Predicting changes in staff morale and burnout at community health centers participating in the health disparities collaboratives.

The introduction of quality improvement (QI) initiatives can present special challenges for health care settings that have limited personnel and financial resources, and high attrition among key staff. In the context of such constraints, the difficulty of balancing daily clinical demands with additional QI responsibilities can lead to lowered staff morale, burnout, and additional turnover, all of which can further compromise quality of care (Cavanagh 1989; Goodall 1993; Busteed, Barwick, and Grubb 1994). While the concerns regarding lowered staff morale are significant, other studies with contradictory findings show that the introduction of QI initiatives can actually lead to improved job satisfaction (Counte et al. 1992; Calomeni, Solberg, and Conn 1999; St. Pierre 2006) by introducing new employee incentives, such as opportunities for training and professional development (Akerboom and Maes 2006; Gilbody et al. 2006). Institutional and physician support can affect both staff satisfaction and the overall success of the QI effort (Neuhauser 2002; Gollop et al. 2004), and there is further evidence that organizational factors such as culture, group cohesion, and support can limit the detrimental effects of stressful work demands on staff in acute inpatient care and long-term care settings (Karsh, Booske, and Sainfort 2005; Shermont and Krepcio 2006). However, relatively little is known about the impact of QI initiatives in resource-challenged ambulatory care settings, and the relative influence of these ancillary factors associated with its implementation, including the use of incentives, levels of QI integration, and institutional support. The Health Resources and Services Administration's Bureau of Primary Health Care (BPHC) funds and oversees over 1,000 community health centers (HCs) that provide care for approximately 15 million medically underserved people at 5,000 sites (National Association of Community Health Centers 2006). The mission of the HCs is to serve as a safety net for individuals who face major barriers to accessing quality health care, including the medically isolated, uninsured, and vulnerable (Sardell 1988). In keeping with its commitment to quality health care and in an attempt to improve health care for all while eliminating disparities, in 1998 the BPHC began the Health Disparities Collaboratives (HDC) on a national basis. The HDC is a sweeping QI initiative that uses the MacColl Institute's Chronic Care Model and the Model for Improvement developed by Associates in Learning (Langley et al. 1996; Wagner, Austin, and Von Korff 1996). The HDC involve HCs in regional or national learning sessions conducted on a quarterly basis during the first year of implementation. Initially 88 HCs participated in a collaborative that targeted improvements in diabetes care and outcomes. Subsequent HDCs have focused on asthma, depression, cardiovascular disease, cancer screening and planned care, finance, and clinical systems redesign. As of April 2007, 1,009 HCs were participating in the HDC (Charles Daly, Health Resources and Services Administration, April 19, 2007, personal communication). Participation in the HDC requires commitment of resources to attend learning sessions, establish and maintain information systems, and introduce and monitor the impact of systems changes. The HDC have been clearly found to improve processes of chronic care management for multiple conditions (Chin et al. 2007; Landon et al. 2007). Patient outcomes such as glucose control levels in diabetes have been found to improve after long-term implementation of the HDC (4-years) (Chin et al. 2007). While the primary aim of HDC activities is to improve patient outcomes (BPHC 2006), their introduction may also produce additional challenges for HCs struggling with already strained resources. For example, an evaluation of the first year of the HDC (i.e., 1999) found that, although quality of diabetes care improved and the HDC was generally well-received by staff, time burdens associated with collaborative activities and staff turnover were prevalent (Chin et al. 2004), although it is unclear if such burden persists once HDC requirements have been integrated into HC practices. Similarly, in an evaluation of 153 HCs participating in the HDC for at least 1 year as of 2003, collaborative team members reported spending on average between 7.6 and 10.7 hours/week working strictly on HDC activities. Among these HCs, fully 21 percent reported having no one with paid protected time for leading QI activities, and a significant proportion of the HC staff surveyed reported that lack of resources and time were significant barriers to implementing the HDC. Moreover, 33 percent reported concerns of staff burnout and 18 percent reported decreased staff morale (Chin et al. in review). These findings raise critical questions about the causes of declining morale and increasing burnout, as well as whether HC leadership can take steps to mitigate these effects. Factors that influence staff morale and the risk of burnout can be either modifiable or nonmodifiable, and can operate at the level of the individual employee or at the level of the HC's structure and resources. By identifying such relationships, HCs implementing the HDC can be better prepared to anticipate and intervene to reduce the risk for staff burnout, lowered staff morale, and by extension, increased staff attrition. This paper seeks to identify predictors of variation in staff morale and burnout in the current HC setting.