Evidence-based Synthesis Program 

The Effect of Working 

Conditions on Patient Care: 

A Systematic Review 

Department of Veterans Affairs 

Health Services Research & Development Service 

January 2012 

Prepared for: 

Department of Veterans Affairs 

Veterans Health Administration 

Health Services Research & Development Service 

Washington, DC 20420 

Prepared by: 

Evidence-based Synthesis Program (ESP) Center 

Minneapolis VA Medical Center 

Minneapolis, MN 

Timothy J. Wilt, MD, MPH, Director 

Investigators: 

Principal Investigator: 

Kandice A. Kapinos, PhD 

Research Associates: 

Patrick Fitzgerald, MPH 

Nancy Greer, PhD 

Indulis Rutks, BS 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

PREFACE 

Health Services Research & Development Service’s (HSR&D’s) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout VA. 

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help: 

• develop clinical policies informed by evidence, 

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge. 

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system. 

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov. 

Recommended citation: Kapinos KA, Fitzgerald P, Greer N, Rutks I, Wilt TJ. The Effect of 

Working Conditions on Patient Care: A Systematic Review. VA-ESP Project #09-009; 2012. 

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the Minneapolis VA Medical Center, Minneapolis, MN funded 

by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Health Services Research and Development. The findings 

and conclusions in this document are those of the author(s) who are responsible for 

its contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., 

employment, consultancies, honoraria, stock ownership or options, expert testimony, 

grants or patents received or pending, or royalties) that conflict with material presented 

in the report. 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

TABLE OF CONTENTS 

EXECUTIVE SUMMARY 

Background.................................................................................................................................................... 1
 

Methods ......................................................................................................................................................... 1
 

Data Synthesis ............................................................................................................................................... 2
 

Peer Review................................................................................................................................................... 2
 

Results ........................................................................................................................................................... 2
 

Conclusions ................................................................................................................................................... 4
 

Future Research............................................................................................................................................. 5
 

INTRODUCTION 

Background.................................................................................................................................................... 6
 

Working Conditions....................................................................................................................................... 7
 

Conceptual Model ......................................................................................................................................... 8
 

Patient Outcomes........................................................................................................................................... 9
 

Provider Outcomes ...................................................................................................................................... 10
 

METHODS 

Topic Development...................................................................................................................................... 12
 

Search Strategy............................................................................................................................................ 13
 

Study Selection............................................................................................................................................ 13
 

Data Abstraction .......................................................................................................................................... 13
 

Quality Assessment ..................................................................................................................................... 13
 

Data Synthesis ............................................................................................................................................. 14
 

Rating the Body of Evidence....................................................................................................................... 14
 

Peer Review................................................................................................................................................. 14
 

RESULTS 

Literature Flow ............................................................................................................................................ 15
 

Key Question #1. How are human resources (HR) practices, such as skill levels, training, 

workload, hours worked, autonomy, and electronic medical records/systems, associated 

with patient outcomes? ................................................................................................................................ 17
 

Key Question #2. How are other working conditions, such as organizational culture or physical 

environment, associated with patient outcomes? ........................................................................................ 24
 

Key Question #3. In studies that report provider outcomes, how are working conditions 

associated with provider outcomes (e.g., job satisfaction, productivity, pay)? ........................................... 30
 

SUMMARY AND DISCUSSION 

Summary of Evidence by Key Question ..................................................................................................... 32
 

Recommendations for Future Research....................................................................................................... 34
 

Conclusions ................................................................................................................................................. 34
 

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REFERENCES ................................................................................................................................................... 36
 

TABLES 

Table 1. Human Resource Practices Studies by HR Practice Studied and Patient Outcome Studied..... 18
 

Table 2. Human Resource Practices – Strength of Evidence for Key Outcomes.................................... 24
 

Table 3. Organizational Culture Studies by Practice Studied and Patient Outcome Studied.................. 26
 

Table 4. Physical Environment Studies by Patient Outcome Studied..................................................... 28
 

Table 5. Physical Environment Outcomes .............................................................................................. 29
 

FIGURES 

Figure 1. Conceptual Model – Quality of Care in Primary Care ................................................................ 9
 

Figure 2. Analytic Framework.................................................................................................................. 12
 

Figure 3. Literature Flow Diagram – Human Resource Practices Studies ............................................... 15
 

Figure 4. Literature Flow Diagram – Organizational Culture Studies...................................................... 16
 

Figure 5. Literature Flow Diagram – Physical Environment Studies....................................................... 16
 

Figure 6. Study Quality of Human Resource Practices Non-Randomized Studies .................................. 23
 

Figure 7. Study Quality of Organizational Culture Non-Randomized Studies......................................... 28
 

Figure 8. Study Quality of Physical Environment Non-Randomized Studies.......................................... 30
 

APPENDIX A. SEARCH STRATEGIES ............................................................................................................. 42
 

APPENDIX B. CRITERIA USED IN QUALITY ASSESSMENT OF NON-RANDOMIzed STUDIES............. 44
 

APPENDIX C. PEER REVIEw COMMENTS/AUTHOR RESPONSES............................................................ 45
 

APPENDIX D. EVIDENCE TABLES 

Table 1. Description of Human Resources Practices Studies – United States ........................................ 48
 

Table 2. Description of Human Resources Practices Studies – Europe .................................................. 51
 

Table 3. Description of Human Resources Practices Studies – Outside of US or Europe...................... 53
 

Table 4. Quality of Care Outcomes – Human Resource Practices Studies ............................................. 54
 

Table 5. Patient Safety Outcomes – Human Resource Practices Studies................................................ 56
 

Table 6. Patient Satisfaction Outcomes – Human Resource Practices Studies....................................... 57
 

Table 7. Description of Organizational Culture Studies.......................................................................... 59
 

Table 8. Quality of Care Outcomes – Organizational Culture Studies.................................................... 63
 

Table 9. Patient Safety Outcomes – Organizational Culture Studies ...................................................... 64
 

Table 10. Patient Satisfaction Outcomes – Organizational Culture Studies ............................................. 65
 

Table 11. Provider Outcomes – Organizational Culture Studies............................................................... 66
 

Table 12. Description of Physical Environment Studies........................................................................... 67
 

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The Effect of Working Conditions 

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EVIDENCE REPORT 

INTRODUCTION 

A patient safety movement that began with a 1999 Institute of Medicine report on the prevalence 

of preventable medical errors has spawned both policy to change health care systems and a 

growing body of literature aimed at understanding the causes of such errors.1-3 A 2003 AHRQ 

systematic review investigated the role that workplace conditions play in explaining patient 

safety and found that workloads, work schedules, lengths of work shifts, and stress levels 

affected rates of non-fatal adverse outcomes, mortality rates, medication errors, and other patient 

safety measures.4

 However, much of this evidence relies on studies based in hospitals and 

focuses on nurse and resident staffing or is based on studies in non-healthcare settings. 

BACKGROUND 

A large body of evidence has shown clear linkages between workplace conditions and employee 

satisfaction and stress in a wide variety of organizational and industry settings.5 In the healthcare 

industry, increasing interest in understanding these linkages has stemmed from the idea that 

healthcare providers’ working environments also affect important patient outcomes, including 

safety, quality of care and satisfaction.6 Additionally, meeting objectives of the current healthcare 

reform to increase healthcare quality by increasing the availability of primary care providers and 

making care safer, more efficient, effective and patient-centered hinges on the ability to deal with 

the documented shortage of primary care providers in the US7,8 and at the same time improve 

patient outcomes. 

The purpose of this report is to systematically review the evidence on the role of primary care 

providers’ workplace conditions in influencing patient outcomes. The focus on primary care 

providers’ work environment will provide evidence on increasing healthcare quality. While the 

focus of this review is on patient outcomes, we do discuss implications for providers and recent 

review studies that highlight the importance of provider wellness as a component of high quality 

care.9

 Results from this review may inform policymakers as they endeavor to implement aspects 

of the healthcare reform related to increasing the supply of primary care providers and improving 

patient outcomes. 

