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Health Services Research & Development

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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

1004 — Assessing Clinic Member Relationships and Implications for Quality in VA Primary Care

Finley EPPugh JALanham H, and Leykum L, South Texas Veterans Health Care System/University of Texas Health Science Center at San Antonio; Veerapaneni P, University of Texas Health Science Center at San Antonio; Parchman ML, Agency for Healthcare Research & Quality;

Since the mid-1990s, improving staff and provider relationships within primary care (PC) settings has been recommended as a strategy to improve quality of care. Research and implementation efforts, however, have been stymied by the absence of an instrument to assess clinic member relationships. Our goal was to assess relationships within PC clinics using a newly developed scale, with the aim of exploring the role of relationships in shaping the quality of PC delivery.

We developed the Clinic Member Relationships Scale (CMRS) based on prior work in this area. The CMRS was administered as part of a mixed-method study of learning and relationships conducted among 18 VA PC clinics in South and Central Texas. 305 staff and providers completed the clinic member survey, and 247 participated in semi-structured interviews.

The 15-item CMRS has excellent internal reliability (Cronbach’s alpha = 0.95) and represents a unidimensional construct (Eigenvalue = 9.4). Significant differences in CMRS scores emerged between clinics, although within-clinic differences (Int = 206.37, p <.0001) exceeded between-clinic differences (Int = 65.9, p <.01). Higher clinic-level CMRS scores were associated with lower within-clinic variability in CMRS scores (-.772, p <.001). In qualitative analysis of interviews conducted in the 6 clinics with lowest and highest CMRS scores, low-scoring clinics were characterized by: less face-to-face communication; poor task coordination, particularly across services; a lack of perceived trust and respect across clinic roles; and communication perceived as primarily one-way (“top-down”). High-scoring clinics exhibited: frequent face-to-face communication; cross-service commitment to teamwork; and perceived trust, respect, and open communication across clinic roles. Participants drew direct links between strong clinic relationships and the ability to learn and adapt to the challenges of delivering high-quality primary care.

The CMRS shows promising validity as a measure assessing the quality of relationships in PC settings. PC clinics with poor relationships report greater variability in clinic member perceptions of relationship quality. Teamwork and strong clinic relationships emerged as central to learning and adaptation in the PC setting, with implications for quality of care.

Relationships play an important role in shaping care delivery, and should be assessed as a standard piece of any effort to improve organizational learning and patient care within VA PC settings.

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