Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Veterans Crisis Line Badge
Go to the ORD website
Go to the QUERI website

IIR 05-221 – HSR&D Study

New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects

IIR 05-221
Team Process and Performance in Primary Care
David C. Mohr II PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Funding Period: January 2008 - August 2010

BACKGROUND/RATIONALE:
An increasing trend in health care is to deliver service at the outpatient level. At the end of 2003, VA reported a total of 49.8 million outpatient visits; including 10 million visits to CBOCs. Despite these numbers, a limited number of studies have examined ambulatory health care teams and the characteristics of teams that provide high quality care; most studies have focused on characteristics of groups that are associated with effective inpatient care. To be able to better deal with the changes and demands of the Veteran population, VA managers and team leaders need information on which characteristics of ambulatory health care teams relate to patient care outcomes. Reports on performance are typically provided for the facility-level, but the study proposes to systematically provide information at the team level. A team-based model that examines structure, process, and outcomes is a useful perspective to apply to understand this variation.

OBJECTIVE(S):
The study will examine ambulatory care divisions within hospitals and CBOCs for variation in levels of care delivered and on important team characteristics. We hypothesized that primary care team structure and process characteristics would be positively associated with measures of patient care including patient satisfaction; team assessment of care, and quality of care indicators. We also hypothesized that the type of facility, such as a CBOC or medical center, and type of clinic, such as women's health or general primary care, would also be associated with significant differences. We sought to examine these differences using both quantitative and qualitative methods.

METHODS:
The study used a cross-sectional and longitudinal observational design in the first phase. Patients were used as the unit of analysis and they were nested within primary care teams. We used data from the 2006 and 2007 census administration of the All Employee Survey (AES) to identify the teams. The AES consisted of three sections to assess perspectives at the individual, team and organizational level. Team measures were tested for the strength of their association with measures of patient care. We also examined the level of analysis, individual, team, or facility explained a greater proportion of the variation in patient outcomes. The second phase involved interviews about team-based structure and processes at eight medical facilities. We selected sites based on high, medium, and low performing facilities on patient satisfaction and quality of care indicators. We interviewed approximately 20 primary care team members at each site and also included four teams; two from the medical center and teams from two CBOCs.

FINDINGS/RESULTS:
Results indicated that the organizational climate and individual job satisfaction assessed at the team level are positively related to a composite measure of patient satisfaction and quality of care indicators, although to a lesser extent for the quality of care indicators. Organizational climate was defined using dimensions of task and relational climate. We found relational climate was related to an increased likelihood of diabetes care process adherence, with significant but small effects for adherence to intermediate outcomes. Task climate was generally not shown to be related to adherence. We also found differential effects of these measures based on the level of task complexity. We found some differences in patient satisfaction and quality of care indicators based on physical structure and type of clinic. We also found that team-level variation can explain more variation in technical quality of care than provider- or facility-level variation. The provider-level explained more variation in patient satisfaction. We found themes of team process and team structure to also be pertinent variables to staff perceptions and quality of care during the site visit interviews We observed differences between teams at CBOCs and medical hospitals within the same facility during the interviews as well.

IMPACT:
The findings on important characteristics of primary care teams that affect patient care can be used to develop training and intervention programs focused on those team characteristics that influence patient care in VHA and external settings and how teams may respond better to certain situational constraints and circumstances.

PUBLICATIONS:

Journal Articles

  1. Benzer JK, Beehler S, Cramer IE, Mohr DC, Charns MP, Burgess JF. Between and within-site variation in qualitative implementation research. Implementation science : IS. 2013 Jan 3; 8(1):4.
  2. Mohr DC, Benzer JK, Young GJ. Provider workload and quality of care in primary care settings: moderating role of relational climate. Medical care. 2013 Jan 1; 51(1):108-14.
  3. Young GJ, Beckman H, Baker E. Financial incentives and performance: A study of pay-for-performance in a professional organization. Journal of Organizational Behavior. 2012 Oct 27; 33(7):964-83.
  4. Church KM, Henalt R, Baker E. Comparison of Metoprolol Succinate Versus Carvedilol in Time to Cardiovascular Admission in a Veterans Affairs Healthcare System; An Observational Study. Journal of Health-System Pharmacy Residents. 2012 Sep 28; 1(2):1-8.
  5. Benzer JK, Beehler S, Miller C, Burgess JF, Sullivan JL, Mohr DC, Meterko M, Cramer IE. Grounded theory of barriers and facilitators to mandated implementation of mental health care in the primary care setting. Depression research and treatment. 2012 Jul 29; 2012(1):597157.
  6. Mohr DC, Young GJ, Burgess JF. Employee turnover and operational performance: the moderating effect of group-oriented organisational culture. Human Resource Management Journal. 2012 Apr 1; 22(2):216-233.
  7. Mohr DC, Young GJ. Slack resources and quality of primary care. Medical care. 2012 Mar 1; 50(3):203-9.
  8. Mohr DC, Young GJ, Meterko M, Stolzmann KL, White B. Job satisfaction of primary care team members and quality of care. American journal of medical quality : the official journal of the American College of Medical Quality. 2011 Jan 1; 26(1):18-25.
  9. Mohr DC, Burgess JF, Young GJ. The influence of teamwork culture on physician and nurse resignation rates in hospitals. Health Services Management Research. 2008 Feb 1; 21(1):23-31.
  10. Young GJ, Burgess JF, White B. Pioneering pay-for-quality: lessons from the rewarding results demonstrations. Health care financing review. 2007 Jan 1; 29(1):59-70.
VA Cyberseminars

