PEDIATRICS Vol. 115 No. 6 June 2005, pp. 1704-1711 (doi:10.1542/peds.2004-1131)
Organizational Characteristics and Preventive Service Delivery in Private Practices: A Peek Inside the "Black Box" of Private Practices Caring for Children
* Center for Children's Healthcare Improvement
Division of General Pediatrics and Adolescent Medicine
Department of Health Policy and Administration, University of North Carolina, Chapel Hill, North Carolina
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ABSTRACT |
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Objective. Although privately owned practices provide the majority of primary care for children, little is known about the organizational characteristics of these practices or how these characteristics affect the quality of care for children. The purpose of this study was to describe selected organizational characteristics and preventive service delivery features that might affect the quality of primary care for children in private practices.
Methods. A cross-sectional study of 44 private pediatric and family medicine practices in 2 regions of North Carolina was performed. Preventive service performance was assessed through chart abstraction for 60 randomly selected children between 24 and 30 months of age, for evaluation of immunizations and anemia, tuberculosis, and lead screening delivery by 2 years of age. Organizational characteristics were determined through surveys of all physicians and staff members. We used descriptive statistics and scatter plots to describe variations in organizational characteristics and preventive services.
Results. Overall, practices demonstrated low levels of preventive service performance, with substantial variation among practices. Only 39% of children received 3 of the 4 recommended preventive services measured (practice range: 2–88%). Few practices demonstrated evidence of a systematic approach to prevention. For example, only 12 (27%) of the 44 practices used >1 of 5 recommended preventive service delivery strategies. Furthermore, practices varied greatly with respect to many of the measured organizational characteristics, which were consistent with organizational stress in some cases. For example, turnover of clinicians and staff members was remarkably high, with practices losing an average of 27% of their clinicians every 4 years (range: 0–170%) and 39% of their office staff members every 2 years (range: 0–170%).
Conclusions. Private practices caring for children in North Carolina demonstrated low overall performance for the 4 recommended preventive services examined, with large variations among practices. Few practices had evidence of comprehensive systems for prevention. There was also evidence of substantial variation in many organizational characteristics. Some organizational characteristics were at levels that might impede delivery of high-quality primary care for children. These findings suggest a growing need for research that examines the impact of organizational characteristics on the quality of care in private practices.
Key Words: private practices • preventive services • organizational management
Abbreviations: FTE, full-time equivalent • RCT, randomized, controlled trial • OSI, Office Systems Index
In a recent report on health care quality, the Institute of Medicine recommended fundamental change in the US health care system, citing remarkable variation as well as shortcomings in many outcomes. 1 For example, Solberg et al 2 found that adult practices have low levels of preventive service delivery, with considerable variation across practices. Although numerous factors may explain variation and low performance levels, one often-repeated theme is the manner in which health care organizations are managed and staffed. Regulatory agencies (eg, the Joint Commission on Accreditation of Healthcare Organizations) attempt to address management issues for large health care organizations. However, less attention has been given to the relatively small organizations that provide the majority of primary care services to children, ie, private pediatric and family medicine practices, which provide >85% of primary care for children in the United States. 3,4
Despite their small size, private practices are complex systems, with work being performed primarily by teams. 5–7 The literature from other industries indicates that team performance is affected by organizational management, including staffing arrangements, communication and conflict management, and leadership. 8–10 These management issues may also be important in private practices. For example, understaffed practices may not have the time to reflect on their work and may assume a reactive (versus proactive) approach to their work, limiting the quality of care they can provide.
Although a substantial body of research has demonstrated the efficacy of clinically focused strategies, such as using physician prompts or reminder systems to improve prevention service performance, few studies have examined a broad set of organizational factors that may affect private practice performance. 11,12 On the basis of studies in family medicine practices, the available evidence does suggest that primary care practices demonstrate wide variations in many organizational characteristics. 6,7,13
The purpose of this study was to describe the organizational characteristics of and preventive service delivery in private practices that care for children, including the degree of variation among practices. We focused on organizational characteristics we deemed practical for physicians and practice managers to modify to improve the quality of care for children. Our intention was to identify organizational characteristics that might be promising targets for future research to improve the quality of care for children.