Following the 2003 AHRQ report,4

 we focused on the following workplace conditions: 1) 

human resource practices 2) organizational culture, and 3) physical environment, but restricted 

our review to studies on primary care providers (physicians, physician assistants, and nurse 

practitioners) in ambulatory care settings. Note that the workplace condition constructs, 

specifically “human resources practices” and “organizational culture”, may overlap. However, 

our categorization of these workplace conditions does not affect the evidence presented; it 

merely serves as a way to organize a long list of workplace conditions. As mentioned above, we 

restricted our analysis to studies focused on the following patient outcomes, broadly defined: 

patient care quality, medical errors, patient safety, and patient satisfaction. We conceptualized 

primary or ambulatory care to include clinics and providers that serve as a first point of contact 

for patients where common illnesses and conditions are treated. Therefore, we excluded 

studies that focused on one specific disease, even chronic conditions that may be managed by a 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

primary care provider, or one specific patient population (e.g. diabetics). We discuss these work 

environment concepts, patient safety measures, and our conceptual model below. 

WORKING CONDITIONS 

Our key questions, study protocol and populations, interventions, settings and outcomes of 

interest were guided by consultation with a panel of experts. 

We delineated workplace conditions of primary care providers into three categories: human 

resources practices, organizational culture and physical environment. Note that some elements of 

“human resources practices” could conceivably be classified as characteristics of a workplace’s 

organizational culture (and vice versa), but we have roughly followed the categorizations 

from the 2003 AHRQ report.4

 In another AHRQ report,10 the authors describe elements of 

organizational climate as part of the healthcare structures, whereas the actual workplace practices 

are part of the processes (see also our conceptual model below). These workplace condition 

classifications are simply geared at organizing the presentation of results and do not change or in 

any way shape the evidence presented. Note that many of these constructs are measured in varied 

ways across studies. We mention some of the most commonly used measures below and provide 

details on the measures used in each study in Appendix D, Tables 1-3, 7, and 12. 

Human Resources Practices 

Human resources practices encompass all organizational practices and policies that pertain to 

managing employees. In this study, we focused on skill levels/training and work systems. Skill 

levels and training reflect some measure of knowledge, either through formal general training 

(i.e., physician vs. nurse practitioner) or more specific training aimed at increasing providers’ 

knowledge or skills in helping patients. Note that we did not include studies that investigated 

the effect of disease specific training on patient outcomes. Work systems include workload, 

scheduling, autonomy, and other systems or structures in place that affect how providers do 

their jobs, such as electronic medical records or computerized systems. Workload is typically 

measured as the “listsize” (number of patients a physician has), by the number of procedures 

performed, the number of patients seen, and time pressures related to work pace. A related 

concept is provider scheduling, which may be measured as shift length, typical hours, or days of 

the week worked. Scheduling is studied less in the ambulatory care setting than in the hospital 

setting. Autonomy or control of one’s work refers to the flexibility that providers have in exactly 

how they get their tasks completed. 

While pay systems, and in particular pay for performance settings, are an important component 

of workplace conditions and human resource practices that likely influence patient (and provider) 

outcomes, we do not systematically review this literature in this report. There is a large existing 

literature on pay for performance spanning several disciplines, in general, but also a large 

growing literature on this topic in healthcare settings. We discuss recent systematic reviews on 

this topic below. 

Organizational Culture 

Organizational culture pertains to issues related to the social norms in a workplace. We focused 

on studies that investigated organizational climate, professional culture, and the structural 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

organization or hierarchies present in a workplace, including the use of teams. Organizational 

climate includes provider perceptions of how open the organization is to change, what is valued 

at the organization (e.g. patient safety, learning), and expectations about how to work and fit in 

at the organization. For example, one VA study identified the following factors of organizational 

climate: employee focus, support (group processes and supervision), and professional demands.11 

Professional culture involves how value perceptions vary across different professions within the 

organization and how teamwork and relationships within the organization are valued. Finally, in 

this study, organizational culture encompasses organizational structures or hierarchies related to 

the division of labor within an organization. We include “team-based care” as a component of 

organizational culture as it is often accompanied with other cultural or structural characteristics 

that facilitate teamwork. The literature on healthcare teams (and related concepts such as 

patient centered care) is large, but for this review, we focused on studies that investigated the 

effectiveness of teams where at least one team member is a physician, nurse practitioner, or 

physician assistant. 

Physical Environment 

Physical environment pertains to issues related to the direct physical characteristics of the 

workplace. We focused on studies that investigate environmental safety, lighting, temperature, 

and physical layout of clinics. Environmental safety includes air quality, indoor pollution, toxic 

exposures, and noise. The physical environment also includes aesthetic and comfort aspects of 

the workplace, such as lighting, temperature, and humidity. Finally, the physical layout at the 

workplace, such as whether there are obstacles or large distances between work stations, may 

influence patient outcomes. 

CONCEPTUAL MODEL 

We draw from several quality of care models from the nurse staffing literature that build on 

Donabedian’s work delineating quality as it relates to healthcare structures, processes, and 

outcomes.12 In Figure 1, we outline the main model noting that these relationships can also be 

outlined at different levels, including individual, group, organizational or system. We also note 

that this model can easily be expanded with the complexity added due to interactions at various 

levels and the possibility of bidirectional effects (of say, structures and processes).13 Additionally, 

we have included intermediary outcomes in this model; in particular, we highlight that an 

underlying behavioral mechanism exists whereby the organizational structures and processes 

affect provider’s job satisfaction, productivity, pay, and similar outcomes. Studies that focused 

solely on these intermediary outcomes are beyond the scope of this report. For the purposes 

of this report, we focused on the general effect of workplace conditions and related clinical 

processes on patient outcomes. 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Figure 1. Conceptual Model – Quality of Care in Primary Care 

STRUCTURES 

Clinic setting – size, location 

Workplace conditions – physical 

environment, organizational 

culture 

PROCESSES 

Clinical care 

Interpersonal interaction 

Clinic processes – staffing, 

workflow, organizational culture 

Provider Outcomes 

Job satisfaction 

Productivity 

Pay 

OUTCOMES 

Quality – access and clinical 

effectiveness of care 

Safety – diagnostic errors, nonmedication treatment errors, 

medication errors 

Patient satisfaction – with provider, 

with clinic/practice 

PATIENT OUTCOMES 

We focused on the following patient outcomes: quality of care, patient safety, and patient 

satisfaction. 

Quality of Care 

Quality of care is typically categorized broadly into a)access to care and b)effectiveness of 

care.14 Accessibility addresses whether patients can actually get the care they need while 

clinical effectiveness addresses whether the care received results in the intended outcome. 

Both constructs are influenced by structures and processes in the healthcare setting. For 

example, access can be limited by both physical location (structure) and affordability (process). 

Effectiveness includes knowledge or evidence-based care, guideline concordant care, or clinical 

effectiveness and is often measured as provider compliance to the guidelines or evidence. 

Patient Safety 

Patient safety can be broadly related to diagnosis errors, treatment errors, and perhaps missing 

preventive services.15 However, because there is some overlap in treatment and diagnostic errors 

with quality of care, we included performance metrics dealing with missing preventive services 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

or other metrics that represent management of disease or appropriate care with the quality 

measure in this report even though failure to manage chronic conditions or ensure preventive 

care utilization can clearly lead to adverse events. Thus, we refer to patient safety as medication 

errors in the remainder of the report. Similar to quality, medication errors may be the result of 

structures within the health care system or clinical and non-clinical processes. 

Patient Satisfaction 

Patient satisfaction often includes components of quality of care and patient safety as patients 

tend to be more satisfied if they feel they are receiving high quality care and they are not subject 

to medical errors.16 Broadly, we classify patient satisfaction as satisfaction with the provider 

and satisfaction with the clinic. Satisfaction can be measured using different scales and may be 

influenced as much by clinical care processes as by structures or the clinic environment (i.e., 

receptionist, waiting time, etc.). 

PROVIDER OUTCOMES 

As noted, the aim of this report was to focus on patient outcomes. However, as outlined in the 

conceptual model (Figure 1), the underlying mechanism of the effect of workplace conditions 

on patient outcomes is likely through the effect of workplace conditions on providers. Although 

we did not systematically review studies focused on providers, we briefly discuss the general 

findings from this literature. 

Following a recent review, we refer to provider outcomes in this context as aspects of provider 

“wellness,” which include physical, mental/psychological, and emotional health.9

 Understanding 

the effects of workplace conditions on provider wellness is likely complicated by the 

interdependent nature the individual provider characteristics, workplace conditions, and larger 

healthcare system factors. 

