Physician- and nursing staff–reported team functioning was associated with patient satisfaction but not with clinical quality or patient portal implementation.
Objectives: Studies evaluating the impact of patient-centered medical homes (PCMHs) have produced mixed results. Missing from these studies has been a consideration of the effect of team functioning. We evaluated the relationships between team functioning and clinical quality, patient satisfaction, and online patient portal implementation among the PCMHs of an integrated health system.
Study Design: Primary care physicians and nursing staff working within 26 PCMH-designated primary care clinics were asked to complete an online survey that included an item specific to team functioning.
Methods: Survey data (response rate, 70%) were joined with information from electronic health records on portal activation, patient satisfaction surveys, and internal health system quality reports. We report clinic-level correlations between positive team functioning and clinical care quality measures, patient satisfaction, and patient portal activation.
Results: On a scale of 1 to 5, where higher values represent more positive team functioning, ratings of clinic-level team culture ranged from 2.6 to 5.0 among nursing staff (mean = 3.6) and from 3.0 to 5.0 among physicians (mean = 4.1). Both nursing staff— and physician-reported team functioning was significantly associated (P <.05) with patient satisfaction as measured by whether patients would recommend their physician and clinic to others. Although team functioning was also positively associated with other outcomes, no other associations reached statistical significance.
Conclusions: We found that positive team functioning is significantly associated with patient-reported satisfaction. Results from this study point to the importance of considering how physicians and other clinical staff within a PCMH perceive the team culture of their clinic and the potential impact of their team perceptions on patient satisfaction and other outcomes.
Am J Accountable Care. 2018;6(3):23-27In response to healthcare reform in the United States, the patient-centered medical home (PCMH) has emerged as an innovative care model.1 Although the model is variable in structure,2 PCMHs are defined by a focus on care that is team-based, data-informed, and able to address the unique needs of patients across the care continuum, whether those needs are preventive, acute, or chronic. The medical home approach to care is defined by being comprehensive, patient-centered, coordinated, accessible, and committed to quality and safety. Providing such care requires teamwork and open and clear communication among a range of care providers, including physicians, physician assistants, nurses, pharmacists, nutritionists, educators, and care coordinators.3
Recent systematic reviews suggest that PCMHs can decrease provider burnout and improve patient and staff experiences, as well as improve the delivery of preventive services and some aspects of chronic disease management, while reducing emergency department utilization.2,4 However, the evidence that PCMHs improve patient experiences and care quality has not been consistent.5-8 One of the factors that could underlie such mixed results may be differences in team functioning among different PCMHs.
The relationship between team functioning and organizational performance is well studied both within9,10 and outside healthcare settings.11 Team functioning may be particularly critical to the delivery of comprehensive primary care as envisioned within PCMHs, as a primary care practice’s organizational culture also impacts its ability to adapt to changing environmental pressures.12 In spite of the potential importance of team functioning to the success of PCMHs, differences in team functioning as reported by physicians and other clinical staff have not, to our knowledge, been explored as a potential factor associated with implementation success, patient satisfaction, or other clinical outcomes among PCMHs.
We evaluate the relationship between primary care physician and nursing staff perceptions of their clinic’s team functioning and measures of (1) preventive and chronic clinical quality, (2) patient satisfaction, and (3) the implementation success of an online patient portal among the 26 PCMH-designated primary care clinics of a large integrated delivery system in southeast Michigan.
Team effectiveness is commonly described based on input-process-output (IPO) models.6,13,14 IPO models explain the effects of organizational inputs, such as organizational culture and team composition, on team outputs, such as team performance and care outcomes.6 As seen in the Figure, the IPO model for PCMHs is complex and includes many input, process, and outcome elements. Within PCMHs, interprofessional team functioning is thought to be a central aspect of effective work processes.15,16 For the purpose of this paper, we therefore focus on the functioning of the clinical team within PCMHs.
Humphrey and Aime defined teamwork as “assemblies of interdependent relations and activities organizing shifting sets or subsets of participants embedded in and relevant to wider resource and institutional environments.”17 This definition of teamwork is useful for describing teamwork in healthcare organizations because the team membership changes based on members’ work tasks, as well as across healthcare organizations. Several studies in the healthcare context have shown the positive effects of team functioning on care quality and safety,18 patient-reported clinical outcomes,9,19 and patient satisfaction.6 Team functioning is not only a key factor for PCMH implementation8 but could also serve as a mediating factor for the effectiveness of PCMHs.15,16 Using this theoretical framework, we assessed the relationships between team functioning and clinical quality, patient experience, and the implementation success of an online patient portal among 26 PCMH-designated primary care clinics.
