Linking Structural Capabilities and Workplace Climate in Community Health Centers.

Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (β = -0.47, P = .007), but positively associated with quality infrastructure (β = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (β = 1.09, P = .006 and β = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (β = 1.35, P = .016), but lower electronic record functionality (β = -0.48, P = .015) and less proactive patient outreach (β = -1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs

Impact of Race/Ethnicity and Socioeconomic Status on Risk-Adjusted Readmission Rates: Implications for the Hospital Readmissions Reduction Program

Under the Hospital Readmissions Reduction Program (HRRP) of the Centers for Medicare & Medicaid Services (CMS), hospitals with excess readmissions for select conditions and procedures are penalized. However, readmission rates are not risk adjusted for socioeconomic status (SES) or race/ethnicity. We examined how adding SES and race/ethnicity to the CMS risk-adjustment algorithm would affect hospitals’ excess readmission ratios and potential penalties under the HRRP. For each HRRP measure, we compared excess readmission ratios with and without SES and race/ethnicity included in the CMS standard risk-adjustment algorithm and estimated the resulting effects on overall penalties across a number of hospital characteristics. For the 5 HRRP measures (heart failure, acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and total hip or knee arthroplasty), we used data from the Healthcare Cost and Utilization Project’s State Inpatient Databases for 2011-2012 to calculate the excess readmission ratio with and without SES and race/ethnicity included in the model. With these ratios, we estimated the impact on HRRP penalties and found that risk adjusting for SES and race/ethnicity would affect Medicare payments for 83.8% of hospitals. The effect on the size of HRRP penalties ranged from −14.4% to 25.6%, but the impact on overall Medicare base payments was small—ranging from −0.09% to 0.06%. Including SES and race/ethnicity in the calculation had a disproportionately favorable effect on safety-net and rural hospitals. Any financial effects on hospitals and on the Medicare program of adding SES and race/ethnicity to the HRRP risk-adjustment calculation likely would be small

Linking Structural Capabilities and Workplace Climate in Community Health Centers.

Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (β = -0.47, P = .007), but positively associated with quality infrastructure (β = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (β = 1.09, P = .006 and β = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (β = 1.35, P = .016), but lower electronic record functionality (β = -0.48, P = .015) and less proactive patient outreach (β = -1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs

State-level scope of practice regulations for nurse practitioners impact work environments: Six state investigation.

Nurse practitioner (NP) scope of practice (SOP) policies are different across the United States. Little is known about their impact on NP work environment in healthcare organizations. We investigated the association between SOP policies and organizational-level work environment of NPs. Through a cross-sectional survey design, data were collected from 1244 NPs in six states with variable SOP regulations (Arizona, New Jersey, Washington, Pennsylvania, Texas, and California) in 2018-2019. Arizona and Washington had full SOP-NPs had full authority to deliver care. New Jersey and Pennsylvania had reduced SOP with physician collaboration requirement; California and Texas had restricted SOP with physician supervision requirement. NPs completed mail or online surveys containing the Nurse Practitioner Primary Care Organizational Climate Questionnaire, which has these subscales: NP-Administration Relations (NP-AR), NP-Physician Relations (NP-PR), Independent Practice and Support (IPS), and Professional Visibility (PV). Regression models assessed the relationship between state-level SOP and practice-level NP work environment. NP-AR scores were higher in full SOP states compared to reduced (β = 0.22, p < 0.01) and restricted (β = 0.15, p < 0.01) SOP states. Similarly, IPS scores were higher in full SOP states. The PV scores were also higher in full SOP states compared to reduced (β = 0.16, p < 0.001) and restricted (β = 0.12, p < 0.05) SOP states. There was no relationship between SOP and NP-PR score. State-level policies affect NP work environment. In states with more favorable policies, NPs have better relationships with administration and report more role visibility and support. Efforts should be made to remove unnecessary SOP restrictions

Patient Use of Cost and Quality Data When Choosing a Joint Replacement Provider in the Context of Reference Pricing

Health plans are encouraging consumerism among joint replacement patients by reporting information on hospital costs and quality. Little is known about how the proliferation of such initiatives impacts patients’ selection of a surgeon and hospital. We performed a qualitative analysis of semistructured interviews with 13 patients who recently received a hip or knee replacement surgery. Patients focused on the choice of a surgeon as opposed to a hospital, and the surgeon choice was primarily made based on reputation. Most patients had long-standing relationships with an orthopedic surgeon and tended to stay with that surgeon for their replacement. Despite growing availability of cost and quality information, patients almost never used such information to make a decision

Measuring Workplace Climate in Community Clinics and Health Centers.

BackgroundThe effectiveness of community clinics and health centers' efforts to improve the quality of care might be modified by clinics' workplace climates. Several surveys to measure workplace climate exist, but their relationships to each other and to distinguishable dimensions of workplace climate are unknown.ObjectiveTo assess the psychometric properties of a survey instrument combining items from several existing surveys of workplace climate and to generate a shorter instrument for future use.Materials and methodsWe fielded a 106-item survey, which included items from 9 existing instruments, to all clinicians and staff members (n=781) working in 30 California community clinics and health centers, receiving 628 responses (80% response rate). We performed exploratory factor analysis of survey responses, followed by confirmatory factor analysis of 200 reserved survey responses. We generated a new, shorter survey instrument of items with strong factor loadings.ResultsSix factors, including 44 survey items, emerged from the exploratory analysis. Two factors (Clinic Workload and Teamwork) were independent from the others. The remaining 4 factors (staff relationships, quality improvement orientation, managerial readiness for change, and staff readiness for change) were highly correlated, indicating that these represented dimensions of a higher-order factor we called "Clinic Functionality." This 2-level, 6-factor model fit the data well in the exploratory and confirmatory samples. For all but 1 factor, fewer than 20 survey responses were needed to achieve clinic-level reliability >0.7.ConclusionsSurvey instruments designed to measure workplace climate have substantial overlap. The relatively parsimonious item set we identified might help target and tailor clinics' quality improvement efforts