In recent years, there has been a growing understanding that organizational culture is related to an organization's performance (Davies, Mannion, Jacobs, Powell, & Marshall, 2007; Gifford, Zammuto, & Goodman, 2002; Scott, Mannion, Davies, & Marshall, 2003a). As a result, health care reform proposals have called not only for structural changes in the way health care is delivered but for cultural changes as well (Scott, Mannion, Davies, & Marshall, 2003b). Organizational culture in health care organizations has gained increased consideration as an important factor that influences the quality of health care (Scott et al., 2003b). The interest in organizational culture is related to the recognition that cultural changes are needed alongside the structural changes to establish gains in quality care. Two landmark reports from the Institute of Medicine, "To Err is Human" (Institute of Medicine, 2000) and "Crossing the Quality Chasm," have stressed the relevance and importance of organizational culture for supporting quality care (Institute of Medicine, 2001). In this article, we described a study that examined the role of organizational culture in predicting job satisfaction and perceived clinical effectiveness among pediatric primary care providers.
Although there has been increased interest in organizational culture as an important factor in quality of health care, there is little consensus regarding the meaning of the term. Definitions of organizational culture include a wide range of social phenomena such as values, behaviors, and assumptions shared by members of an organization or a social group (Scott et al., 2003a). Schein (1990) described culture as a pattern of basic assumptions invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration that has worked well enough to be considered valid and therefore to be taught to new members as the correct way to perceive, to think, and to relate to those problems.
Some studies have shown associations between organizational culture and such performance outcomes as provider satisfaction (Zazzali, Alexander, Shortell, & Burns, 2007), medication administration error reporting (Wakefield, Blegen, Uden-Holman, Vaughn, Chrischilles, & Wakefield, 2001), quality of diabetes care (Bosch, Dijkstra, Wensing, van der Weijden, & Grol 2008), and initiating quality improvement practices (Shortell et al., 1995). However, several other studies have not established a link between culture and performance (Hann, Bower, Campbell, Marshall, & Reeves, 2007). This inconsistency across studies is best explained not only by the variety of settings in which organizational culture and quality in health care has been examined but also by the absence of a generally accepted framework that allows for a consistent approach to the conceptualization and measurement of organizational culture.
The Competing Values Framework offers a useful conceptual lens from which to view organizational culture. This framework has been widely used to assess organizational culture in health care organizations and its association with various health care outcomes (Helfrich, Li, Mohr, Meterko, & Sales, 2007; Scott et al., 2003a). The framework identifies four idealized culture types: group, developmental, hierarchical, and rational. A group culture emphasizes teamwork, cohesiveness, and participation. The developmental culture is one that promotes innovation and risk taking. The rational culture promotes achieving competitive advantage, and employees are rewarded for acquiring the needed resources to meet organizational goals. Hierarchical culture emphasizes stability, rules, and regulations, where leaders are supported for emphasizing order. Every organization's culture reflects these four cultural types to some degree, and the competing values framework allows an organization to assess where it stands with regard to each dimension.
To date, relatively few studies have examined organizational culture in medical group practices. It has been argued that organizational culture may hold greater salience in small physician group practices because they typically lack the formalized structure of a large health care organization; as a result, culture may be an especially important determinant in health care performance (Zazzali et al., 2007). Recent studies in physician practices have found that organizational culture is associated with physician job satisfaction (Zazzali et al., 2007) and reduction in medication errors (Kaissi, Kralewski, Dowd, & Heaton, 2007). Although the research that has examined the contribution of organizational culture in medical group practices shows promise, a stronger evidence base is required to elucidate the role of organizational culture on performance of physician practices. This study seeks to further this evidence by applying the Competing Values Framework to examine the relationship of organizational culture on provider job satisfaction and perceived clinical effectiveness in pediatric primary care practices. We hypothesized that a group-oriented culture in a pediatric primary care practice will be associated with provider job satisfaction and perceived clinical effectiveness because this culture emphasizes teamwork and shared decision making.