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METHODS |
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Participants and Recruitment
We conducted a cross-sectional study in private pediatric and family medicine practices in North Carolina. Study practices were recruited for a randomized, controlled trial (RCT) to evaluate an intervention to increase rates of preventive services in private practices. Recruitment details were published elsewhere. 14 Briefly, we identified all 453 pediatric and family medicine practices in 39 counties surrounding 2 metropolitan areas in North Carolina (Raleigh and Charlotte), by using listings of physicians from the North Carolina Medical Licensure file, the North Carolina Division of Medical Assistance file, professional associations, and local telephone listings. Practices meeting the following criteria were eligible for the study: sufficient newborns enrolled each month (>5 newborns for family practices and >10 for pediatric practices) to meet preventive service chart review sample size requirements; not part of an academic institution or a publicly funded health center; and, for the region surrounding Raleigh, North Carolina, annual Medicaid billing in excess of $50000 (a requirement of 1 funding agency). Of the 59 eligible practices, 44 (75%) agreed to participate. The 15 nonparticipating practices were more likely to be family medicine practices than were participating practices (28% vs 18%), enrolled fewer newborns per month (21 newborns vs 36 newborns), and had slightly higher Medicaid participation rates (36% vs 29%). The present study used baseline data (collected in 1997, before the intervention phase of the RCT) for all 44 intervention and control practices.
Preventive Services
We assessed the proportion of children in each practice who were up to date on 3 of 4 recommended preventive services (specifically, immunizations and screening or risk assessment for anemia, tuberculosis, and lead). We selected these preventive services because they are cost-effective, evidence-based, preventive services for young children that are standardized through national recommendations. 15,16 We selected a group of preventive services, rather than a single preventive service (such as immunizations), to identify overall practice performance, rather than performance in a single area in which practices might have a particular focus or interest. In addition, before assessing preventive service performance, we surveyed all clinicians to obtain their estimations of their practices' preventive service rates.
Children were considered up to date in immunizations at 24 months if they met the Centers for Disease Control and Prevention 4:3:1:3:3 criteria, namely 4 diphtheria-tetanus toxoids-pertussis, 3 oral polio vaccine, 1 measles-mumps-rubella, 3 Haemophilus influenzae type b (with 
1 after 11.5 months), and 3 hepatitis B vaccinations. 17 If a child was not up to date, we also searched the North Carolina immunization registry, to determine whether the child had received immunizations not recorded in the practice charts. A child was considered up to date in screening procedures if a screening test or risk assessment was completed by 24 months of age for lead and tuberculosis and by 18 months of age for anemia. 15,16 These criteria are consistent with national guidelines that North Carolina practices would have used during the study period.
Chart abstraction procedures were published elsewhere. 14,18,19 Briefly, data were obtained from a random sample of 60 charts for children between 24 and 30 months of age (identified with billing data) who had 3 practice visits and had no evidence in the chart of having transferred out of the practice. Chart abstractors received extensive training and were required to pass a certification process, to ensure accurate reliable data collection. Data quality assessments included a rereview of a randomly selected 20% of the charts for evaluation of inter-rater reliability. Abstractors maintained a 
of >.85 for each preventive service in the reabstracted charts.
Practice Measures
We obtained data on 4 groups of organizational characteristics of private practices (Table 1), ie, staffing and staff stability, preventive service orientation, organizational culture, and practice setting variables. Except for the few exceptions noted below, staff surveys were the source of these data. The response rate for staff surveys was 100% of all staff members for 41 of the 44 practices, and responses included the majority of staff members for each of the 3 remaining practices.
