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Primary care providers are increasingly under pressure to do more with fewer resources. We examined the effect of workload on patients' experiences of quality of care, measured through approximately 44,000 patient experience surveys in a sample of 222 primary care clinics in the Veterans Health Administration. We tested the extent to which relational climate, a measure of teamwork, moderated the relationship between workload and patient ratings of quality of care. Our outcome measures included patient complaints, time spent with provider, and overall visit quality. Workload was negatively associated with patients' quality of care ratings and relational climate moderated the relation between workload and quality of care ratings. Patients seen in clinics with higher workload and greater relational climate reported better care compared with patients in clinics with higher workload but lower relational climate. Findings highlight the importance of relational climate as an important teamwork factor when managing and developing clinic policies, practices, and procedures in resource-constrained settings.

Multistakeholder regional collaboratives have assumed a prominent role in producing public reports about health care providers' performance. I conducted an in-depth study of eight such US collaboratives, examining their accomplishments, management practices, and future challenges. I found that these collaboratives have made key contributions to public reporting and have built trust and cooperation among stakeholders who, in other settings, are competitive or even adversarial. Challenges for collaboratives include securing ongoing funding; negotiating complex and contentious issues around expanded reporting activities, such as publishing measures of providers' efficiency; and establishing more flexible and efficient decision-making processes.

Background: Research generally shows that greater resource utilization fails to translate into higher-quality healthcare. Organizational slack is defined as extra organizational resources needed to meet demand. Divergent views exist on organizational slack in healthcare. Some investigators view slack negatively because it is wasteful, inefficient, and costly, whereas others view slack positively because it allows flexibility in work practices, expanding available services, and protecting against environmental changes., Objective: We tested a curvilinear relationship between organizational slack and care quality., Methods: The study setting was primary care clinics (n=568) in the Veterans Health Administration. We examined organizational slack using the patient panel size per clinic capacity ratio and support staff per provider ratio staffing guidelines developed by the Veterans Health Administration. Patient-level measures were influenza vaccinations, continuity of care, and overall quality of care ratings. We obtained 2 independent patient samples with approximately 28,000 and 62,000 observations for the analysis. We used multilevel modeling and examined the linear and quadratic terms for both organizational slack measures., Results: We found a significant curvilinear effect for panel size per clinic capacity for influenza vaccinations and overall quality of care. We also found support staff per provider exhibited a curvilinear effect for continuity of care and influenza vaccinations. Greater available resources led to better care, but at a certain point, additional resources provided minimal quality gains., Conclusions: Our findings highlight the importance of primary care clinic managers monitoring staffing levels. Healthcare systems managing a balanced provider workload and staff-mix may realize better patient care delivery and cost management.

In recent years, hospitals and payers have increased their efforts to improve the quality of patient care by encouraging provider adherence to evidence-based practices. Although the individual provider is certainly essential in the delivery of appropriate care, a team perspective is important when examining variation in quality. In the present study, the authors modeled the relationship between a measure of aggregate job satisfaction for members of primary care teams and objective measures of quality based on process indicators and intermediate outcomes. Multilevel analyses indicated that aggregate job satisfaction ratings were associated with higher values on both types of quality measures. Team-level job satisfaction ratings are a potentially important marker for the effectiveness of primary care teams in managing patient care.

This article reports six overarching lessons learned from seven pioneering initiatives in the pay-for-quality (P4Q) movement. These lessons relate to the specific design and implementation challenges sponsors of P4Q programs can expect. The lessons are: (1) P4Q can prioritize providers' quality goals, (2) provider engagement is difficult, (3) P4Q escalates concerns for data accuracy and validity, (4) P4Q increases the need for population-based information technology and infrastructure, (5) tradeoffs exist between stimulating investment in quality infrastructure and diluting the power of incentives for individuals, and (6) significant challenges exist in documenting a positive return on investment.

Background: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program., Objective: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians., Participants: There were 334 participating primary care physicians in Rochester, New York., Design: The design of the study is a retrospective cohort study using pre/post analysis., Measurements: The measurements adhere to 4 diabetes performance measures between 1999 and 2004., Results: While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program., Conclusions: This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.

Background: Health care reorganizations, with a change in focus from inpatient to outpatient care, are becoming increasingly frequent. Little is known regarding how reorganizations may affect risk-adjusted outcomes for those programs, usually inpatient, that lose resources as a result of the change in organizational focus., Objectives: To determine changes in risk-adjusted rates of pressure ulcer development over an 8-year period, the final 3 of which were characterized by a significant reorganization of the health care system., Design: This was an observational study that used an existing database., Subjects: Subjects were residents of Department of Veterans Affairs long-term care units between 1990 and 1997 who were without a pressure ulcer at an index assessment., Measures: The study examined risk-adjusted rates of pressure ulcer development, and proportions of new ulcers that were severe (stages 3 or 4) were calculated for successive 6-month periods., Results: Between 1990 and 1994, risk-adjusted rates of pressure ulcer development declined significantly, by 27%. However, beginning in 1995, rates began to increase, and in 1997 they were similar to those in 1990. The proportion of new ulcers that were severe increased significantly over time (P = 0.01)., Conclusions: The reorganization of the VA that began in 1995, with its emphasis on outpatient care, was associated with an increase in rates of pressure ulcer development. This highlights the need to carefully monitor the quality of care in programs that may be losing resources as a result of the reorganization.

Background: There are a growing number of efforts to compare the service quality of health care organizations on the basis of patient satisfaction data. Such efforts inevitably raise questions about the fairness of the comparisons. Fair comparisons presumably should not penalize (or reward) health care organizations for factors that influence satisfaction scores but are not within the control of managers or clinicians. On the basis of previous research, these factors might include the demographic characteristics of patients (eg, age) and the institutional characteristics (eg, size) of the health care organizations where care was received., Objectives: The goal of this study was to examine the extent to which a patient's satisfaction scores are related to both his/her demographic characteristics and the institutional characteristics of the health care organization where care was received., Methods: We conducted an analysis of secondary data from the Veterans Health Administration (VHA), US Department of Veterans Affairs. The database contained patient responses to self-administered satisfaction questionnaires and information about demographic characteristics. Additional data from VHA were obtained regarding the institutional characteristics of the hospitals where patients received their care., Results: Among demographic characteristics, age, health status, and race consistently had a statistically significant effect on satisfaction scores. Among the institutional characteristics, hospital size consistently had a significant effect on patient satisfaction scores., Conclusions: Study results can be interpreted as justifying the need to adjust patient satisfaction scores for differences in patient population among health care organizations. However, from a policy perspective, such adjustments may ultimately create a disincentive for health care organizations to customize their care.