  1. Mohr DC. Organizational Slack Resources and Quality of Care - HERC Health Economics Seminar. [Cyberseminar]. 2012 Jan 18.
Conference Presentations

  1. Benzer JK, Mohr DC, Stolzmann KL, Meterko MM, White RA, Osatuke K, Nealon Seibert M, Moore S, Charns MP, Young GJ. Collaborating for high performance: A mixed methods study of relational climate, organizational culture, and quality of care. Poster session presented at: Society for Industrial and Organizational Psychology Annual Conference; 2013 Apr 12; Houston, TX.
  2. Mohr DC, Benzer JK, Young GJ. Making the most of limited resources through relational climate: A study of primary care clinic. Presented at: Academy of Management Annual Meeting; 2012 Aug 5; Boston, MA.
  3. White S, Osatuke K, Barnes, S, Mohr DC, Benzer JK, White RA, Dyrenforth S. Strategies Supporting the VA Transition to Patient Aligned Care Teams. Paper presented at: VA HSR&D National Meeting; 2012 Jul 16; National Harbor, MD.
  4. Benzer JK, Cramer IE, Sullivan JL, Mohr DC, Charns MP, Burgess JF. Implementation of Coordinated Mental Health Treatment in Primary Care. Poster session presented at: VA HSR&D National Meeting; 2012 Jul 14; National Harbor, MD.
  5. Benzer JK, Young GJ, Stolzman KL, Osatuke K, Meterko MM, Caso AC, White RA, Mohr DC. Relationships between Organizational Climate and Diabetes Quality of Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
  6. Bilka NJ, Baker E, Hournieh A. A retrospective analysis of telaprevir therapy for chronic hepatitis C virus (HCV) infection Veterans Affairs Boston Healthcare System (VABHS): A pilot study. Poster session presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2012 May 3; Hershey, PA.
  7. Wolf AL, Baker E, Roefaro J. Resolution of tachycardia in critically ill Veterans on levalbuterol versus albuterol: a pilot study. Presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2012 May 2; Hershey, PA.
  8. Benzer JK, Mohr DC, Young GJ, McIntosh NM, Charns MP. Task networks: A unitary theory for conceptualizing interdependence in teams. Paper presented at: Society for Industrial and Organizational Psychology Annual Conference; 2012 Apr 27; San Diego, CA.
  9. Benzer JK, Young GJ, Charns MP, Mohr D. Organizational climates for task direction and relational support: A contingency-based framework. Presented at: Academy of Management Annual Meeting; 2011 Aug 12; San Antonio, TX.
  10. Benzer JK, Young GJ, Charns MP, Mohr DC, Young GJ. Performance implications of organizational climates for task direction and relational support: A contingency-based framework. Presented at: Academy of Management Annual Meeting; 2011 Aug 12; San Antonio, TX.
  11. Mohr DC, Young GJ. Slack Resources and Quality of Primary Care. Presented at: Academy of Management Annual Meeting; 2011 Aug 12; San Antonio, TX.
  12. Nagy MS, Mohr DC, Magley V, Hershcovis S, Belton L. Questioning the Boundaries of Civility and Incivility in the Workplace. Presented at: Society for Industrial and Organizational Psychology Annual Conference; 2011 Apr 16; Chicago, IL.
  13. Benzer JK, Young GJ, Stolzman KL, Osatuke K, White RA, Mohr DC. Relationships Between Organizational Climate and Diabetes Quality of Care. Paper presented at: VA HSR&D National Meeting; 2011 Feb 23; Washington, DC.
  14. Benzer JK, Young GJ, Caso AC, Stolzman KL, Meterko MM, Osatuke K, White RA, Mohr DC. Organizational climate and chronic disease management. Paper presented at: VA HSR&D National Meeting; 2011 Feb 14; Washington, DC.
  15. Young GJ. Have Measures, now What About Payment? Presented at: Agency for Healthcare Research and Quality Annual Conference; 2010 Dec 4; Bethesda, MD.
  16. Mohr DC, Osatuke K, Moore S, Yanovsky B, Brassell T, Nagy M. Organizational survey of workplace climate: Differences in representation across response modes. Poster session presented at: American Evaluation Association Annual Conference; 2010 Nov 11; San Antonio, TX.
  17. Mohr DC, Osatuke K, Brassell T. Changing Nature of Healthcare Performance Measurement. Poster session presented at: American Evaluation Association Annual Conference; 2010 Nov 10; San Antonio, TX.
  18. Young GJ. Medicare Advantage: Aligning the Stars for Health Plans. Paper presented at: Healthcare Education Association Annual Meeting; 2010 Oct 8; Orlando, FL.
  19. Benzer JK, Mohr DC, Meterko MM, Stolzman KL, White RA. Job satisfaction of primary care team members and quality of care. Paper presented at: Academy of Management Annual Meeting; 2010 Aug 6; Montréal, Canada.
