Learning and Relationships in Primary Care
Condition: Chronic Disease
MeSH terms: Chronic Disease
Study type: Observational

Summary: 
      Within every primary care clinic is a small team of people who provide care to a group of
      patients who consider this clinic to be their medical home. Rapid advances in medical
      knowledge and technology require that these teams constantly adapt so that they can provide
      the best care to their patients. The goal of this study is to examine how people in these
      primary care teams learn and relate to each other as they change an adapt. This will be done
      by observing and interviewing people who work in these teams and by giving them and their
      patients a survey to fill out. We will then look at the performance of these clinics to see
      if it is related to how they learn and the quality of their relationships. Our ultimate goal
      is to design effective interventions that will improve the quality and outcomes of care
      received by Veterans in primary care outpatient clinics within the VHA.
    

Detailed description: 
      Anticipated Impacts on Veterans Healthcare: Our ultimate goal is to improve the health of
      veterans by designing interventions at the clinical microsystem level that will facilitate
      the integration of KM-SD roles in primary care through improving relationships and learning.
      We anticipate that such a cross-cutting intervention has the potential to improve clinical
      performance as well as staff and patient satisfaction. If we are successful, this could be a
      breakthrough in the efficiency of VA organizational change. Project Background: The way in
      which we conceptualize the basic nature of the primary care clinic (PCC) greatly influences
      our beliefs and ideas about what should work to improve its operations. If we view it as a
      production line, then we design our improvement efforts using systems engineering techniques
      aimed at standardizing, reducing variation, and improving efficiency. If instead we view the
      PCC as an organic and complex social system, then we might design our improvement efforts
      using methods designed to embrace rather than eliminate surprise (which is inevitable in
      health care settings), to enhance the connections and communication between the individuals
      in the PCC rather than focusing on improving the skill sets of the individuals, and to use
      feedback and time for reflection as part of a strategy for the PCC to make sense of their own
      operations and behaviors in relation to their mission and goals. For the purpose of this
      proposal, this latter approach will be denoted by the term knowledge management techniques.
      We propose to study whether PCC performance correlates with the presence of higher levels of
      use of knowledge management techniques within PCCs. The VA has been in the forefront of
      implementing some knowledge management practices, such as sue of performance data systems and
      integrated health records, but has not yet paid sufficient attention to other such as
      relationship management, increasing diversity in decision making, active learning, and
      sense-making. Project Objectives: Describe the range of knowledge management techniques,
      including relationship management and active learning) currently employed by 15 VA and 5 VA
      contract PCCs. 2. Analyze the relationship between the nature and roles of relationships and
      learning in PCCs and their performance across multiple outcomes including clinical
      performance measures, worker satisfaction and turnover, and patient satisfaction. Our
      research propositions are: (1) High performing PCCs exhibit higher quality relationships and
      more active learning than low performing clinics; (2) The quality of relationship within PCCs
      will have the largest effects on worker and patient satisfaction. Research Propositions: 1.
      High performing VA and VA contract primary care clinics will exhibit higher quality
      relationships and more active learning than low performing clinics. 2.a. Variation in
      temporal change in both relationships and learning among the 20 clinics over the 30 months
      will be observed. 2.b. The temporal change in relationships (such as stable, improving or
      deteriorating between adjacent years) will be associated with a similar temporal change in
      patient and employee satisfaction.2 c. The temporal change in learning (such as stable,
      improving or deteriorating between adjacent years) will be associated with a similar temporal
      change in process of care quality indicators and with intermediate clinical outcomes. Project
      Methods: Descriptive, iterative study of 15 VA and 5 VA contract primary care clinics within
      VISN 17. Using ethnographic, qualitative and quantitative data collection methods, each
      clinic will be profiled on the nature of relationships between staff and between staff and
      patients and the nature of learning. Clinical outcomes (patient functional status, BP,
      cholesterol, HgA1c, preventable admissions), patient satisfaction, employee satisfaction and
      turnover will serve as outcomes. The association of these outcomes with the nature of
      relationships and learning will be explored qualitatively and quantitatively. Stability of
      these profiles will be evaluated in two subsequent waves of data collection.
    

Observational model: Other
Time perspective: Cross-Sectional
Sampling method: Non-Probability Sample
Study population: 
        clinicians and staff in VA primary care outpatient clinics in VISN 17
      
Keywords: primary health care; organizations; learning; quality of health care