Design and Study Sample
This cross-sectional study represented baseline data drawn from a randomized, controlled trial (clinical trial no. NCT00345514) that compared practitioner- and organization-focused interventions designed to enhance the implementation of asthma practice guidelines. Primary care pediatric practices were eligible for entry into the study if practice providers and staff had been trained and were using Easy Breathing, an asthma management program for primary care clinicians based on the National Asthma Education and Prevention Program (Cloutier,Hall, Wakefield, & Bailit, 2005; Cloutier, Wakefield, Hall, & Bailit, 2002). Forty-six practices in Hartford, New Britain, and Waterbury, Connecticut, and the surrounding areas were invited, and 36 agreed to participate.
All staff in the practice was eligible to participate in the study. Staff was characterized as either clinicians or nonclinicians. Clinicians were those in the practice responsible for the diagnoses and treatment of patients such as physicians and midlevel practitioners (e.g., advanced practice registered nurse [APRN], pediatric nurse practitioner [PNP], or physician's assistant [PA]). Nonclinicians were all other staff in the practice (e.g., administrative support personnel [billing, filing, and receptionist], office managers, nurses, and medical assistants). The study was approved by the institutional review boards at the University of Connecticut Health Center and the Connecticut Children's Medical Center.
The practice office manager, in consultation with the senior physicians, completed a questionnaire that collected information regarding practice characteristics, such as ownership, size, staffing, payment methods, and patient volume. All clinicians and nonclinical staff in the participating practices who agreed to participate completed a series of questionnaires designed to assess clinician and staff characteristics and perceptions related to organizational characteristics. Questionnaires were completed by study participants during a lunchtime session, which typically took 25 minutes. Questionnaires were left at the practice for those who were unable to attend the session. A research assistant visited each practice distributing and collecting completed questionnaires. The presence of the research assistant in the practice allowed participants to address any questions they had about the study or the questionnaires. Incentives for completing the questionnaires included lunch and a raffle for a gift card to a local restaurant or bookstore.
Information about practice characteristics was obtained from the office manager and consisted of the ratio of full-time (defined as 40 hours per week, full-time equivalent) nonclinicians (receptionist, billing personnel, etc.) to full-time clinicians, the ratio of full-time midlevel practitioners (APRN, PNP, or PA) to full-time physicians (MDs) and doctors of osteopathy, the number of walk-in appointments, the practice insurance profile (percent of patients with public insurance), and the total practice size (number of all staff and clinicians).
Organizational Culture Survey.
Organizational culture was determined using a 20-item previously validated questionnaire (Shortell et al., 2000) that assessed the practice on the four cultural domains (group, developmental, rational, and hierarchical). The 20 items were arranged into five groups of four questions. The four questions in each group represented the different culture dimensions (group, developmental, rational, and hierarchical). For each of the five groups of items, a respondent distributed a total of 100 points among the four items according to the extent to which they perceived the description in the item as matching the culture of their practice. A respondent's points for each dimension were then averaged over the five groups to obtain a score for each culture type. Scores could range between 0 and 100. Previous studies have demonstrated adequate validity and reliability of the instrument, with a Cronbach's alpha for the four culture types ranging from .40 for the rational scale to .70 for the group scale (Bosch et al., 2008; Hann et al., 2007; Meterko, Mohr, & Young, 2004). This instrument has also been associated with relevant outcomes in health care (Scott et al., 2003a; Shortell et al., 1995; Wakefield et al., 2001).
Primary outcomes job satisfaction and perceived effectiveness were subscales of the previously validated Primary Care Organizational Questionnaire (PCOQ; Hall, Tennen, Wakefield, Brazil, & Cloutier, 2006). Both subscales consisted of items evaluated using Likert scales with scores from 1 (strongly disagree) to 5 (strongly agree). The perceived effectiveness subscale consisted of three items, which evaluated staff and clinicians' perceived effectiveness: (a) our clinic/practice almost always meets its patient care treatment goals, (b) our clinic/practice does a good job of meeting family member needs, and (c) our clinic/practice does a good job of applying the most recently available technology to patient care needs. The job satisfaction subscale consisted of three items, which measured job satisfaction-(a) Would you recommend this organization to someone who is seeking a job? (b) Do you consider your organization a desired place for employment? (c) Overall, how satisfied are you with your job?-a perception important in determining staff turnover and teamwork (Coomber & Barriball, 2007; Landon, Reschovsky, Hoangmai, & Blumenthal, 2006). The estimated Cronbach's alpha was .89 for perceived effectiveness and .92 for job satisfaction.