Practice Setting and Participants
Survey-eligible participants were the 189 family and general internal medicine physicians and 216 nursing employees (nurse managers and medical assistants) working in the 26 adult primary care clinics of the Henry Ford Health System in July 2014. The health system, located in southeast Michigan, serves Detroit and the surrounding suburbs. Each of the health systems’ adult primary care clinics was designated as a PCMH by the state of Michigan’s largest insurer, Blue Cross Blue Shield of Michigan. Because the health system uses 1 integrated electronic health record (EHR) system, which includes a centralized system of decision support, routine performance monitoring, and other clinical informatics features, in addition to a common staffing model and centralized services (eg, population care management), these care inputs are constant across each of the primary care clinics, enabling a focus on team functioning, which was expected to vary across primary care clinics. The study was approved under expedited review by the health system’s institutional review board.
In July 2014, eligible employees were emailed a link to an online survey that included items from the Clinician Staff Survey20 and demographic questions. Included within the Clinician Staff Survey is an item specifically designed to assess the respondent’s perceptions of their clinic’s team functioning. Study participants were provided with a $30 gift card to compensate them for their time. Survey responses were managed using REDCap electronic data capture tools.21 REDCap is a secure Web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for importing data from external sources.
Administrative data were used to compile study outcomes. Specifically, health-system dashboard reports covering the 1-year period ending March 31, 2014, were used to ascertain measures of clinical care quality; patient satisfaction was assessed using the subset of health-system patient satisfaction surveys pertaining to primary care visits occurring in the 1-year period ending March 31, 2014; and data available within the EHR repository were used to determine portal account activation from portal introduction on December 1, 2012, until March 31, 2014.
Team functioning. Team functioning was assessed via responses to the item, “People in this clinic operate as a real team.” Answer choices ranged from 1 to 5, where 1 indicated disagreement and 5 indicated agreement; thus, higher values represent more positive team functioning. Individual responses, stratified by physician and nursing staff, were summed for each clinic and divided by the corresponding number of responses to generate a mean team functioning score as perceived by physicians and nursing staff within each PCMH.
Outcome measures. Clinical care quality was measured via commonly used evidence-based cancer screening and diabetes care management performance measures. For colorectal, breast, and cervical cancer screening measures, we report the proportion of eligible patients who were up to date with screening as recommended by the United States Preventive Services Task Force.22 Using the standards of medical care as established by the Healthcare Effectiveness Data and Information Set,23 we also used an available composite measure of diabetes care quality, the proportion of patients who met all 5 diabetes quality measures (those who received glycated hemoglobin [A1C] and low-density lipoprotein [LDL] cholesterol tests and achieved desired control levels [ie, A1C <8%, blood pressure <140/90 mm Hg, and LDL cholesterol <100 mg/dL) during the 1-year measurement period. Denominators for these metrics were age- and guideline-appropriate patients with an outpatient visit.
For patient satisfaction, we report the percentage of respondents endorsing the highest possible rating (“top-box scores”) from the 5-point Likert scale responses for the questions regarding how likely the patient respondent was to recommend the clinic and recommend their care provider to others. Finally, we measured patient portal implementation as the percentage of patients with a primary care visit with an activated portal account by March 31, 2014.
We used means (SDs) and percentages to describe physician and nursing staff participants, their perceptions of team functioning, clinical quality, patient satisfaction, and portal implementation success. Using the clinic/PCMH as the unit of analysis, we used Pearson correlation coefficients to assess the association between physician- and nursing staff—reported team functioning and each of the outcomes of interest.
A total of 119 physicians (63% response rate) and 165 nursing staff members (76% response rate) responded to the survey. Physician respondents were 59% female, 51% Caucasian, and 25% Asian/Pacific Islander. Nursing staff were primarily female (95%), 48% Caucasian, and 47% African American.
Mean clinic-level team functioning scores ranged from 3.0 to 5.0 for physicians (mean [SD] = 4.07 [0.51]) and 2.6 to 5.0 for nursing staff (mean [SD] = 3.67 [0.64]). The relationship between the clinic-level outcomes and positive team functioning as perceived by physicians and nursing staff is described in the Table. Positive team functioning as perceived by either physicians or nursing staff was not significantly associated with the measures of clinical care quality or portal implementation success. However, nursing staff—reported team functioning was significantly and positively correlated with patients’ reporting that they would recommend their clinic to others (r = 0.576; P = .003) and that they would recommend their care provider to others (r = 0.531; P = .006). Physician-reported team functioning was also significantly and positively correlated with these patient satisfaction measures, recommending their clinic (r = 0.498; P = .010) and their care provider (r = 0.471; P = .015).