One of the most frequently studied provider outcomes is psychological stress, which correlates 

with poor physical and mental health. Various healthcare workplace conditions have been linked 

to increased stress levels and negative physical health for providers, including workload, pay, 

organizational structure (bureaucratic), restricted autonomy, and a professional culture that does 

not encourage providers to seek medical help for themselves.9 

Beyond the immediate physical and mental health effects of workplace conditions on providers 

are the effects that ripple through the healthcare system. The effects of job stress on healthcare 

providers’ absenteeism, burnout, performance, and intention to quit or leave,17-20 have been 

well documented in the literature. Not surprisingly, stressed employees are more likely to be 

absent from work, be low performers, and have greater turnover rates than other employees. 

Similarly, satisfied providers are more likely to have satisfied patients.21,22 At the organizational 

level, these effects can permeate the organizational culture to create an unhealthy and ineffective 

workforce.20,23 Furthermore, stressed and dissatisfied healthcare providers are more likely to 

make medical mistakes that effect patients24-26 and have dissatisfied patients.27 

As noted above, these relationships are complex and dynamic in such a way that not only are 

the effects felt at many levels (provider, patient, healthcare system), but also they create a cycle 

of reinforcing behaviors and outcomes. For example, a heavy workload may cause a provider 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

excessive psychological stress, which may in turn influence her physical health and also cause 

her to be more prone to medical errors, which may create even more distress repeating the 

cycle.28,29 

As outlined in the Wallace et al. review,9 there are several potential policy interventions at 

various levels that might positively influence provider wellbeing. In this study, we focused 

on studies that shed light on possible workplace interventions (as opposed to provider selfcare or higher-order system level interventions) that will ultimately impact patient outcomes. 

Such changes to workplace conditions will likely also influence provider outcomes. While 

examples of workplace changes that positively affect both providers and patients exist, such as 

an organizational culture that emphasizes quality, reduces provider stress and increases quality 

of care for patients,6

 we point out that there are some workplace changes that may yield greater 

patient outcomes at the expense of poorer provider outcomes, such as electronic medical records. 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

METHODS 

TOPIC DEVELOPMENT 

This project was nominated by Michael Hodgson, MD, MPH. The primary aim was to review the 

evidence on the associations between primary care workplace conditions and patient outcomes 

as depicted in Figure 2. The key questions and scope of the report were refined with input from a 

technical expert panel. 

The final key questions are:
	

Key Question #1. How are HR practices, such as skill levels, training, workload, hours worked, 

autonomy, and electronic medical records/systems, associated with patient outcomes? 

a. quality of care (access and effectiveness) 

b. safety (medication errors) 

c. patient satisfaction (with provider, with clinic/practice) 

Key Question #2. How are other working conditions, such as organizational culture or physical 

environment, associated with patient outcomes? 

a. quality of care (access and effectiveness) 

b. safety (medication errors) 

c. patient satisfaction (with provider, with clinic/practice) 

Key Question #3. In studies that report provider outcomes, how are HR practices and working 

conditions associated with provider outcomes (e.g., job satisfaction, productivity, pay)? 

Figure 2. Analytic Framework 

KQ1, KQ2 

Ambulatory Primary 

Care Clinic Working 

Conditions* 

Adverse Effects: 

Stress, burnout 

Turnover/intent to 

leave 

Adverse Effects: 

Diagnostic errors, communication 

errors, procedure errors 

Patient safety (adverse drug events, 

mortality) 

Patient Outcomes: 

Quality of care (receipt 

of recommended care, 

hospitalization for ambulatory care 

sensitive conditions) 

Access 

Patient satisfaction 

KQ3 Provider 

(Intermediate) 

Outcomes: 

Job satisfaction 

Productivity 

Pay 

*Working Conditions of Ambulatory Primary Care Clinics 

1. Human resources practices (work volume, scheduling, training/skills required, task design, information systems) 

2. Organizational culture (organizational climate, professional culture, hierarchy) 

3. Physical environment (safety, lighting/temperature, physical layout) 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

SEARCH STRATEGY 

We conducted searches for human resource practices [separate searches for staffing and 

workflow], organizational culture, and physical environment in MEDLINE and PsycINFO. We 

developed our search strategies based on the 2003 AHRQ report.4 To insure that we captured 

studies of team-based approaches to care (as requested by our TEP), we also did focused 

searches in both MEDLINE and PsycINFO. MEDLINE search strategies are presented in 

Appendix A. We included randomized controlled trials, systematic reviews, and prospective 

studies published in English from 2000 to September 2011. Our search focused on primary care 

physicians, nurse practitioners, and physician assistants as providers and adult patients receiving 

care in ambulatory, primary care settings. For provider outcomes, we searched MEDLINE and 

the Cochrane Effective Practice and Organization of Care (EPOC) Group Web site for recent 

systematic reviews or meta-analyses. Additional citations were identified from reference lists of 

related articles. 

STUDY SELECTION 

Titles and abstracts were reviewed by researchers trained in the critical analysis of literature. Full 

text versions of potentially eligible articles were retrieved for review. Our inclusion criteria were: 

1. Study published in English language 

2. Randomized trial, observational study or systematic review (the article had to present 

data analysis results) 

3. Outpatient, adult, primary care setting, without focus on one specific disease or patient 

population 

4. Study addressed working conditions for primary care physician, nurse practitioner, or 

physician assistant 

5. Reported outcomes of interest: 

Patient Outcomes – quality of care, patient safety, patient satisfaction
 

Provider Outcomes – job satisfaction, productivity, pay
 

DATA ABSTRACTION 

We abstracted the following data for each included study for Key Questions #1 and #2: author, 

date of publication, country where study was conducted, funding source, characteristics of 

included patients, providers and/or clinics, study design, working conditions evaluated, and 

patient outcomes (quality [access, effectiveness], safety [ medication errors], and satisfaction 

[with provider, with practice or care]). We also abstracted data on provider outcomes, where 

provided. Additional data for Key Question #3 was obtained from recent systematic reviews or 

meta-analyses. All abstraction was done by trained research personnel under the supervision of 

the Principal Investigator. 

QUALITY ASSESSMENT 

We assessed study quality of randomized trials according to the following criteria: 1) adequate 

allocation concealment, 2) blinding of key study personnel, 3) analysis by intention-to-treat, and 

4) reporting of number of withdrawals/dropouts by group assignment.30 Studies were rated as 

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The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

good, fair, or poor quality. A rating of good generally indicated that the trial reported adequate 

allocation concealment, appropriate blinding, analysis by intent-to-treat, and reasons for 

dropouts/attrition. Studies were generally rated poor if the method of allocation concealment was 

inadequate or not defined, blinding was not defined, analysis by intent-to-treat was not utilized, 

and reasons for dropouts/attrition were not reported and/or there was a high rate of attrition. 

For non-randomized trials, we determined risk of bias based on critical elements related to the 

population, intervention, outcomes, measurement, and confounding (Appendix B). 

DATA SYNTHESIS 

We constructed evidence tables showing the study characteristics and results for all included 

studies, organized by working condition. We critically analyzed studies to compare their 

characteristics, methods, and findings. Due to heterogeneity of interventions and outcomes 

assessed we were unable to pool results from different studies. We compiled a summary of 

findings for each working condition, and drew conclusions based on qualitative synthesis of the 

findings. 

RATING THE BODY OF EVIDENCE 

We assessed the overall quality of evidence using the method reported by Owens et al.31 Briefly, 

for each outcome evaluated, the strength of the evidence was assessed based on: 1) risk of bias; 

2) consistency; 3) directness; and 4) precision. Based on these four domains, the overall evidence 

was rated as: 1) high, meaning high confidence that the evidence reflects the true effect; 2) 

moderate, indicating moderate confidence that further research may change our confidence in the 

estimate of effect and may change the estimate; 3) low, meaning there is low confidence that the 

evidence reflects the true effect; and 4) insufficient, indicating that evidence either is unavailable 

or does not permit a conclusion. 

PEER REVIEW 

A draft version of this report was reviewed by members of our technical expert panel as well as 

VA clinical leadership. Their comments and our responses are presented in Appendix C. 

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The Effect of Working Conditions 

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RESULTS 

LITERATURE FLOW 

Figures 3-5 detail the exclusion criteria and the number of references related to each of the key 

questions. Separate searches were conducted for the human resource practices components of 

staffing and work flow. For the staffing search, we identified 1008 abstracts and excluded 913. 

Of 95 full text articles reviewed, we included 14. For the work flow search, we identified 1,581 

abstracts and excluded 1,487. Of 94 full text articles reviewed, we included 9. Four articles were 

added from our hand search of reference lists resulting in a total of 27 references included for 

human resource practices (Key Question #1). 