  20. Young GJ, Caso AC, Stolzman KL, Meterko MM, Osatuke K, White RA, Mohr DC. Role of primary care team climate in diabetes care. Paper presented at: Academy of Management Annual Meeting; 2010 Aug 6; Montréal, Canada.
  21. Mohr DC, Benzer JK, Young GJ, Nealon Seibert M, White RA. The role of slack resources and influenza vaccinations for primary care practices. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jul 27; Boston, MA.
  22. Mohr DC, Stolzman KL, Osatuke K. Comparing Cancer Screening Rates in VA Divisions with and without Women’s Health Clinics. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 14; Washington, DC.
  23. Mohr DC. Comparing primary care appointment wait time for women Veterans when both general primary care clinics and women’s health clinics are available. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.
  24. Mohr DC. When a patient calls…Relationship between satisfaction with getting an appointment and patient no-show rates. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.
  25. Mohr DC, Stolzman KL, Osatuke K, Meterko MM, Nealon Seibert M. Primary care workload and staffing differences in VA urban and rural practices. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME.
  26. Stolzman KL, Benzer JK, Meterko MM, Osatuke K, Mohr DC. Primary Care Quality and Patient Satisfaction in Rural and Urban Veterans Health Administration Settings. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME.
  27. Bernier NL, Houranieh A, Kaloupek DG, Esses J, Baker EH. Evaluating the efficacy and tolerability of PTSD medications initiated in returning Iraq and Afghanistan Veterans: A Pilot Study. Paper presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2010 Mar 1; Hershey, PA.
  28. Church K, Smith GL, Brennan W, Baker EH. Comparison of Metoprolol Succinate versus Carvedilol in Heart Failure Patients in a Veterans Affairs Healthcare System: A Pilot Study. Paper presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2010 Mar 1; Hershey, PA.
  29. Embran M, Brennan W, Daryanani A, Baker EH. Assessing the relationship of large doses of insulin U-100 to hemoglobin A1c reduction : A Pilot Study. Paper presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2010 Mar 1; Hershey, PA.
  30. Oelrich T, Lazzari A, Roefaro J, DuSault P, Baker EH. Chronic opiate therapy hypopituitarism: A Pilot Study. Paper presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2010 Mar 1; Hershey, PA.
  31. Paquin A, Baker EH, Brophy M, Lubarsky A, Roefaro J, Scagliarini M. Does entrance into a smoking cessation program affect international normalized ratio and warfarin dose? Paper presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2010 Mar 1; Hershey, PA.
  32. Vu T-VT, Ford J, Baker EH. Does Choice of Sleep Medication Have an Effect on the Incidence of New Onset Delirium in Elderly Medical Inpatients? A Pilot Study. Paper presented at: Eastern States Conference for Pharmacy Residents and Preceptors; 2010 Mar 1; Hershey, PA.
  33. Mohr DC, Burgess JF, Young GJ. Employee Turnover and Operational Performance: The Moderating Effect of Culture. Paper presented at: Academy of Management Annual Meeting; 2009 Aug 7; Chicago, IL.
  34. Mohr DC, Charns MP, Meterko MM, Young GJ. The Influence of Service Lines on Physician’s Professional Interest Identification. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
  35. Mohr DC. Evaluating Patient Satisfaction in the Patient Centered Medical Home. Paper presented at: Primary Care Research Methods and Statistics Annual Conference; 2009 Jun 24; Washington, DC.
  36. Belton LB, Hodgson MJH, Meterko MM, Mohr DCM, Moore SCM, Nagy MSN, Osatuke KO, Scrugss RSS. Exploring the Boundaries of Civility and Incivility. Paper presented at: Society for Industrial and Organizational Psychology Annual Conference; 2009 Apr 2; New Orleans, LA.
  37. Stolzman K, Meterko MM, Mohr DC, Shwartz M, White RA. Understanding Variation in Quality Indicator Adherence and Patient Satisfaction in the Department of veterans Affairs. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jan 1; Chicago, IL.


DRA: Health Systems
DRE: none
Keywords: Outpatient, Quality assessment, Satisfaction (patient)
MeSH Terms: none

Questions about the HSR&D website? Email the Web Team.

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.