1. 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

2. Overview Background/Theory/Model Background/Theory/Model Methods Methods Results Results Conclusions Conclusions Policy Implications Policy Implications

3. Study Focus and Goals Focus shifting from individual to group Focus shifting from individual to group Factors of potential influence: Factors of potential influence: Culture Culture Structure Structure Incentives are temporary; we need sustained change and improvement 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)

4. Theoretical View of Culture Concepts of Culture from Anthropology Themes in Organization and Management Research Concepts of Organizations in Organizational Theory Culture is an instrument serving human biological and psychological needs Malinowskis functionalism Cross-Cultural or Comparative Management Organizations are social instruments for task accomplishment Classical Management Theory

5. Model Inputs Environment Culture Physicians Work Structure Outputs Unit (Group) Individual (Physician) Adaptation of Nadler et al.s Congruence Model

6. Methods Culture Survey Culture Survey Surveyed 1,206 physicians from 57 groups; received 734 from 45 groups (61% response rate) Surveyed 1,206 physicians from 57 groups; received 734 from 45 groups (61% response rate) Structure Survey Structure Survey Surveyed office administrators/managers from 57 groups; received 45 completed surveys Surveyed office administrators/managers from 57 groups; received 45 completed surveys Quality Data from local Insurer Quality Data from local Insurer Regression Analysis Regression Analysis DEA (aka Frontier) Analysis DEA (aka Frontier) Analysis

7. Cultural TraitDescription 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

8. Structure Variables Clinical information system capacity Yes/No Physician profilingYes/No Clinical guideline useScale 0 to 10 BenchmarkingScale 0 to 5 Physician workloadTotal hours per physician per week Practice sizeTotal number of FTE physicians and support staff Nurse PractitionersYes/No

9. Quality of Care Outcome Variables Diabetic Care Diabetic Care Eye Exams Eye Exams HbA1C control HbA1C control LDL control LDL control Cholesterol Management Cholesterol Management High Blood Pressure Management High Blood Pressure Management Adult Well Visits Adult Well Visits

10. Results Descriptive Statistics for Sample (n = 45) Size (in physician FTEs) Percentage 6-1549% 16-3033% 31-4912% 50 +6% Cultural Dimensions Descriptive Statistics (n = 45) Cultural Dimension MeanSD Collegiality3.560.18 Information Emphasis3.170.25 Quality Emphasis3.170.97 Organizational Identity3.020.92 Cohesiveness3.190.96 Business Emphasis2.480.57 Organizational Trust2.930.86 Innovativeness2.290.48 Autonomy2.930.84

11. Results * Dependent Variable = Cholesterol Management Independent Variable Parameter Estimate t Value Pr > l t l Organizational Trust25.863.68.0009 Autonomy-27.59-3.85.0006 Work-1.95-2.62.0134 Nurse Practitioners25.993.12.0039 Adj R-Sq =.4168 Dependent Variable = Well Visits for Adults Benchmarking6.061.950.057 Quality Emphasis8.382.140.037 Innovativeness-10.89-2.130.039 Adj R-Sq =.1181 * Only significant variables presented Culture Structure Culture Structure

12. Conclusions Variance of culture and structure exists among physician groups in MA 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 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 Aspects of structure explain some of the quality of care variations among physician groups in MA A nationwide study should be conducted to strengthen these findings and apply them nationally A nationwide study should be conducted to strengthen these findings and apply them nationally

13. Potential Policy Implications Physician profiling tools need to include culture and structure to support… Physician profiling tools need to include culture and structure to support… Sustained change and improvement Sustained change and improvement Meaningful incentives Meaningful incentives Quality-oriented group processes Quality-oriented group processes

14. Acknowledgements My Committee Members My Committee Members Stanley Wallack, PhD – Chair Stanley Wallack, PhD – Chair John Kralewski, PhD John Kralewski, PhD Christopher Tompkins, PhD Christopher Tompkins, PhD Jody Hoffer Gittell, PhD Jody Hoffer Gittell, PhD Jon Chilingerian, PhD Jon Chilingerian, PhD AHRQ Fellowship/Training Grant AHRQ Fellowship/Training Grant