurtado, PhD
Kristin Carman, PhD
Steven Garfinkel, PhD
Jim Lubalin, PhD
AcademyHealth Annual Research Meeting
Boston, MA
June 28, 2005
Funding: Agency for Healthcare Research and Quality (AHRQ)
Overview of Critical Incident Technique
 Systematic, qualitative research method
 Used to collect and analyze reports of
behaviors associated with specific outcomes
 Highly focused on providing solutions to
practical problems
Criteria for A “Good Incident"
 The incident describes a SINGLE behavior
 The behavior is CRITICAL to the outcome
 Another person can understand what is going
on
 Non-essential information is eliminated
 Unstated inferences do not have to be made
Study Goals
 Develop a comprehensive taxonomy of the
components of quality ambulatory health
care, based on both patient and clinician
perspectives
 Use this taxonomy to identify factors
associated with quality care that are not
being assessed in existing CAHPS draft
survey instrument
 Develop draft items for inclusion in CAHPS
survey
Study Design
 In-depth interviews (45-60 minutes)
 Providers (physicians, nurse practitioners, and
physician assistants)
 Patients (4 different race/ethnicity groups)
 Goal of interviews – elicit examples of specific
behaviors that are responsible for good quality
health care or poor quality health care
 Categorize provider and staff behaviors
responsible for the quality of care into a
taxonomy of behaviors
Population Studied
About 20 providers and 80 patients from
each of two geographic locations
(Chicago and Hawaii)
 A total of 3,011 specific behaviors were
collected from 207 respondents

 13.7
specific behaviors/patient
respondent, on average
 17.7 specific behaviors/provider
respondent, on average
Example of Patient Critical Incident
What was the situation?
I went to see an internist for a regular physical.
What happened? What did the person do?
He checked my heart, my glands, my back, my
temperature, my reflexes, etc. It was fast. He
explained what he was doing as he was doing it,
as well as what he was looking for and what he
was not. My blood pressure was a little high. I
told him I do eat a lot of salt. He told me to cut
down on the sodium.
Example of Provider Critical Incident
What was the situation?
A patient with chronic knee pain came in. He was recently
diagnosed as also being diabetic. His most recent lab tests
were abnormal.
What happened? What did you do?
I reviewed his chart about his present complaint and his
family history. I asked him if he knew about diabetes or if he
knew anyone who had it. He knew just the basics. I went over
the lab data with him. I asked him to go through diabetes
education with a nurse-trainer. When he agreed, I made an
in-house referral to diabetes education that is part of our
medical group.
Major Taxonomic Categories
 Clinical skills (34% of  Accessibility/




all incidents)
availability (3%)
 Information seeking
Rapport (28%)
(2%)
Health-related
communication (21%)  Above & beyond
(1%)
Office practices (8%)
 Ethical behavior
Patient advocacy (5%) (<1%)
Examples of Subcategories within
Health-related communication
 Provides literature, diagrams, models, or refers to
websites
 Explains medical condition thoroughly and in terms
patient/caregiver can understand
 Provides information on non-medical ways patient can
care for self (lifestyle changes) or for condition
(includes classes, counseling)
 Gives patient complete and accurate information
and/or instructions regarding tests, treatment,
treatment options, treatment plan, medications, followup care, post-operative care
Findings – Patient Characteristics
(More Likely to Mention)
Provider Behavior
Related to…
Hispanic
+
Health-related communication
Accessibility/availability
Female
++
+++
Clinical skills
Prescribing or recommending appropriate/effective
medication or other treatment
+
++
Giving appropriate referrals
++
Ensuring patients get needed care
Facilitating access to medications or medical supplies
Above and beyond
Age
>50
+
+
+++
Note: +++ = significant at p<.01, ++ = significant at p<.05, + = significant at p<.10
Findings – Patient Characteristics
(Less Likely to Mention)
Provider Behavior
Related to…
Hispanic
Asian or
Pacific
Islander
African
American
+
Courtesy and respect
Giving patient complete
and accurate
information regarding
treatment
+
Ordering tests
+++
Giving appropriate
referrals
+++
Ensuring patients get
needed care
Age
>50
+
Note: +++ = significant at p<.01, ++ = significant at p<.05, + = significant at p<.10
Findings – Patients vs. Providers
(More Likely to Mention)
Provider Behavior Related to…
Patients
Rapport
+++
Engaging patient (e.g., asking about patient
or family)
+++
Providers
Asking questions (rapport or clinical)
+++
Providing information on non-medical ways
patient can care for self or condition
++
Ensuring patients get needed care
+++
Information seeking (e.g., reviewing patient’s
medical records)
+++
Note: +++ = significant at p<.01, ++ = significant at p<.05
Conclusions
 Individuals with different demographic
characteristics appear to value different aspects of
health care quality, as do patients and providers.
 To ensure patient satisfaction with the quality of
care they receive, providers may need to modify
their behaviors or emphasize different aspects of
the encounter based on the demographic
characteristics of the patient.
Policy Implications
 This study presents important information
regarding
….what patients and providers value in a health
care encounter, and
….the extent to which the concept of health care
quality differs by patients’ demographic
characteristics.
 This information can be used
….in quality improvement efforts, and
….in developing policies and practices that
effectively address the areas of greatest concern to
patients.
Contact Information
Karen K. Shore, PhD
American Institutes for Research
kshore@air.org
650-843-8121 (phone)