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IIR 01-185 – HSR&D Study

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IIR 01-185
Evidence Based Approaches to Primary Care Staffing
Richard G. Best PhD MS BS
South Texas Health Care System, San Antonio, TX
San Antonio, TX
Funding Period: July 2003 - June 2005

BACKGROUND/RATIONALE:
VHA has shifted a large portion of its resources from inpatient to outpatient care and within outpatient care to establishing primary care as the backbone of its array of services. Although the Institute of Medicine (IOM) compiled its first definition of primary care in 1978, since that time fewer than expected advances have occurred in describing optimal methods for delivery of the services that comprise primary care. In particular, the nature of the tasks that comprise primary care and the most effective and efficient staffing mixes and job design to accomplish the tasks are not yet well described. Functional Job Analysis provides the means to conceptualize and operationalize primary care work in order to address initiatives for high quality, efficient primary care using an evidence-based tool.

OBJECTIVE(S):
We used well-established job design theories and functional job analysis methodologies to: 1) Describe the content of primary care tasks done in a range of VHA primary care settings (i.e., using Subject Matter Experts within primary care settings; 2) Verify the tasks performed by each primary care job title using a survey checklist method; and 3) Perform responsibility allocation trade off modeling based on the data generated in objectives 1 & 2. Allocation of tasks in primary care will be optimized for task complexity and autonomy, and the effect on cost, employee satisfaction, and patient satisfaction will be modeled.

METHODS:
The first phase of this project involved qualitative focus groups among job incumbents to develop a database of task statements that comprehensively describe the work of primary care in VHA. We interviewed subject matter experts from a range of primary care jobs (i.e., MD, NP/PA/PharmD, RN, LVN, Health techs and MAS) in a series of focus groups across geographically dispersed sites. Certified job analysts rated each task statement along eight dimensions: (data, people, things, reasoning, math, language, autonomy, and human error consequence). We then invited the full array of primary care personnel from each of the participating sites to complete a survey-based checklist of the entire set of task statements as a way to validate the comprehensiveness of this database. Respondents indicated whether or not they perform each task, as well as the frequency, duration and importance of performing those tasks. These results will be used to model, or simulate potential changes in staffing and job design and the impact of these changes on personnel costs, employee satisfaction, and patient satisfaction.

FINDINGS/RESULTS:
In the first phase of our project, we engaged 8 VAMC facilities representing a variety of characteristics such as academic affiliation, size, and degree of service line implementation. We emphasized a participatory action research design to facilitate and sustain local participation during the focus groups. We conducted a training workshop for the particiapting sites to instruct in the theory and use of functional job analysis techniques. The results of the focus groups yielded 243 task statements across the primary care job titles targeted for this project (see above). Preliminary results of the task analyses suggest findings such as, although the preponderance of work performed by physicians has a moderately high consequence of error, there is little discretion in the performance of these tasks.

IMPACT:
Responsibility allocation trade off modeling could be used at the facility level to aid staffing decisions in primary care and at the VISN and national level to inform policy regarding staffing needed to perform primary care.

PUBLICATIONS:

Journal Articles

  1. Hysong SJ, Best RG, Moore FI. Are we under-utilizing the talents of primary care personnel? A job analytic examination. Implementation science : IS. 2007 Mar 30; 2:10.
  2. Best RG, Hysong SJ, Pugh JA, Ghosh S, Moore FI. Task overlap among primary care team members: an opportunity for system redesign? Journal of Healthcare Management / American College of Healthcare Executives. 2006 Sep 1; 51(5):295-306; discussion 306-7.
Conference Presentations

  1. Hysong SJ, Best RG, Pugh JA. Overlap of job tasks in VHA primary care: implications for staffing and clinic efficiency. Poster session presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA.
  2. Hysong SJ, Best RG, Moore FI. Patient safety in primary care: the relationship between human error consequence and physician discretion. Paper presented at: AcademyHealth Annual Research Meeting; 2005 Jun 26; Boston, MA.
  3. Best RG, Moore FI, Hysong SJ, Zugec L. Participatory action research in primary care settings [seminar]. Paper presented at: Primary Care Research Methods and Statistics Annual Conference; 2004 Dec 3; San Antonio, TX.
  4. Best RG, Moore FI, Hysong SJ. Advances in Academic-Practitioner Collaborative Action Research Learning [workshop]. Paper presented at: Academy of Management Action Research Community Program Annual Practitioner Series; 2004 Aug 7; New Orleans, LA.
  5. Best RG, Hysong SJ. Exploring Organizational Knowledge Creation Using a Mixed Methods Approach. Paper presented at: Primary Care Research Methods and Statistics Annual Conference; 2003 Dec 5; San Antonio, TX.


DRA: Health Systems
DRE: none
Keywords: Organizational issues, Primary care, Staffing
MeSH Terms: none

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