Among 26 primary care clinics designated as PCMHs, we found that positive team functioning, as reported by both nursing staff and physicians, was significantly associated with patient-reported satisfaction as measured by the patient’s willingness to recommend their clinic and their care provider. Such patient satisfaction scores have long been monitored by healthcare administrators, but they have recently taken on new importance as patient-reported experiences are increasingly being tied to provider compensation.24 Although a study has recently linked interdisciplinary teamwork10 to patient experiences in the context of cancer care, less is known about how team functioning within a primary care clinic relates to patients’ experiences or care quality. Our results point to the likely importance of clinician and staff subjective experiences of working in a team to patient experiences. How team functioning directly or indirectly affects the implementation of key PCMH attributes and other dimensions of PCMH performance warrants additional study. This is especially true given that prior studies have noted that more successful implementation of PCMHs is also associated with higher patient satisfaction.2
Notably, although we did find a positive association between physician and nursing staff perceptions of positive team functioning and measures of care quality or portal implementation success, these findings were not statistically significant. In contrast, others have found relationships between team functioning and quality-improvement initiatives in small primary care settings.25 It may be that in clinics like the ones studied here, in which there is strong decisional support and centralized population health infrastructure, relatively small differences in positive team functioning may be insufficient to alter the delivery of routine preventive and chronic care services. Whether the same is true among smaller practices, where care management support and other infrastructure may be minimal, is a question that warrants future study.
As Lemieux-Charles and McGuire point out, it is critical to understand how and under what conditions healthcare teams can be effective and address the problems that have limited healthcare organizations’ ability to provide high-quality care.6 Using the IPO model as a framework, this study has shown that team functioning may be an important factor to consider when studying the impact of PCMHs. In addition, team functioning may be an important mediating factor between the resources, or inputs, clinics are allocating to PCMHs and the ability of those clinics to successfully implement the key attributes of PCMHs, and ultimately to their ability to impact patient care experiences.
Given the potentially important role that front desk and other nonclinical staff play within PCMHs, their exclusion from the survey-eligible population is a limitation. In addition, the limited number of clinics (N = 26) precluded the ability to control for other factors that may impact positive team functioning or practice outcomes. Similarly, the relatively small sample of PCMHs likely limits the ability to detect statistically significant associations. In addition, we acknowledge that organizational characteristics such as team functioning are dynamic and thus difficult to classify based on a single cross-sectional survey.
In the context of PCMHs, it is critical to understand how a primary care clinic’s team functioning can influence not only how patients experience their care, but also how it can ultimately affect care quality and patient outcomes. Results from this study point to the importance of considering how physicians and other clinical staff within a PCMH perceive the team culture of their clinic and the potential impact of their team perceptions on patient satisfaction and other outcomes.Author Affiliations: School of Social Work, Michigan State University (DAS), East Lansing, MI; Department of Health Policy and Management, The Gillings School of Global Public Health (AAT), and Lineberger Comprehensive Cancer Center (JEL), and Eshelman School of Pharmacy, Institute for Healthcare Quality Improvement (JEL), University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University (CAM), Richmond, VA; Center for Health Policy and Health Services Research, Henry Ford Health System (DAS, JEL), Detroit, MI.
Source of Funding: None.
Author Disclosures: The authors have no conflicts of interest to disclose.
Authorship Information: Concept and design (DAS, JEL); acquisition of data (DAS); analysis and interpretation of data (DAS, AAT, CAM, JEL); drafting of the manuscript (DAS, AAT, CAM, JEL); critical revision of the manuscript for important intellectual content (DAS, AAT, JEL); statistical analysis (AAT, CAM); obtaining funding (JEL); administrative, technical, or logistic support (JEL).
Send Correspondence to: Deirdre A. Shires, PhD, Michigan State University, School of Social Work, 655 Auditorium Rd, 122 Baker Hall, East Lansing, MI 48824. Email: email@example.com.REFERENCES
1. Korda H, Eldridge GN. ACOs, PCMHs, and health care reform: nursing’s next frontier? Policy Polit Nurs Pract. 2011;12(2):100-103. doi: 10.1177/1527154411416370.
2. Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: a systematic review. Ann Intern Med. 2013;158(3):169-178. doi: 10.7326/0003-4819-158-3-201302050-00579.
3. Jackson GL, Williams JW. Does PCMH “work”?—the need to use implementation science to make sense of conflicting results. JAMA Intern Med. 2015;175(8):1369-1370. doi: 10.1001/jamainternmed.2015.2067.
