The way in which we conceptualize the basic nature of the primary care clinic (PCC) greatly influences our beliefs and ideas about what should work to improve its operations. If we view it as a production line, then we design our improvement efforts using systems engineering techniques aimed at standardizing, reducing variation, and improving efficiency. If instead we view the PCC as a complex adaptive system, then we might design our improvement efforts using methods designed to embrace rather than eliminate surprise (which is inevitable in health care settings), to enhance the connections and communication between the individuals in the PCC rather than focusing on improving the skill sets of the individuals, and to use feedback and time for reflection as part of a strategy for the PCC to make sense of their own operations and behaviors in relation to their mission and goals. In this study we observed, developed or refined measures of, and identified potential points for intervention for two of the five complex adaptive system characteristics: learning and relationships.
1. Describe the nature and roles of learning and relationships in 17 VA primary care clinics. We anticipated that there would be variance in the nature and roles of learning and relationships present among the 17 clinics and that it would be possible to identify patterns of relationships and learning within each clinic. 2. Analyze the relationship between the nature and roles of relationships and learning in VA primary care clinics and the clinics' performance across multiple outcomes including clinical outcomes and patient satisfaction. 3. Using an iterative process with the clinics, identify locally acceptable and feasible interventions as well as potential barriers and facilitators to improving learning and relationships in VA primary care clinics.
Research Propositions: 1. High performing VA primary care clinics will exhibit higher quality relationships and more active learning than low performing clinics, across a variety of performance outcomes. 2. Higher quality relationships will be associated with higher patient satisfaction with care.
We conducted a descriptive, iterative study of 17 VA primary care clinics in VISN 17, using ethnographic, qualitative, and quantitative data collection methods. A profile was developed for each clinic based on ethnographic observations conducted during 3-5 day clinic visits. Key informants were selected for each clinic based on these observations and those who consented participated in in-depth qualitative interviews regarding the nature of learning and relationships within the clinic. These qualitative data have been analyzed by the research team in terms of emergent themes and dimensions of learning and relationships previously described in the literature. Staff and providers within each clinic were also invited to participate in a clinic member survey that included measures assessing learning, relationships, and relational coordination. Additional outcomes were derived from a patient survey mailed to patients of each clinic, as well as administrative data sources including VISTA and the VA Survey of Health care Experiences of Patients (SHEP). Associations between patient outcomes and the nature of relationships and learning within clinics were explored qualitatively and quantitatively. Findings for each clinic were presented back to clinics for feedback and discussion.
We completed profiles of 17 VA primary care clinics in South and Central Texas, including interviews with 247 clinic members and surveys collected from 457 clinic members and 7402 patients. Both qualitative and quantitative analysis is ongoing. Findings and products to date include the following:
1. As predicted, we identified significant variation in learning and relationships across clinics. We developed and validated a 15-item measure to assess work relationships in VA primary care clinics, the Work Relationship Scale (WRS). We are also in the process of conducting factor analysis and validation on a distinct scale of learning-related items, for which preliminary analysis also reveals significant variation across clinics.
2. Also as predicted, we found a significant association between clinic WRS scores and outcomes associated with patient satisfaction and quality of care, specifically patient ratings for Overall Rating of Personal Doctor/Nurse (r2=0.43, p<.01) and Overall Rating of Healthcare (r2=0.25, p<.05). We also found an association with WRS scores and self-rated health (SF1) (P<.0001).
3. We identified characteristics of complex adaptive systems emergent within these clinic settings, particularly the seven characteristics of work relationships (e.g., trust, respect, rich vs. lean communication, mindfulness, etc.) previously identified in the literature (Lanham et al., 2009). All seven characteristics were emergent in qualitative clinic profiles. Moreover, clinics with more positive working relationships as assessed by the WRS were more likely to show marked presence of these characteristics, while clinics with poorer working relationships as assessed by the WRS were likely to show marked absence of these characteristics.
4. We have not found significant relationships between WRS and chronic disease outcomes (e.g., HbA1C, systolic blood pressure, LDL, prevention measures, etc.) or clinic functioning (e.g., wait times, patient experiences of hassles in receiving care). Based on qualitative analysis to date, we believe that the VA's use of evidence-based practice guidelines, performance measures with feedback, and extensive use of the electronic health record, including clinical reminders and patient registries, may function to promote high quality chronic disease outcomes across markedly varied clinic settings.
5. We have achieved a deeper understanding of the specific circumstances in primary care which are most influenced by staff relationships and learning (urgent complaints and symptoms and individual patient interactions) whereas routinized care (annual screening exams, medication titration, etc.) is less dependent on these.
Our ultimate goal was to improve the health of veterans by designing interventions at the clinical microsystem level that would capitalize on the characteristics of complex adaptive systems rather than work against them. Working to improve clinic member relationships may be an important component of improving patient perception of well being (SF1) and satisfaction with VA care. Developing and implementing strategies to improve relationships among staff in clinics may facilitate the realization of more patient centered care within the VHA, a system-wide goal. Our next efforts will be focused on working with our clinical partners to help design such interventions.
Through multiple somewhat redundant mechanisms, the VA has been able to achieve high performance on the more routine aspects of primary health care across a wide variation in staff relationships and learning. These mechanisms should be maintained although downsides to patient interactions should be understood as well (based on our qualitative data).
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- Pugh JA, Finley EP. Developing effective surveys: how to develop, deploy, and analyze a survey. Paper presented at: Society of Hospital Medicine Annual Meeting; 2012 Apr 4; San Diego, CA.
- Lanham HJ, Parchman ML, Palmer R, Noel PH, Arar NH, Leykum L. The role of reciprocal learning in high performing primary care teams. Poster session presented at: North American Primary Care Research Group Annual Meeting; 2011 Nov 14; Banff, Canada.
- Arar NH. Identifying Learning Patterns in Primary Care Clinics at the VHA: Implications for PACT. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 13; Seattle, WA.
- Arar NH, Leykum L, Lanham HJ, Finley EP, Parchman ML. Identifying learning patterns in primary care clinics at the VHA: implications for PACT. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
- Finley EP, Lanham HJ, Leykum L, Arar NH, Veerapaneni P, Parchman ML. Patient perceptions of clinic member relationships: How much do Veterans know about what goes on in VA primary care clinics? Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
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