We found that patients who received their care at practices characterized by higher levels of local practice autonomy and with greater clinical support resources in primary care were more likely to receive CRC screening; this was especially true for smaller institutions.
Practice autonomy may be foundational to a broad range of performance measures given the complexity of managing the demands of primary care practice (Crabtree et al. 1998
). The ability to have control over the work of primary care may be a key ingredient for implementing prevention-oriented care processes, including “office-systems” approaches emphasizing internal restructuring of care processes (e.g., chart flowsheets, feedback reports) (Carpiano et al. 2003
). Adequate clinical support resources (e.g., adequately equipped exam rooms, sufficient computer access) may support implementation of these care processes and offset competing demands in busy office settings by leveraging physicians' time (Jaen, Stange, and Nutting 1994
). Empirical evidence also suggests a strong mediating role for the electronic medical record by improving documentation and physician guideline adherence (Elson and Connelly 1995
Interestingly, these performance differences were not associated with concomitant needs for more nonphysician staff or greater staffing authority, and were accomplished in smaller care environments. Evidence regarding the influence of practice size on preventive service delivery is mixed. In studies of high-, medium-, and low-volume primary care practices, patients seen by high-volume physicians had lower preventive service rates (Zyzanski et al. 1998
). In contrast, practice volume was a positive predictor of higher cervical cancer screening both within (Goldzweig et al. 2004
) and outside the VA (Battista, Williams, and MacFarlane 1990
). Diffusion theory suggests size is typically a positive predictor of organizational innovativeness, but probably as a function of what size “buys” in terms of other structural attributes (e.g., resources) (Rogers 1995
). However, we focused on larger clinics than those typically studied; as practices grow in size and complexity, they tend to increase the number of hierarchical levels and become more formal and bureaucratic (Kralewski, Pitt, and Shatin 1985
). Our finding is thus consistent with Rogers' assertion that formalization (more common in larger organizations) is negatively associated with innovation (in this case, structures and processes to facilitate CRC screening). This also raises an important issue about the nature of screening: while all screening tests require certain minimum training standards, some are single-encounter activities (e.g., flu shot), while others require coordination across work-units. CRC screening is in the latter group due to the coordination needed to achieve a complete diagnostic evaluation (Yabroff et al. 2005
At the heart of the Institute of Medicine's Crossing the Quality Chasm
was the need to address the improvement of quality of care through major changes in how health care is organized (Institute of Medicine 2000
). Their central tenet was that only through significant, sustained and innovative efforts to reorganize the health care system were substantive gains in quality of care and health outcomes possible. VA's reorganization of care presaged this report by having already launched significant internal restructuring of the care delivery system, including changes in delivery models (e.g., primary care teams) and adoption of new technologies (e.g., performance standards) and management strategies (e.g., reminders, guidelines, performance audit-and-feedback). While these structural changes in the aggregate have been found to be associated with substantial gains in VA quality over time and in comparison with Medicare (Jha et al. 2003
), relatively little is known about discrete organizational characteristics that empirically contributed to these changes in performance. This work begins to open the “black box” underlying these performance gains and demonstrates at least in part the impact of VA's “primary care directive” (1994), which mandated development of primary care teams throughout VA (Soban and Yano 2005
). This policy shift began the process of over-turning VA's emphasis on specialty-oriented hospital-based care and provided the organizational substrate on which the subsequent highly publicized VA reorganization could be launched.
In contrast to recent work among over 3,500 doctors in the Community Tracking Study, we also identified discrete mutable features of primary care practice associated with higher CRC screening performance. In that study, no organizational characteristics were associated with CRC screening in contrast to influenza and pneumonia vaccinations, mammography, diabetic eye exams or HbA1c monitoring (Pham et al. 2005
). They also combined academic facilities, hospital-based primary care and HMOs into an “all other” category, which unlike our study, limited their ability to examine organizational factors in these other settings. At the same time, since the clinics we studied were relatively large, our findings may be more applicable to other academic group practices, clinic systems, and health plans than to small group or solo practices.
To further place our findings in organizational context, the VA has been described as being most akin to a staff-model HMO, which provides the rationale for benchmarking services and quality to Kaiser Permanente health care settings (Kerr et al. 2004
). However, with the reorganization of the mid-1990s, VA reinvented itself a step further as an integrated delivery system (IDS), each practice being linked through electronic medical records, policies, procedures, and reporting authority and performance accountability back through an established hierarchical management infrastructure (i.e., vertical reporting of community-based outpatient clinics to medical centers, horizontal consolidations of medical centers into health systems, and integration of geographically proximal systems, centers and clinics into networks) (Gillies, Shortell, and Young 1997
). Focused on the health care needs of a specific community—in this case, veterans—the VA may be achieving some of the promise of a “community health management system” (Shortell, Gillies, and Anderson 1994
). Such integrated delivery systems outside the VA, especially those in HMO settings, typically outperform less organized care models (Kellie et al. 1996
This study has several limitations. While grounded in theory, our conceptual framework does not incorporate all possible explanatory variables, and unmeasured characteristics at the organizational, provider, and patient levels may also account for some of the variation seen (e.g., culture, climate, patient preferences). While our sample size of practices is large, we also have limited degrees of freedom for evaluating some of our existing measures given their prevalence and/or distribution (e.g., within academic practices, by hospital-versus community-based practices). As an observational study, we are also unable to attribute causality to these structural attributes.
The VA's performance gains have garnered significant interest as a public sector turn-around (Stires 2006
), generating questions about how to translate lessons from these successes into opportunities for quality improvement outside the VA (Lomas 2003
). The largest U.S. integrated health care delivery system, the VA annually serves over 4 million veterans, who on average tend to have worse health status, fewer options and lower income compared to nonusers and to same-age, same-gender civilians (Rogers et al. 2004
). For many, the VA is a safety net provider for uninsured and underinsured veterans who rely on VA's extensive coverage of prescription benefits, mental health care and nursing home care (Shen et al. 2003
). Veterans' acute and chronic care needs also pose barriers to addressing their preventive service needs (Flocke, Stange, and Goodwin 1998
). As a result, the VA's ability to accomplish this level of screening among such chronically ill, older veterans is unusual compared with other care settings.
While the VA's mission focus on veterans may be unique, the organizational structures of care within the VA's primary care practices that we measured are not unlike those evaluated in other medical group practices in managed care environments in terms of administrative controls, patient care systems standardization and integration, and other care management processes (Kralewski et al. 1998
). It is the degree of organization that the VA has accomplished in the past decade in the face of survival threats that has yielded higher accomplishment of these management objectives. That being said, the VA certainly has its own organizational inertia, cultural milieu, and substantial bureaucracy. The VA case example simply provides additional evidence that the obstacles to improving the quality of care in U.S. health care settings may be overcome when the provider, organizational, and public policy barriers are adequately addressed.