We identified 541 abstracts pertaining to organizational culture. After excluding 497, we reviewed 

44 full text articles and included 2. One article was added from the specific team-based care search 

and 6 articles were added from hand searching resulting in a total of 9 included references. 

The physical environment search resulted in 49 abstracts. We excluded 46 and reviewed the full 

text of 3 articles. All 3 were excluded. The 2 articles included in the report were added after hand 

searching. 

Figure 3. Literature Flow Diagram – Human Resource Practices Studies 

STAFFING 

search results 

= 1008 

references 

Pulled for full 

text review = 

95 references 

Included 

studies = 14 

references 

Excluded = 913 references 

Not English language = 2 

Case series, case report, 

editorial, letter, book, 

dissertation = 135 

Not outpatient, adult, ambulatory 

(primary care) care setting = 155 

Does not address working 

conditions = 386 

No outcomes of interest = 220 

Duplicate listings = 15 

Excluded = 81 

references 

Not relevant to 

key question = 81 

references 

Handsearched references = 

4 references 

Included 

studies = 9 

references 

Pulled for full 

text review = 

94 references 

WORKFLOW 

search results 

= 1581 

Excluded = 1487 references references

Case series, case report, 

editorial, letter, book, 

dissertation = 232 

Not outpatient, adult, 

ambulatory (primary care) 

care setting = 432 

Does not address working 

conditions = 512 

No outcomes of interest = 307 

Duplicate references = 4 

Excluded = 85 

references 

Not relevant to 

key question = 85 

references 

TOTAL HR included 

studies = 27 references 

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The Effect of Working Conditions 

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Figure 4. Literature Flow Diagram – Organizational Culture Studies 

Search results = 541 references 

Pulled for full text review = 44 

references 

Included studies = 9 references 

Excluded = 497 references 

Not English language = 1 

Case series, case report, editorial, letter, book, dissertation = 118 

Not outpatient, adult, ambulatory (primary care) care 

setting = 202 

Does not address working conditions = 155 

No outcomes of interest = 13 

Duplicate listings = 8 

Excluded = 42 references 

Not relevant to key question = 42 references 

Team-based care search = 1 reference 

Handsearched references = 6 references 

Figure 5. Literature Flow Diagram – Physical Environment Studies 

Search results = 49 references 

Pulled for full text review = 3 

references 

Included studies = 2 references 

Excluded = 46 references 

Case series, case report, editorial, letter, book, dissertation = 6 

Not outpatient, adult, ambulatory (primary care) care 

setting = 19 

Does not address working conditions = 19 

No outcomes of interest = 1 

Duplicate listings = 1 

Excluded = 3 references 

Not relevant to key question = 3 references 

Handsearched references = 2 reference 

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KEY QUESTION #1. How are human resource practices, such as skill 

levels, training, workload, hours worked, autonomy, and electronic 

medical records/systems, associated with patient outcomes? 

a. quality of care (access and effectiveness) 

b. safety (medication errors) 

c. patient satisfaction (with provider, with clinic/practice) 

Twenty-seven studies (12 set in the US, 13 set in Europe, and 2 set outside of the US/Europe) 

met inclusion criteria.6, 32-57 We summarize these studies in Appendix D, Tables 1-3. In Table 

1, we present an overall summary of studies by HR practice and patient outcome studied. 

We reviewed studies that investigated the following HR practices a) skills (measured as MD 

versus NP or PA skill level), b) training (different training interventions to increase patient 

communication, visit efficiency or clinical effectiveness), c) workload (measured most often 

as the provider’s listsize), d) hours (measured as either full time versus part time work, as 

a continuous measure of hours worked, or hours worked after being on-call), e) autonomy 

(provider report of control over work tasks), and f) electronic medical records (EMR) system 

or other computerized system (e.g., referral system). We discuss the main findings for each HR 

practice below. 

17
 
ns on Patient Care: A Systematic Review Evidence-based Synthesis Program 

ctices Studies by HR Practice Studied and Patient Outcome Studied 

Quality of Care Patient Safety Patient Satisfaction 

or, Year Clinical Effectiveness or Access Reduced Errors1 With Provider With Practice or Care 

0632 n/a n/a ↔ 

 Daele 200933 n/a n/a ↔ 

0834 n/a n/a ↓ 

2000*35 n/a n/a ↔ 

4*36 n/a n/a ↓ ↔ 

9*37 ↔ 

00438 ↔ 

739 ↑ 

*40 ↔ 

*41 ↑ ↔ 

00142 ↓ 

00543 ↓ 

0644 ↔ 

45 ↑ 

0946 ↔ 

9*6 ↔ ↔ 

47 ↑ ↑ 

148 ↓ 

009*49 ↑ 

01050 ↔ ↔ 

001*51 ↓ ↔ 

152 ↔ ↔ 

2003*53 ↓ ↔ 

9*6 ↔ ↑ 

200754 ↓ 

s 2008*55 ↑ ↑ 

010*56 ↑ 

9*57 ↑ 

12 3 14 7 

 in the U.S. 1This outcome has been reverse coded in this table so that a positive effect (up arrow) indicates the study found 

ured as Medicare caseload in this study. 3EMR refers to an electronic referral system in this study. 4This is a count of the total 

atient outcome. There are 27 total studies that evaluate at least one HR practice and one patient outcome. An “up” arrow 

ntation of an HR practice (training, autonomy, EMR) or the increase in a practice (skill level, workload, or hours) was associated 

uced errors (i.e., better patient safety), or greater patient satisfaction. A “down” arrow indicates that increasing/implementing the 

of care, fewer reduced errors, or less patient satisfaction. The ↔ arrow indicates that no significant association was found. 

18 
 

 

 

 

 

 

 

 

 

 

The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Skills 

Two US and three European studies were included that focused on how provider skill level (MD vs. 

NP/PA) influenced patient satisfaction. Overall, the evidence was inconsistent on the effect of provider 

skill level on patient satisfaction. One large cross-sectional study of over 26,000 Kaiser Permanente 

patients in Georgia found that patients were about 15 percent (p<0.05) more likely to be satisfied with 

the provider interaction received when seeing a PA/NP instead of an MD, but found no significant 

difference in satisfaction with care by skill level of the provider,36 as did one smaller scale crosssectional study set in the Netherlands.34 However, two studies where patients were randomly assigned 

to either an MD or an NP found no evidence of differences in patient satisfaction by skill level.33,35 We 

identified one VA study that examined patient satisfaction scores from 1.6 million veterans seen in 

21 VISNs and reported aggregate changes in patient satisfaction over time by VISN, but the authors 

did not report these results stratified by skill level except for three specific VISNs where satisfaction 

increased when more NP/PAs were hired,58 so we were unable to include this study in our review. 

Overall, the evidence was inconsistent on the effect that provider skill level has on patient satisfaction. 

We do note that the two randomized control studies found no effect. Following the 2003 AHRQ 

report, we did not review studies that examined the effect of skill levels on patient quality of care or 

patient safety as it is widely accepted that medical school or more training increases quality of care.4 

Training 

Five studies (three US, one Canadian, and one European) were included that evaluated the 

effectiveness of a training intervention on patient satisfaction and quality of care. All four that 

examined patient satisfaction found no effect of various training programs. These training 

programs included training on how to effectively structure visits,40 communication skills 

workshops,41 shared decision making and risk communication training,38 and a provider report 

of having received cultural competence training.37 The latter study was not an analysis of the 

intervention and only examined correlations between provider report of having received cultural 

competence training and patient satisfaction (i.e., no pre/post analysis).37 However, two studies 

(one US and one Canadian study) found a positive effect of training (communication skills 

workshop and a remedial professional development program) on clinical effectiveness measured 

from audits of patient charts for guideline concordant care.39,41 Overall, we find some evidence 

that training might improve clinical effectiveness, but little evidence that it affects patient 

satisfaction. There were no studies included in our review that examined the effect of training 

on patient safety, in this case medication errors; however, there is a large literature investigating 

the role of training on patient safety in hospital settings (e.g., surgical training) that has found, in 

general, that more training improves patient safety (e.g., Wachter, 2004;2

 Shapiro et al., 200459). 

Workload 

Ten studies were included that investigated how provider workload affects patient outcomes. 