Each practice had a score for each of the four organizational culture types that were calculated by averaging the individual scores for each culture type for all individuals in the practice. Job satisfaction and perceived effectiveness were considered personal characteristics and analyzed at the individual level. Hierarchical linear models using a restricted maximum likelihood estimation method were used to evaluate whether the practice culture types predicted job satisfaction and perceived effectiveness. These models take into account the nesting of individuals within a practice. Intraclass correlation coefficients were first calculated from an unconditional model (i.e., intercept only-no covariates) to confirm that there was significant variation between practices.
Using a hierarchical linear model, we first compared the perceived effectiveness, satisfaction, and culture scores of clinicians with nonclinicians. We repeated the analyses to make comparisons by gender and length of service at practice (<15 years vs. >15 years). Next, we conducted the primary analyses (culture scores predicting perceived effectiveness and satisfaction) separately for clinicians, nonclinicians, and overall for the practice. Thus, there were eight models (two outcomes for each of four cultures) for each of the three groups: clinicians, nonclinicians, and practice. Potential covariates included the practice's insurance profile, the nonclinician-to-clinician ratio, and the midlevel-to-MD ratio, the number of walk-in appointments, and the total practice size. All models were fit using SAS version 9.2 (SAS Institute Inc., Cary, NC).
Of the 138 clinician participants, 11 completed neither the Organizational Culture Survey nor the PCOQ. This left data from 127 clinicians for the analyses. Of the clinicians, two thirds were physicians and one third were midlevel practitioners who included APRN, PNPs, and PAs (Table 1). Fifty-nine percent of physicians and 91% of midlevel practitioners were women. Seventy percent of physicians and 40% of midlevel practitioners had received their highest degree more than 10 years previously. Thirty-five percent of physicians and 9% of midlevel practitioners had been with the practice for at least 15 years.
Of the 247 nonclinician participants, 17 did not complete the Organizational Culture Survey and 31 did not complete the PCOQ survey, leaving 199 nonclinicians for the analyses (Table 1). Nonclinicians included administrative support personnel (billing, filing, and receptionist), office managers, nurses, and medical assistants.
Organizational Culture, Job Satisfaction, and Perceived Effectiveness
The intraclass correlation for job satisfaction was .26 and for perceived effectiveness was .34, indicating substantial variability across practices in the two outcomes and demonstrating the importance of conducting the analyses at both the individual and the practice level.
Table 2 presents the descriptive statistics for study variables, all of which were assessed at three levels: the individual clinician, the individual nonclinician, and the group practice level. Both the average perceived effectiveness score and the average satisfaction score were high at greater than 4 on a Likert scale of 1 to 5. Among the four culture types, the group culture had the highest average score. There were no significant differences in average culture scores, job satisfaction, and between clinicians and nonclinicians. Clinicians had lower perceived effectiveness scores than nonclinicians (p < .0001).
We also compared the two outcomes and four culture types by gender and length of service (<15 vs. 15+ years; data not shown in Table 2). There were no differences in job satisfaction by gender (p = .769). However, individuals with a length of service of 15 or more years were more satisfied with their jobs (p = .029). Women had higher perceived effectiveness scores (p = .029); however, this difference was no longer observed after controlling for clinician versus nonclinician status (p = .671). There was no difference in perceived effectiveness by length of service with the practice. Among the four culture types, there were no significant differences by gender or length of service.
Relationship of Organizational Culture to Job Satisfaction and Perceived Effectiveness
For each outcome (satisfaction and perceived effectiveness), models were run separately for the clinicians, the nonclinicians, and the practice. Each model contained one culture type, along with the following final set of covariates: nonclinician-to-clinician ratio, midlevel-to-MD ratio, insurance profile (for perceived effectiveness models only), and midlevel-to-MD ratio (for satisfaction models only). For practice models, we also controlled for clinician versus nonclinician. Table 3 shows the results of these analyses. Participants with higher group culture scores compared with those with lower scores rated themselves as more satisfied with their work and as more effective. For each 10-point increase in group culture score (possible range = 0-100), there was a .21 increase in perceived effectiveness and a .28 increase in job satisfaction among clinicians (possible range = 1-5). In contrast, participants with higher hierarchical and rational culture scores described themselves as less satisfied with their work, and they viewed themselves as less effective (Table 3). The developmental culture score was unrelated to both outcome variables. These relationships were true for the clinicians, the nonclinicians, and the practice.
