The context in which primary care is delivered is rarely evaluated as part of quality improvement initiatives or research projects. Data from our MEMO Study (Minimizing Error, Maximizing Outcome) confirm a relationship between the work environment, provider reactions, and patient care. Time pressure is associated with physician satisfaction, stress, burnout, and intent to leave as well as lower quality care for hypertensive patients. Lack of values alignment between physicians and leaders is associated with physician satisfaction, stress, burnout, and intent to leave as well as poorer diabetes care and fewer prevention activities. Thus, providers are not the only ones at risk in adverse work conditions. An important coexisting factor is the impending primary care physician shortage. Less than optimal work conditions are associated with physician intent to leave and with reduced medical student interest in primary care. This randomized study will assess the impact of applying a novel quality improvement strategy designed to create """"""""healthy workplaces"""""""". We hypothesize that addressing adverse primary care work conditions (workflow, work control, organizational culture) will lead to greater clinician participation in programs to improve health care delivery. As part of MEMO, we developed the Office and Work Life (OWL) measurement tool. The OWL assesses the primary care workplace and identifies specific working conditions that impact provider outcomes and quality of care. The current application will assess the ability of the OWL and a focused QI process to facilitate changes in the work environment and improve outcomes for providers and patients. Thirty-four primary care clinics will be recruited in New York City and the upper Midwest. Physicians, physician assistants, and nurse practitioners (n=238) will be surveyed to collect OWL data on provider outcomes, and organizational structure and culture. Managers will provide information on clinic structure, policies and procedures. Eight patients per provider (n=1904) with hypertension and /or diabetes will be surveyed on health literacy, quality of life, medication compliance, satisfaction, and trust. Patient charts will be audited to assess hypertension and diabetes management. The data will then be compiled into an OWL measure for each clinic. The 34 clinics will be randomized. Local leaders, providers, and staff in 17 intervention clinics will receive their OWL measure and discuss the successes and challenges to care illustrated by the data. Assisted by the study team, they will develop QI plans focusing on workplace variables that we've found contribute to care quality: time pressure, work control, work pace (chaos), and organizational culture. Twelve months later, OWL data will be recollected in all 34 clinics and compared. New OWL data will be fed back to personnel in the 17 intervention clinics to formalize its role in continuous QI processes. Control clinics will receive their OWL data at study end. Subsets of data will be analyzed to determine the best ways to modify the work environment to improve outcomes for underrepresented groups (women and minority providers and minority patients).

Public Health Relevance

The health of the public depends upon smoothly functioning physician offices that promote the health of both workers and their patients. This study targets ambulatory health care offices with rapid paced, chaotic environments. We will measure adverse outcomes for providers and staff (e.g., stress and burnout), the impact these have on quality of care for hypertensive, diabetic and depressed patients, and identify areas where practice redesign to create healthy workplaces improves these outcomes.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Health Care Quality and Effectiveness Research (HQER)
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Genevro, Janice
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Minneapolis Medical Research Fdn, Inc.
United States
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Linzer, Mark; Sinsky, Christine A; Poplau, Sara et al. (2017) Joy In Medical Practice: Clinician Satisfaction In The Healthy Work Place Trial. Health Aff (Millwood) 36:1808-1814
Linzer, Mark; Poplau, Sara; Grossman, Ellie et al. (2015) A Cluster Randomized Trial of Interventions to Improve Work Conditions and Clinician Burnout in Primary Care: Results from the Healthy Work Place (HWP) Study. J Gen Intern Med 30:1105-11