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Publication Briefs

Study Examines Relationship between Resources and Quality of VA Primary Care

Much research has been devoted to understanding the relationship between resource use and the quality of healthcare services. This study examined the relationship between resource use and care quality in VA primary care clinics using the concept of organizational slack. Organizational slack is defined as extra organizational resources (i.e., staff, budget, equipment) available to meet a given level of demand. Divergent views exist about organizational slack’s role in healthcare: some view it as allowing greater flexibility and innovation (i.e., expanding services, engaging community outreach); while others view it as wasteful and inefficient (i.e., extra resources may divert benefits away from patients). Using VA administrative data for 568 VA primary care clinics from 10/06 through 3/07, investigators assessed organizational slack using two measures in accordance with VA staffing guidelines: 1) patient panel size per clinic capacity, and 2) support staff per provider. Investigators used VA guidelines that recommend 1,200 patients per full-time physician and 900 patients for non-physician providers (e.g., nurse practitioner, physician assistant), with an average of two support staff per provider. Investigators selected three variables to capture different dimensions of quality of care that are potentially sensitive to organizational slack resources in primary care settings: influenza vaccination, continuity of care, and quality of care ratings.


  • Veterans seen in VA primary care clinics where staffing was below the recommended level were more likely to experience lower quality of care.
  • Although some level of organizational slack resource for staffing was associated with better quality of care, additional staffing – beyond guideline recommendations – exhibited diminished returns. Thus, the addition of staffing resources in primary care clinics contributed to higher levels of quality, but only to a point, at which more staff appeared to make only minimal contributions to quality.


  • Findings are relevant to understanding the cost and benefits of adding staff to new models of primary care, such as panel management and the Patient-Aligned Care Team (PACT). Also, staff cost and quality trade-off issues may be an increasingly important issue in future policy discussions.


  • This study did not account for certain staffing-sensitive measures, such as vacancies, job rotation, or turnover rates, which may be mediators or moderators between organizational slack and quality relationships.
  • Aggregate clinic scores were used for staffing measures; however, variations in patient panel size and case mix among individual providers has been shown to influence clinical performance rankings.

This study was funded by HSR&D (IIR 05-221). Drs. Mohr and Young are part of HSR&D’s Center for Organization, Leadership and Management Research in Boston, MA.

PubMed Logo Mohr D and Young G. Slack Resources and Quality of Primary Care. Medical Care December 20, 2011;e-pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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