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Staffing and Staff Stability
"Staffing" of a practice included the overall number of full-time equivalent (FTE) clinicians (medical doctors or osteopaths, physician assistants, and nurse practitioners), the use of physician extenders (the ratio of FTE physician assistants and nurse practitioners to physicians), the ratio of daily patient visits to FTE clinicians, and the extent to which support staff members were employed by the practice (the ratios of FTE clinical staff members and total staff members to clinicians). We divided clinicians and staff members into full-time (1 FTE) or part-time (0.5 FTE) on the basis of whether they worked >30 or <30 hours per week in the practice. Staffing data were obtained from surveys of the administrative leader (office manager) in each practice.
We obtained information on the stability of clinicians (over a 4-year period) and staff members (over a 2-year period) in each practice by examining turnover rates (number of staff members leaving during the time period divided by the number of staff members at the beginning of the time period). 20 Turnover data were obtained from the administrative leader in each practice in 2000, to overlap temporally with other cross-sectional data in this study. We measured the degree to which nurses and medical office assistants participated in patient care by asking staff members which of 16 selected screening and counseling procedures (eg, conducting vision screening, assessing lead risk, counseling parents about injury prevention, or assessing home safety hazards) they typically performed.
Preventive Service Orientation
In previous studies, we noted marked differences among practices in the extent to which they used a systematic approach to providing preventive services. 18,19,21,22 On the basis of those observations, we developed an Office Systems Index (OSI) for prevention, which assesses the extent to which practices use 5 evidence-based procedures to deliver preventive services. The 5 OSI elements are (1) an office coordinator whose focus is delivery of preventive services, (2) a tracking system to identify patients who are due for preventive care, to avoid children "falling through the cracks," (3) a system to prompt providers to consider preventive services during visits, (4) use of preventive service prompting sheets to remind clinicians which preventive services are due at appropriate intervals, and (5) regular measurement of immunization rates (defined as a chart review conducted by the practice during the previous 12 months). Data were obtained from surveys of the lead physician and lead nurse in each practice (items 1, 2, 3, and 5) and from chart abstractions (item 4). Each practice received 1 point for each strategy used; therefore, OSI scores could range from 0 (ie, no strategies in place) to 5 (all strategies in place).
When clinicians within a practice use a uniform schedule for providing preventive services, this creates an environment in which staff members and patients understand when preventive services are routinely performed, making it easier for both staff members and patients to comply. Such a system, when consistent with guidelines, reduces the potential for omissions and/or unnecessary delays. Therefore, we assessed the extent to which all clinicians in a practice complied with the brief windows of time recommended in existing guidelines (we called this "guideline timing compliance"). We asked all clinicians in each practice to report their usual timing for 6 specific screening and immunization services (ie, H influenzae type b, diphtheria-tetanus toxoids-pertussis, and measles-mumps-rubella immunization and screening for anemia, lead, and tuberculosis). Each practice received 1 point when all of their clinicians' timing was consistent with guidelines from the American Academy of Pediatrics and the US Preventive Services Task Force for each preventive service. 15,16 Therefore, scores for guideline timing compliance could range from 0 (ie, timing of none of the services was consistent with guidelines for all clinicians) to 6 (timing of all of the services was consistent with guidelines for all clinicians).
Organizational Culture
"Organizational culture" can be described as "the set of shared, taken-for-granted, implicit assumptions that a group holds and that determines how it perceives, thinks about, and reacts to its various environments." 23 The culture of an organization affects how people work together, communicate, and resolve conflict. It is important to note that measures of culture are by their nature perceptual; what is most important is not how managers wish or believe their culture to be but how individuals in the organization perceive it. It is these perceptions that affect attitudes and behavior.
We obtained information on perceptions of organizational culture through surveys of all staff members, including clinicians. Because there is no consistent agreement on the measurement of organizational culture, or even the dimensions that constitute culture, we combined 2 instruments to assess a variety of dimensions; both instruments were validated in previous studies. 24–26 The final instrument included 49 questions in 12 dimensions, which used a Likert scale ranging from strongly agree to strongly disagree (full instrument available at www.childhealthimprovement.org/resources/cchipubs).