Three of the four studies (all European) that specifically examined patient satisfaction found 

no correlation between workload and patient satisfaction. However, the measures of patient 

satisfaction in two of these studies included satisfaction with wait time or ability to get an 

appointment.46,50 Only one study found a positive correlation between provider workload and 

patient satisfaction measured specifically as satisfaction with the care received.47 Thus, we 

conclude that there is little evidence that workload affects patient satisfaction with the provider, 

though it might influence satisfaction with the ability to get an appointment. 

19 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Three of the five studies (one US and three European) found that workload negatively affects 

quality of care, measured as guideline concordant care for management of chronic conditions,42 

access to provider,43 and rates of ambulatory care sensitive hospitalizations.48 One study reported 

that care quality scores were not significantly different for providers with high time pressure 

or for those who worked in a “chaotic office.”6 The fifth study reported that greater Medicare 

caseloads were needed to obtain higher rates of patients getting preventive care screening.49 

However, as that study uses a different measure of workload (which may arguably not be a good 

proxy for workload), we conclude that there is some evidence suggesting that higher workloads 

negatively influence quality of care. 

Finally, two studies (one in the US and one in China) investigated workload and patient safety. 

The US study surveyed almost 1,800 patients across 119 clinics in 5 urban and rural area and 

found that a greater workload (time needed per patient divided by the time allotted per patient) 

had no effect on non-medication treatment errors assessed from chart audits.6

 However, a large 

study of over 20,000 prescriptions written from 680 primary care clinics in rural China found 

that physicians with greater workloads (patient visits/month) were about 70 percent more likely 

to prescribe 5 or more drugs per patient than those with lighter workloads.45 Thus, given that 

these studies are not representative and yield conflicting findings, we conclude that there is 

insufficient evidence about the role of workload on patient safety. However, as discussed in 

the previous paragraph, two studies found no effect of workload on guideline concordant care 

and one found no effect on ambulatory care sensitive hospitalizations, all of which could be 

considered measures of patient safety. 

Hours 

Three studies (two US and one European) were included that investigated how provider 

work hours affects patient satisfaction and quality of care. All three studies found no effect of 

providers’ work hours on patient satisfaction; regardless of whether hours were measured as 

full time vs. part-time (less than 30 hours per week),51 as a continuous measure of appointment 

hours,53 or designated as hours surrounding “on call” versus “off call” duty.52 However, two of 

these studies also examined the effect of hours on patient quality of care and found that providers 

who work fewer hours were more likely to be compliant with guidelines for preventive care 

screening and management of a chronic disease.51,53 Thus, based on these three studies, our 

review suggests that while provider’s work hours may not have influenced patient satisfaction, 

there was some preliminary evidence that longer work hours may have negatively affected 

quality of care provided. We note that most of these studies meet few of the low risk of bias 

quality criteria described in the Appendix. There were no studies included in our review that 

investigated hours and patient safety (in this case, medication errors), though there is a large 

literature examining the effect of hours worked among nurses, residents and in hospital settings 

(see AHRQ report4). 

Autonomy 

Two studies (one US and one European) were included that investigated provider reports of 

autonomy, or provider control over work tasks, and patient outcomes. The Linzer et al., study 

(described above),6 found that providers who reported greater control (based on a 14 item 

scale that was then dichotomized) did not have greater quality “scores” based on chart audits 

20 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

assessing their management of chronic conditions but did have lower error “scores” based on 

chart audits assessing their missed treatment opportunities, inattention to behavioral factors 

and guideline non-adherence. A study based in Scotland found that patients were less satisfied 

with how they were treated by staff and wait time for visits where the provider reported greater 

control of work.54 Although these two studies are suggestive, this is insufficient evidence to draw 

conclusions about the role of job autonomy on patient outcomes. 

Electronic Medical Records 

Three studies (all US) were included that investigated EMRs or other computerized systems that 

affected how providers do their jobs. All three studies found that EMR systems improved quality 

of care by alerting providers to critical lab values, assisting providers to provide preventive 

care, order lab work, tests, or specialty referrals.55-57 One study also found evidence that an EMR 

system that gave warnings and clinical decision support was more effective in helping providers 

prevent drug allergies or dangerous medication interactions over more basic systems without 

those capabilities.55 While these three studies suggest that EMR systems have improved patient 

quality of care, one study relied on provider reports of how the system aided work, as opposed 

to more objective measures.55 One large study utilized panel data methods to assess specialty 

referrals before and after an electronic medical referral system was put in place,57 but the other 

two studies relied on cross-sectional or cohort analysis. Thus, the evidence is suggestive that 

EMR systems improve patient quality, but more intervention analyses should be done and there 

is insufficient evidence on how EMR systems affect patient satisfaction. 

Pay for Performance 

One theoretical component of workplace conditions is the practice of Pay for Performance (P4P) 

where providers are partially compensated with incentive payments based on quality of care. 

A large body of literature focused on P4P exists, but we discuss two more recent systematic 

reviews without doing a systematic review of the P4P literature.60,61 Although Christianson et al.60 

reported improvement in select quality measures, they also concluded that the role of financial 

incentives for providers in quality improvement is unclear. The authors underlined variation in 

targeted outcomes, criteria for incentives, and questions based on provider reactions to incentives 

as topics for further research. A 2010 review of one hundred twenty-eight evaluation studies61 

made similar conclusions. Thus, while there may be some evidence of the effectiveness of P4P 

systems, two recent systematic reviews conclude that there is too much variation in the evidence, 

study designs, and provider attributes to make clear conclusions about the effect of P4P on 

patient outcomes. 

Summary of Findings 

We identified three randomized controlled trials, seven longitudinal (cohort or pre-post with 

repeated cross-sections) studies, and 17 cross-sectional studies investigating the role of HR 

practices in primary care clinics in explaining patient outcomes. 

Nine of eleven studies we examined that focused on patient quality of care as an outcome, 

specifically measured clinical effectiveness, thus there is insufficient evidence on the role of 

provider workplace conditions on access as a quality of care measure. The most frequently 

studied HR practice for quality of care was workload and, in general, the evidence suggests 

21 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

that an increased workload results in lower quality of care. However, the only two US studies 

found either no effect6

 or a positive effect.49 Furthermore, all of the workload studies were 

cross-sectional and often were not low risk of bias studies. The other HR practices studied were 

evaluated less frequently, but there was more consistency in the results across studies: more 

training (2 studies), shorter hours (2 studies), and computerized systems (3 studies) lead to better 

quality. Only one study we reviewed examined provider autonomy or flexibility and found mixed 

effects on quality of care scores; this is insufficient evidence for the role of autonomy. Overall, 

these results are suggestive but make it difficult to make strong conclusions about the role of HR 

practices on patient quality of care. 

We identified three studies in our review that explicitly examined the role of workplace 

conditions on patient safety, measured as medication errors, in the primary care setting. While 

these were relatively well designed studies, more studies are needed. Because only two studies 

examined workload, one examined autonomy and one examined computerized systems, there is 

insufficient evidence to answer our key question about how HR practices influence patient safety. 

We identified 17 unique studies that investigated how HR practices influence patient satisfaction 

with either the provider or the clinic. We found mixed evidence on the role of provider skills 

(MD vs. NP/PA) on patient satisfaction; two studies found no effect and two cross-sectional 

studies found a negative effect of skills. We also found mixed evidence on the role of provider 

workload with one study finding a positive effect and two finding no effect. All four of the 

studies that examined provider training and all three that examined provider work hours found 

that they had no effect on patient satisfaction. Overall, there is suggestive evidence that training 

and work hours do not effect patient satisfaction, but again, because of the lack of studies, 

we cannot make strong conclusions about these findings. Similarly, we conclude that there is 

inconsistent evidence on the role of skills and workload. We identified no studies that looked at 

how computerized systems affect patient satisfaction. 

Quality of Evidence for Key Question #1 

Quality of randomized and non-randomized trials was assessed as described in the Methods 

section. Items considered in assessing the quality of randomized trials are presented with the 

study description (Appendix D, Tables 1-3). Figure 6 depicts the percent of the non-randomized 

trials that met the criteria for each quality dimension assessed. 

22
 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Figure 6. Study Quality of Human Resource Practices Non-Randomized Studies 

Notes: There were 24 (out of 27) non-RCT studies examining HR practices and patient outcomes. Only 4 of these studies 

included intervention (and thus were evaluated on that dimension). The numbers on each bar indicate the number of studies that 

either met the study quality criteria (dark gray) or did not (light gray). 