4. Hoff T, Weller W, DePuccio M. The patient-centered medical home: a review of recent research. Med Care Res Rev. 2012;69(6):619-644. doi: 10.1177/1077558712447688.
5. Day J, Scammon DL, Kim J, et al. Quality, satisfaction, and financial efficiency associated with elements of primary care practice transformation: preliminary findings. Ann Fam Med. 2013;11(suppl 1):S50-S59. doi: 10.1370/afm.1475.
6. Lemieux-Charles L, McGuire WL. What do we know about health care team effectiveness? a review of the literature. Med Care Res Rev. 2006;63(3):263-300. doi: 10.1177/1077558706287003.
7. Solberg LI, Asche SE, Fontaine P, Flottemesch TJ, Pawlson LG, Scholle SH. Relationship of clinic medical home scores to quality and patient experience. J Ambul Care Manage. 2011;34(1):57-66. doi: 10.1097/JAC.0b013e3181ff6faf.
8. True G, Stewart GL, Lampman M, Pelak M, Solimeo SL. Teamwork and delegation in medical homes: primary care staff perspectives in the Veterans Health Administration. J Gen Intern Med. 2014;29(suppl 2):S632-S639. doi: 10.1007/s11606-013-2666-z.
9. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246-1251. doi: 10.1001/jama.291.10.1246.
10. Tremblay D, Roberge D, Touati N, Maunsell E, Berbiche D. Effects of interdisciplinary teamwork on patient-reported experience of cancer care. BMC Health Serv Res. 2017;17(1):218. doi: 10.1186/s12913-017-2166-7.
11. Delarue A, Van Hootegem G, Procter S, Burridge M. Teamworking and organizational performance: a review of survey-based research. Int J Manage Rev. 2007;10(2):127-148. doi: 10.1111/j.1468-2370.2007.00227.x.
12. Nutting PA, Miller WL, Crabtree BF, Jaén CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7(3):254-260. doi: 10.1370/afm.1002.
13. Ilgen DR, Hollenbeck JR, Johnson M, Jundt D. Teams in organizations: from input-process-output models to IMOI models. Annu Rev Psychol. 2005;56:517-543. doi: 10.1146/annurev.psych.56.091103.070250.
14. Littlepage GE, Schmidt GW, Whisler EW, Frost AG. An input-process-output analysis of influence and performance in problem-solving groups. J Pers Soc Psychol. 1995;69(5):877-889. doi: 10.1037/0022-3518.104.22.1687.
15. Tuepker A, Kansagara D, Skaperdas E, et al. “We’ve not gotten even close to what we want to do”: a qualitative study of early patient-centered medical home implementation. J Gen Intern Med. 2014;29(suppl 2):S614-S622. doi: 10.1007/s11606-013-2690-z.
16. Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The changes involved in patient-centered medical home transformation. Prim Care. 2012;39(2):241-259. doi: 10.1016/j.pop.2012.03.002.
17. Humphrey SE, Aime F. Team microdynamics: toward an organizing approach to teamwork. Acad Manag Ann. 2017;8(1):443-503. doi: 10.5465/19416520.2014.904140.
18. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):122-131. doi: 10.1016/j.outlook.2007.02.006.
19. Strasser DC, Falconer JA, Herrin JS, Bowen SE, Stevens AB, Uomoto J. Team functioning and patient outcomes in stroke rehabilitation. Arch Phys Med Rehabil. 2005;86(3):403-409. doi: 10.1016/j.apmr.2004.04.046.
20. Jaén CR, Crabtree BF, Palmer RF, et al. Methods for evaluating practice change toward a patient-centered medical home [erratum in Ann Fam Med. 2010;8(4):369. doi: 10.1370/afm.1158]. Ann Fam Med. 2010;8(suppl 1):S9-S20, S92. doi: 10.1370/afm.1108.
21. Harris PA. Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi: 10.1016/j.jbi.2008.08.010.
22. Published recommendations. U.S. Preventive Services Task Force website. uspreventiveservicestaskforce.org/BrowseRec/Index. Accessed November 6, 2017.
23. HEDIS & performance measurement. National Committee for Quality Assurance website. ncqa.org/tabid/59/Default.aspx. Accessed November 6, 2017.
24. Salary surveys show more physicians being paid for quality. PYA website. pyapc.com/salary-surveys-show-physicians-paid-quality. Published August 29, 2014. Accessed November 6, 2017.
25. Bower P, Campbell S, Bojke C, Sibbald B. Team structure, team climate and the quality of care in primary care: an observational study. Qual Saf Health Care. 2003;12(4):273-279.