This study examined whether organizational culture is related to job satisfaction and perceived clinical effectiveness in primary care pediatric practices. We found that high hierarchical- and rational-oriented pediatric practices had employees, both clinicians and office staff who reported lower job satisfaction and perceived work effectiveness. In contrast, high group scores were associated with higher job satisfaction and greater perceived work effectiveness.
A hierarchical-oriented culture has been described as an environment that places emphasis on centralized authority, with respect for formal authority, uniformity, and adherence to rules and regulations. The management emphasis in this type of environment is toward stability, predictability, and smooth operations. Our findings suggest that for small organizations, such as the practices that participated in our study, a managerial approach that emphasizes authority and control to achieve efficiency may undermine provider and staff job satisfaction and perceived clinical effectiveness.
This study confirmed results of recent studies in primary care showing that primary care organizations primarily have group cultures (Bosch et al., 2008; Hann et al., 2007; Marshall, Mannion, Nelson, & Davies, 2003). This finding may reflect the fact that primary care practices typically consist of small groups that lack the formalized structure of a large health care organization. This suggests that small group work units may be prone to supporting cultural attributes reflective of those identified in the Competing Values Framework as a group culture collaboration, shared decision making, and team work.
Analyses in this report were calculated at the individual level and practice level. Individual analyses revealed similarities between clinicians and nonclinicians on perceptions of culture and job satisfaction. However, clinicians did report significantly lower levels of perceived clinical effectiveness than nonclinicians. In our study, clinicians described those individuals who have the role of ascertaining a diagnoses and identifying patient treatment plans. Lower levels of perceived effectiveness observed in this group may be due to perceived individual efficacy in favorable patient outcomes, where efficacy does not rest solely with the individual clinician but is also contingent on patient and system level attributes (Brazil, Cloutier, Tennen, Bailit, & Higgins, 2008).
This study's findings should be considered within the constraints of cross-sectional associations, thus limiting the ability to draw causal inferences. Further, it should be noted that both dependent variables were derived from the same instrument. Keeping this limitation in mind, the results provide a foundation for further work.
As reported earlier in this article, there is a growing emphasis in health policy circles that cultural changes are needed alongside the structural changes to establish gains in quality care (Scott et al., 2003b). Culture and cultural change initiatives have been described as "diffuse health technology" (Keen, Bryan, Muris, Weatherburn, & Buxton, 1995). Diffuse health technologies describes innovations that intervene in a systemic fashion to change organizational processes rather than addressing specific health care outcomes. Consequently, establishing the link between diffuse health technologies and service outcomes is challenging. This challenge calls rise to creative methodological strategies to diagnose and to evaluate culture and cultural change initiatives. Systems level thinking taking into consideration the organization and provider patient perspectives is required for effective diagnoses and evaluation on the role and impact of culture and cultural change on improving quality care. In particular, there is a need for longitudinal studies and intervention-oriented studies that examine whether organizational culture can be changed and whether these changes are associated with changes in organizational performance and attitudes.
Although there are numerous strategies and technologies to improve performance in primary care settings (Grol, 2001; Rosen, 2000), our study demonstrates that the culture of the practice is associated with job satisfaction and perceived clinical effectiveness and should be recognized when trying to improve practice performance. Leaders in primary care practices need to be sensitive to the culture of the organization before implementing structural change in the practice. Some structures initially designed to improve quality of care may become counterproductive if they are not aligned with the organizational culture. Initiatives to improve quality and outcomes of care are being increasingly driven by forces outside of primary care practices (Ferlie & Shortell, 2001). Recognizing the traditional independence and self-regulation of practitioners in this setting calls for greater attention to how changing practice in primary care is initiated. Collaborative engagement that is seen by primary care providers as supporting their practice will facilitate successful adoption of the change effort. Our findings suggest that an assessment should be undertaken to ensure that structural changes are aligned with organizational culture of the practice.
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