We hypothesized that factor analysis could be used to decrease the number of organizational culture variables from an original set of 12 dimensions. A subgroup of the project team, consisting of clinicians and an organizational management expert (G.R., B.F., P.M., and C.L.), reviewed factor analysis output to assess the face validity of the final variables. The final organizational culture variables were (1) the extent to which the practice demonstrates good teamwork (including communication openness, communication accuracy, quality of working relationships, personal caring among staff members, and perceived practice effectiveness), (2) the extent to which conflicts among staff members are resolved in an authoritarian manner (compared with collaboratively or avoiding conflict), as rated by clinicians, (3) the extent to which conflicts among staff members are resolved in an authoritarian manner, as rated by staff members, (4) the work style of the practice (production oriented, rules oriented, or risk-taking oriented), and (5) the perceived leadership effectiveness, as rated by clinicians. Practice culture variables were derived by averaging the scores for all staff groups (clinicians, clinical staff members, and nonclinical staff members), because scores were correlated strongly among groups. The only exception was for conflict management style, for which separate scores were used for clinicians and staff members, because perceptions of conflict management differed substantially between them. In addition, we report clinician scores for leadership effectiveness, because this dimension did not fit with other dimensions in the factor analysis (staff ratings of leadership effectiveness were incorporated into the work style variable). All 5 of the variables derived from factor analysis had a Cronbach's 
of >.70. Finally, we determined (from the administrative leader survey) whether the practice was physician or hospital owned, because practice ownership may affect practice management and culture.
Practice Setting
Descriptive practice setting characteristics were assessed in the following ways: administrative leaders reported the percentage of practice children who were Medicaid recipients, rural or urban practice location was determined from metropolitan and nonmetropolitan county designations by the US Office of Management and Budget, 27 and pediatric or family medicine practice type was based on the specialty in the majority.
Statistical Analyses
All statistical analyses were performed with the practice as the unit of analysis. Therefore, the sample size was 44 practices. We used simple descriptive statistics, including means, proportions, and ranges, and scatter plots to describe the selected organizational characteristics and preventive services. The sample size of 60 charts generated a 95% confidence interval of ±12% for preventive service rates for each practice. All statistical analyses were performed with Stata 6 for Windows (Stata Corp, College Station, TX).
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RESULTS |
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Practices employed 4.3 FTE clinicians, on average (Table 1). Practices reported seeing an average of 27 patients per FTE clinician per day, with an interquartile range of 18 to 38. On average, 29% of patients were Medicaid recipients, which is likely relatively high because of our selection criteria. Similarly, our selection criteria (requiring a minimal volume of newborns enrolling) limited the number of family medicine practices in our sample to 8 practices (18%). Because North Carolina has a significant rural population, a relatively large number of study practices (23%) were in rural counties, compared with national data on pediatrician and family physician distributions. 28,29
Practices lost an average of 39% of their office staff members over a 2-year period and 27% of their clinicians over a 4-year period (Table 1). Practices infrequently used evidence-based strategies for preventive service delivery (components of the OSI). For example, only 7% of practices used preventive service prompting sheets, 9% measured immunization rates in the previous year, 9% had a majority of physicians using prompts, and 11% used tracking systems (data not shown). On average, practices used only 1 of the 5 recommended strategies. Only 12 of the 44 practices (27%) had >1 strategy in use, and only 7% had >2 strategies in use (data not shown). In addition, we found low levels of guideline timing compliance. On average, all clinicians within a practice reported performing the preventive services during the recommended time frame for only 3 of the 6 preventive service time frames we assessed.
Few practices rated their teamwork or leadership effectiveness positively. Only 23% of practices scored in the agree/strongly agree range for good teamwork, and only 16% scored in the agree/strongly agree range for effective leadership. For both clinician and staff ratings, 30% of practices had scores indicating an authoritarian conflict management style (data not shown).