We evaluated the strength of evidence for the workplace conditions and patient outcomes for 

which we had at least three studies (Table 2). Strength of evidence overall was low for patient 

satisfaction and provider skills, workload, and hours; and for quality of care and provider 

workload and electronic medical records. Most of the evidence was rated high or moderate on 

risk of bias due to the lack of many well-designed RCTs or observational studies that address 

potential biases. There was also inconsistent measurement of both the workplace condition 

constructs and the patient outcome constructs, which made comparisons across studies difficult. 

There was insufficient evidence for patient safety and all workplace conditions, quality of care 

and training and hours, and patient satisfaction and EMR. Additionally, there was insufficient 

evidence on provider autonomy and all patient outcomes. 

23 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Table 2. Human Resource Practices – Strength of Evidence for Key Outcomes 

Workplace 

Condition 

& Patient 

Outcome (#

of studies) 

Domains of Strength of Evidence Overall Strength of

Evidence (SOE)

(effect if

consistent) 

Risk of 

Bias 

Consistency Directness Precision Other Notes 

Patient 

Satisfaction 

& Provider 

Skills (5) 

High Inconsistent Direct Imprecise Low SOE 

Patient High Consistent Direct Precise Training is Low SOE (positive 

Satisfaction measured effect) 

& Provider inconsistently across Training (4) studies 

Patient Moderate Consistent Indirect Precise Workload is often Low SOE (no effect) 

Satisfaction measured as 

& Provider “listsize” 

Workload (4) 

Patient 

Satisfaction 

& Provider 

Hours (3) 

High Consistent Direct Precise Low SOE 

(no effect) 

Quality High Inconsistent Indirect Precise Workload is often Low SOE 

of Care & measured as 

Provider “listsize” 

Workload (5) 

Quality Moderate Consistent Indirect Precise EMR/computerized Low SOE 

of Care & systems are (positive effect) 

Electronic measured 

Medical inconsistently across Records (3) studies 

KEY QUESTION #2. How are other working conditions, such as 

organizational culture or physical environment, associated with 

patient outcomes? 

a. quality of care (access and effectiveness) 

b. safety (medication errors) 

c. patient satisfaction (with provider, with clinic/practice) 

Organizational Culture 

Nine studies met inclusion criteria.6,62-69 Six studies were conducted in the United States and 

three in Canada. We summarize study characteristics in Appendix D, Table 7. We reviewed 

studies that examined the following four organizational culture components: a) patient-centered 

medical homes (PCMH) (patient-centered approach to care management and coordination 

through a practice based care team), b) team-based care (multi-disciplinary care centered around 

the primary care physician to facilitate communication among care team members), c) care 

environment (environment and culture focused on delivering care to a specific demographic 

of the population), and d) clinic values (perceptions of how organizational values line up with 

personal values of providers). Table 3 provides an overview of the distribution of studies by 

reported outcomes (quality of care, patient safety, patient satisfaction, and provider outcomes). 

24 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

PCMH 

Two pre-post observational studies reported quality of care outcomes based on the organizational 

culture component of PCMH.63,64 Both studies showed improvements in quality of care at clinics 

where PCMH was implemented. Although Reid et al. found no improvement in hospitalization 

rates for PCMH clinics compared with usual care, PCMHs resulted in significant improvements 

in hospitalizations for ambulatory care sensitive conditions (ACSC).64 The second study 

demonstrated significant improvement in hospital admission and readmission rates for PCMH 

clinics against modeled controls.63 Reid et al.64 also found that patient satisfaction with provider 

(quality of interaction, shared decision making, coordination of care, access to provider) and 

care (patient involvement, goal setting/tailoring) increased after the implementation of PCMH. 

Although there were only two studies reviewed, both employed a pre-post observational design 

and suggested that PCMH improved quality of care and patient satisfaction. 

Team-based Care 

Five studies reported outcomes for the primary care cultural component of team-based care.65-69 

Three studies evaluated the effect of team based care on quality of care outcomes.65,67,68 Two of 

these studies, including one randomized controlled trial,68 found that team based care significantly 

increased quality of care, measured as chronic disease management and preventive care with 

the use of team care68 and patient rated quality of life.67 However, the third study, a case-control 

design, demonstrated no change in hospitalizations or emergency room (ER) visits.65 Two studies 

evaluated patient satisfaction with team-based care65,66 and found mixed results. One cross-sectional 

study showed no improvement in patient satisfaction,65 whereas the randomized controlled trial 

study found a two-fold increase in patient rating of chronic care for team-based guided care versus 

usual care.66 Finally, one study randomized 48 physicians and their patients to receive pharmacists’ 

consultations or usual care and found that face-to-face patient-pharmacist consultations identified 

at least one drug problem in 79 percent of the intervention population with no data provided for 

control physicians.69 Overall, these studies present contradictory evidence making it difficult to 

make conclusions about how effective team-based primary care is for improving quality of care or 

patient satisfaction. We identified only one study that evaluated the effect of teams on patient safety 

in the ambulatory care setting,69 but comparison data were not presented in this study. 

Care Environment 

We reviewed one cross sectional study that reported patient satisfaction with care based on the care 

environment.62 Specifically, among women using the Veterans Health Administration (VHA) system 

of care, attending a women’s clinic was a significant positive predictor for all measures of patient 

satisfaction with care (privacy and comfort, communication, complete care, follow-up, receiving 

care, overall) when compared with usual primary care clinics. This one study is insufficient to make 

conclusions about the role of the care environment on patient satisfaction. We identified no studies 

that investigated the relationship between the care environment and quality of care or patient safety. 

Clinic Values 

One cross-sectional study looked at clinic values in relation to provider satisfaction, and quality of care.6 

The study found a positive association between clinical values such as quality emphasis, information 

and communication emphasis, organizational trust, workplace cohesiveness, and values alignment and 

total quality measured by diabetes care, hypertension management, and preventive care. Thus, there is 

insufficient evidence on the role of clinic values or norms in explaining patient outcomes. 

25 
ns on Patient Care: A Systematic Review Evidence-based Synthesis Program 

re Studies by Practice Studied and Patient Outcome Studied 

Quality of Care Patient Safety Patient Satisfaction 

hor, Year Clinical Effectiveness or Access Reduced Errors With Provider With Practice or Care 

yberry 

09*6 

010*63 

↑ ↑ 

↑ 

*64 ↑ ↑ ↑ 

0*65 ↔ ↔ 

9*66 ↑ 

e 201167 ↑ 

968 ↑ 

0369 ↔ 

6 1 1 4 

in the U.S.

of unique studies for each outcome. There are 8 total studies that evaluate at least one organizational culture practice and 

indicates that the increase in /implementation of an organizational culture practice was associated with higher quality of care, 

ent safety), or greater patient satisfaction. A “down” arrow indicates that increasing/implementing the organizational practice 

er reduced errors, or less patient satisfaction. The ↔ arrow indicates that no significant association was found. 

26
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Summary of Findings for Organizational Culture 

There is limited evidence from two pre-post quasi-experimental studies on PCMH as a primary 

care cultural component. These studies reported positive effects of PCMHs on quality of care, 

and the one study that evaluated the effect of PCMH on patient satisfaction found a positive 

effect. We conclude that there is suggestive evidence that PCMHs increase quality of care, but in 

general insufficient evidence on the effect of PCMHs on patient outcomes. PCMH studies were 

assessed to have a high risk of bias meeting only two of five quality criteria for non-randomized 

studies as described in the methods section. 

Limited data from five studies provided inconsistent evidence that team-based care improved 

quality, patient safety, or patient satisfaction. Two studies found positive effects of team-based 

care and patient quality of care, however one of these was a high risk of bias study. The other 

study on quality of care and teams found no effect. Thus, while the evidence is suggestive that 

team-based care improves patient quality of care, more well-designed studies are needed. Results 

for patient satisfaction were unclear as one cluster-randomized controlled trial with a low risk 

of bias reported that patients seen by guided care teams had twice greater odds of rating chronic 

care highly66 and one cross-sectional study found no significant association. Finally, results for 

patient safety or medication errors are inconclusive for team-based care due to limited evidence 

from one randomized controlled trial with a high risk of bias69 that did not report comparison 

effects. 

Evidence for the effect of care environment on patient satisfaction is also unclear. One cross 

sectional study which met one of four quality criteria for non-randomized controlled trials 

showed higher patient satisfaction with care among women attending a women’s clinic at the 

Veterans Health Administration. Related studies investigating the effect of “clinic values” and 

quality of care suggested a positive correlation with quality of care. However, validated measures 

of the care environment or clinic values are needed in order to make comparisons across studies. 

Strength of Evidence for Organizational Culture 

The strength of evidence for the affect of PCMH on quality of care is low primarily due to a 

high risk of bias, and inconsistencies in reported effect size. The studies directly related PCMH 

interventions to quality of care without surrogates, but a rating of precision was not applicable 

due to lack of pooled outcomes. Only one study reported on patient satisfaction with PCMH 

therefore the body of evidence is insufficient for strength assessment. 

The strength of evidence for the effect of team-based care on quality of care is low due to studies 

with a high risk of bias, inconsistencies in the reported effect sizes, and indirect reporting using 

surrogate measures for quality of care. Again, a rating of precision was not applicable due to 

lack of pooled outcomes. Only one study reported on patient safety with team-based care and 

therefore the body of evidence is insufficient. The strength of evidence for the effect of teambased care on patient satisfaction is low due to studies with a high risk of bias, an indirect link 

to patient satisfaction, and inconsistent effect sizes. A measure of precision was not applicable. 

The evidence for the effect of care environment or clinic values on quality of care or patient 

satisfaction is insufficient as each component of organizational culture included only one study. 

27 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Figure 7. Study Quality of Organizational Culture Non-Randomized Studies 

Notes: There were 6 (out of 9) non-RCT studies examining organizational culture practices and patient outcomes. Only 5 of 6 

studies provided outcomes based on interventions. The numbers on each bar indicate the number of studies that either met the 

study quality criteria (dark gray) or did not (light gray). 

Physical Environment 

Two studies met inclusion criteria70,71 are summarized in Appendix D, Table 12. One study was 

conducted in the United States71 and one was conducted in the United Kingdom (UK).70 We also 

present data from a systematic review of patient satisfaction with electronic health record (EHR) 

use in examination rooms. 

Table 4. Physical Environment Studies by Patient Outcome Studied 

Quality of Care Patient Safety Patient Satisfaction 

First Author, Year Clinical Effectiveness 

or Access 

Reduced Errors With Provider With Practice 

or Care 

Arneill 200271 ↑* ↑** 

Rice 200870 ↑ 

*Study measured “perceived” quality of care; **Study measured “perceived” comfort in environment 

An “up” arrow indicates that “better” physical environment was associated with higher quality of care or greater patient 

satisfaction 

28 
 

 

 

 

 

 

 

 

 

The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

The UK study evaluated patient anxiety and satisfaction and patient-doctor communications 

before and after relocating to a new clinic facility.70 Enhanced environmental features of the 

new clinic included lighting, sound, space, privacy, furnishings, and artwork. Patients reported 

significantly less anxiety both before and after a provider consultation in the new facility 

(Table 5). They also preferred the new reception/waiting area and consultation rooms and rated 

satisfaction with doctor-patient communication higher in the new facility. 

Table 5. Physical Environment Outcomes70 

Variable Phase 1 

(pre-move) 

Phase 2 

(post-move) 

Significance

STAI Pre-consultationa 11.7 10.9 p<0.001 

STAI Post-consultationa 10.5 10.1 p=0.03 

Reception/Waiting Area Ratingb 33.3 39.8 p<0.001 

Consultation Room Ratingc 23.0 26.7 p<0.001 

Communication with Provider 

Ratingd 

37.6 38.5 p=0.003 

a

STAI=Spielberger State-Trait Anxiety Inventory, range of scores 6 to 24; brange 9-45; crange 

6-30; drange 6-42; erange 0-12 

In the US study, participants were asked to view and rate slide images of clinic waiting rooms.71 The 

slides were from 28 waiting rooms and included clinics in renovated houses, in office buildings, 

and connected to hospitals. The rooms varied in size, color, lighting, and furnishings. A factor 

analysis found that perceived quality of care was higher for waiting rooms rated high on “attractive 

lighting” and “colorful and neat” and lower for waiting rooms rated as “unusual-looking.” There 

were differences between the college student and the senior citizen groups and a significant gender 

by number of office visits interaction. The factor analysis for comfort in the environment found that 

people were more comfortable in waiting rooms described as “tasteful” or “decorative” and less 

comfortable in waiting rooms described as “dark and sparse” or “strange and uncomfortable.” There 

were differences between the college students and senior citizens and between men and women. 

Although clinic waiting rooms are not, by strict definition, provider working areas, we have included 

this study as it presents patient perceptions of the overall clinic environment. 

A systematic review of seven studies assessing patient satisfaction with the use of EHRs in the 

exam room during visits with providers found mixed results.72 The authors noted methodological 

problems with the studies. Pooled results from 3 studies indicated higher patient satisfaction 

following the introduction of EHRs in the exam rooms (mean difference of 3.7%). One of the 

studies included in the review was done in a VA primary care clinic. That study found that 

patients seeing residents were more likely to report a negative effect of the EHR on the patientphysician interaction but that only 8% of patients thought that the computer interfered with their 

relationship with their physician. 

Summary of Findings for Physical Environment 

The available evidence suggests that physical environment can affect patients’ anxiety levels 

before and after their appointments, satisfaction with doctor-patient communications, and 

29 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

perceived quality of care. However, additional research is needed to determine the specific 

elements of the environment that influence these outcomes and whether environment may also 

have an effect on additional outcomes such as patient safety and quality of care. 

Quality and Strength of Evidence for Physical Environment 

The percentage of studies meeting quality criteria for non-randomized trials is shown in Figure 

8. With only one study reporting actual patient satisfaction there is insufficient evidence for this 

outcome. 

Figure 8. Study Quality of Physical Environment Non-Randomized Studies 

Notes: Only one study involved an intervention and the study did not meet the quality criteria for an intervention. The numbers 

on each bar indicate the number of studies that either met the study quality criteria (dark gray) or did not (light gray). 

KEY QUESTION #3. In studies that report provider outcomes, how 

are working conditions associated with provider outcomes (e.g., job 

satisfaction, productivity, pay)? 

As noted in the background and conceptual model sections, we do not systematically review 

the evidence on the intermediate link between workplace conditions and provider outcomes. 

However, among the studies included in our review for evidence on the role of workplace 

30 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

condition on patient outcomes, three (two US and one European) also report findings on 

provider outcomes. We discuss those findings here, noting that these results are not necessarily 

representative of the evidence published to date on provider outcomes and workplace conditions 

in primary care settings. Linzer and colleagues6 found that greater workloads and less job 

autonomy resulted in greater physician ratings of stress and burnout and lower ratings of job 

satisfaction. They also found evidence that certain aspect of organizational culture (e.g. trust, 

quality emphasis, workplace cohesion) had similar affects on provider outcomes. The other US 

study of approximately 2,700 MDs from the 2007 American Medical Association file found that 

job satisfaction was not affected by the use of more advanced electronic medical records systems 

as compared to more basic systems.55 One study found that providers had higher levels of stress 

when working after a night “on call” compared to working after a night of not being on duty.

52 

In addition to the study by Linzer et al.6 reported above, two other organizational culture studies 

reported provider outcomes.64,67 In one study, physicians and physician assistants at PCMH 

clinics reported significantly lower emotional exhaustion.64 In the second study, physicians 

reported that office atmosphere, quality of life at work, and workload all improved when 

psychologists were integrated into family practice.67 

One study of physical environment also reported limited provider outcome data.70 Staff members 

expressed significantly greater work satisfaction in a new facility but there were no differences 

in psychological symptoms. They felt the new work environment was more professional and 

allowed them to provide improved service to patients 

31
 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

SUMMARY AND DISCUSSION 

SUMMARY OF EVIDENCE BY KEY QUESTION 

Key Question #1 

We identified three randomized controlled trials, seven longitudinal (cohort or pre-post with 

repeated cross-sections) studies and 17 cross-sectional studies investigating the role of HR 

practices in primary care clinics in explaining patient outcomes. 

Nine out of eleven of the studies we examined that focused on patient quality of care as an 

outcome, specifically measured clinical effectiveness, thus there is insufficient evidence on 

the role of provider workplace conditions on access as a quality of care measure. The most 

frequently studied HR practice for quality of care was workload and while three of the studies 

suggested that an increase in workload results in lower quality of care, one study also found 

a positive effect and one found no effect. The other HR practices studied were evaluated less 

frequently, but there was more consistency in the results across studies: more training (2 studies), 

shorter hours (2 studies), and computerized systems (3 studies) lead to better quality. Only one 

study we reviewed examined provider autonomy or flexibility and found mixed effects on quality 

of care scores; this is insufficient evidence for the role of autonomy. Overall, these results are 

suggestive but make it difficult to make strong conclusions about the role of HR practices on 

patient quality of care. 

We identified three studies in our review that explicitly examined the role of human resource 

practices on patient safety in the primary care setting. While these were relatively well designed 

studies, more studies are needed. Because only two studies examined workload, one of 

which also examined autonomy, and the third study examined computerized systems, there is 

insufficient evidence to answer our key question about how HR practices influence patient safety. 

We identified 17 unique studies that investigated how HR practices influence patient satisfaction 

with either the provider or the clinic. We found mixed evidence on the role of provider skills 

(MD vs. NP/PA) on patient satisfaction; two studies found no effect and two studies found a 

negative effect of skills. We found mostly no effect of provider workload on patient satisfaction 

(3 studies), with the exception of one Norwegian study reporting that a longer listsize resulted in 

greater patient satisfaction. All four of the studies that examined provider training and all three 

that examined provider work hours found that they had no effect on patient satisfaction. Thus, 

there was suggestive evidence that training and work hours do not effect patient satisfaction, 

but again because of the lack of well-designed studies, we cannot make strong conclusions 

about these findings. Similarly, we conclude that there is inconsistent evidence on the role of 

skills and workload. We identified no studies that looked at how electronic medical records or 

computerized systems affect patient satisfaction. 

Key Question #2 

The available literature provides low strength or insufficient evidence for varied components of 

organizational culture including PCMH, team-based care, care environment, and clinic values 

and their effect on outcomes highlighted in our key questions. Such evidence does not permit 

conclusions with regard to quality of care, patient safety, and patient satisfaction. 

32 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

Our report on the influence of organizational culture parallels a systematic review published 

by the Cochrane Collaboration in 2011 titled “The Effectiveness of Strategies to Change 

Organizational Culture to Improve Healthcare Performance.”73 The report considered any 

strategy intended to change organizational culture in order to improve healthcare performance. 

While the Cochrane review identified similar outcomes of interest (quality of care, patient 

satisfaction, organizational performance, and provider outcomes), no studies met their inclusion 

criteria. The Cochrane review was not limited to ambulatory primary care settings, but sought 

only studies meeting quality criteria developed by the Cochrane Effective Practice and 

Organisation of Care Group (EPOC). While our review used a similar definition of organizational 

culture, we included a broader range of methodologies. 

The 2003 AHRQ review4 looked at the effect of organizational culture on measures of patient 

safety. The authors discussed difficulty in examining the affect of cultural factors on patient 

outcomes rooted in the broadly defined concepts ranging from cultural norms, to more concrete 

practice interventions. Their report concluded that despite multiple studies using diverse study 

methodologies conducted in different workplace settings, there was insufficient evidence related 

to the effect of organizational factors on patient safety. Similarly, our report found insufficient 

evidence across diverse constructs of organizational culture to draw conclusions related to 

quality of care, patient safety, and patient satisfaction. 

Although there has been research on the effect of physical environment (notably lighting, color, 

auditory stimuli, and temperature) on workplace performance, much of that work has been done 

in industrial settings and what has been done in healthcare has largely focused on hospitals.4,74 

We found few studies that examined the effect of physical environment in primary care clinics. 

No study attempted to isolate any one component of the physical environment. Reported 

outcomes focused on patient self-report of anxiety and satisfaction with no objective measures of 

patient safety, quality of care, or provider performance. 

Key Question #3 

Consistent with more thorough systematic reviews of the literature examining how workplace 

conditions affect providers’ stress, job satisfaction, etc., among the studies in our review that also 

examined provider outcomes, we found that greater workloads and less control over work tasks 

resulted in greater provider stress, burnout, and job satisfaction. One study we examined found 

that electronic medical records did not result in greater provider stress. 

The relationships between workplace conditions, provider outcomes, and patient outcomes 

are complex and dynamic in such a way that not only are the effects felt at many levels 

(provider, patient, healthcare system), but also they create a cycle of reinforcing behaviors 

and outcomes. There are several potential policy interventions at the various levels that might 

positively influence provider wellbeing. In this study, we focus on studies that shed light on 

possible workplace interventions (as opposed to provider self-care or higher-order system 

level interventions) that will ultimately impact patient outcomes. Such changes to workplace 

conditions will likely also influence provider outcomes. However, we present these results as 

only suggestive, but consistent with other literature, including systematic reviews, that has 

established evidence on the intermediate link between workplace conditions and provider 

outcomes. 

33 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

RECOMMENDATIONS FOR FUTURE RESEARCH 

As shown in Tables 1, 3, and 4, there is little research that investigates the effects of working 

conditions on patient safety, which we measure specifically as medication errors, in the primary 

care setting. More generally, more well-designed studies are needed to replicate the few that 

have been conducted. For example, all ten of the studies we reviewed that investigated the 

role of workload were cross-sectional studies. While undertaking randomized controlled trials 

may be impractical, well-designed cohort studies or other pre-post designs will allow for more 

convincing evidence on the causal effect of the workplace conditions. 

Additionally, there is a need for research that looks rigorously at the interdependent role of 

human resource practices (such as hours worked, provider autonomy, and electronic medical 

records), organizational culture, and physical environment in explaining patient outcomes 

in primary care settings. Research on the role of workplace conditions in explaining worker 

productivity, turnover, burnout, and other employee outcomes suggests that many of these 

characteristics are “bundled”75-77 and complementary. For example, a clinic that rolls out 

team-based care will likely also have other workplace conditions and workflow designs that 

facilitate teamwork, such as electronic medical records or an organizational culture that values 

teamwork. However, none of the studies we reviewed investigated how the “system” or complete 

workplace environment affected patient outcomes. Studying the effect of one HR practice, such 

as electronic medical records or teams, ignores the fact that these practices occur within a larger 

organizational setting with a particular organizational culture and related or complementary 

practices. Thus, isolating the marginal effect of just one of these practices is empirically 

difficult. Larger scale studies that are able to compare more clinics or hospitals and more fully 

characterize the workplace are needed. 

The development of or more consistent use of construct valid measures of both working 

conditions and patient or provider outcomes in the primary care settings is needed to make 

comparisons across studies easier. Future research should incorporate randomized controlled 

trials or high quality quasi-experimental designs. 

CONCLUSIONS 

Overall, the studies we reviewed suggest that in primary care settings: 

• a lighter provider workload/shorter work hours, more provider training, and computerized 

systems result in higher patient quality of care 

• provider training and work hours have no effect on patient satisfaction. 

We find mixed evidence on the effect of provider skill levels and workload on patient 

satisfaction. We identified very few studies in our review that explicitly examined the role 

of workplace conditions on patient safety or the role of the physical environment on patient 

outcomes in the primary care setting, thus more studies are needed. Several workplace conditions 

have been insufficiently studied and thus there is no evidence on how these practices matter 

in ambulatory care settings: the effect of computerized systems, provider autonomy and teams 

on patient satisfaction; and the effect of autonomy on quality of care. We also note that the 

lack of evidence does not necessarily imply the lack of a relationship; we also do not explore 

other possible hypotheses, including the possibility that workplace conditions affect healthcare 

34 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

providers, but healthcare providers are still able to do their jobs adequately such that patients are 

not affected. 

The available literature provides low strength or insufficient evidence for varied components of 

organizational culture including PCMH, team-based care, care environment, and clinic values 

and their effect on outcomes highlighted in our key questions. Such evidence does not permit 

conclusions with regard to quality of care, patient safety, and patient satisfaction. 

We found two studies that focused on the effect of physical environment in primary care clinics. 

No study attempted to isolate any one component of the physical environment. Reported 

outcomes included self-report of anxiety and satisfaction with no objective measures of patient 

safety or quality of care. 

Consistent with more thorough systematic reviews of the literature examining how workplace 

conditions affect providers’ stress, job satisfaction, etc., among the studies in our review that also 

examined provider outcomes, we found that greater workloads and less control over work tasks 

resulted in greater provider stress, burnout, and less job satisfaction. One study we examined 

found that electronic medical records did not result in greater provider stress. 

35
 
The Effect of Working Conditions 

on Patient Care: A Systematic Review Evidence-based Synthesis Program 

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