In general, practices varied greatly in many of the measured organizational characteristics. Variation was particularly high for staffing and staff stability measures (Figs 1 and 2). As depicted in these scatter plots, practices demonstrated wide variation in ratios of support staff members to clinicians and in turnover rates for both clinicians and staff members. Among the organizational culture variables, there was greater variation in leadership effectiveness (interquartile range: 3.2–3.8) and teamwork (interquartile range: 3.6–4.0) than in the other organizational culture ratings.
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Preventive service performance also varied greatly among practices (Fig 3), ranging from 2% to 88% on the overall preventive service measure (3 of 4 recommended services up to date). On average, 39% of children received 3 of the 4 recommended preventive services. Among individual preventive services, children were more likely to be up to date on immunizations (68%) and anemia screening (64%) than on lead (38%) and tuberculosis (41%) screening. Actual preventive service rates were 19% to 42% lower than clinicians' expectations about their preventive service rates; clinicians thought that immunizations rates were 87% and their rates of screening were 84% (anemia), 80% (lead), and 67% (tuberculosis).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study described a broad set of organizational characteristics (staffing, culture, and orientation to prevention) in private practices that serve children. We observed substantial variation in many of these organizational characteristics and in preventive service performance among private practices that care for children in North Carolina. These private pediatric and family medicine practices exhibited high rates of physician and staff turnover, wide variation in staffing levels, little use of evidence-based systems for prevention, a lack of practice-wide agreement on the timing of preventive services, and organizational culture rated low in teamwork and high in authoritarian conflict management. Furthermore, practices had low rates of successful preventive service delivery, with tremendous variation among practices. Clinicians overestimated substantially their practices' performance regarding preventive services. These findings are consistent with previous studies of practices delivering adult preventive services. 2,7,30,31 Of note, a few practices had no children up to date for lead or tuberculosis screening, which suggests that clinicians in those practices might not agree with screening or risk assessment for these conditions. Overall, however, clinicians thought that 80% of their children were up to date on lead screening and 67% were up to date on tuberculosis screening, indicating that most clinicians do intend to screen for these conditions.
Because of the low power of the present study (n = 44), we did not assess which, if any, organizational factors were associated with greater preventive service delivery. However, because of the degree of variation demonstrated in these private practices and some features that suggest organizational stress (eg, high staff turnover rates), we speculate that many of the organizational characteristics we examined are promising targets for future research.
Numerous studies found substantial variation in small geographic areas and among clinicians for health care expenditures, utilization patterns, referral patterns, and preventive service delivery. 30,32–38 The present study demonstrates tremendous variation in organizational and management characteristics and preventive service delivery among practices as well. These findings raise many intriguing questions. Why do some practices have 2 FTE staff members for every FTE clinician and some have 3 times this ratio? Why do some practices lose more than one half of their staff members in 1 year and some have little or no turnover? Why do clinicians in the same practice risk sending mixed messages to patients and staff members by performing immunizations and screening at different times? What are a few practices doing differently to achieve much higher rates of preventive service delivery than others?
Quality improvement experts view such variation as a "smoking gun" for potential quality problems. 39,40 Although variation can be attributable to intentional tailoring of a process to local conditions or patient populations, we speculate that the degree of variation found in the present study exceeds variation intended to customize care and thus may reduce the quality of care delivered in private practices. On a more positive note, this degree of variation could provide an excellent opportunity for learning more about how to improve care. For example, groups interested in improving the quality of preventive care could arrange site visits with practices in the lowest and highest performing groups, to identify underlying differences in management and care delivery processes; such differences could be sources of new ideas to improve care. Statistical methods exist that can aid in identifying the low and high performers (compared with random variation) within a population of practices. 41
The most striking result in the present study was the degree of staff and clinician turnover. Turnover in primary care practices is important for several reasons. First, this degree of turnover represents an enormous potential drain on practice financial resources. For example, it is estimated that the total cost of recruiting and replacing a single pediatrician is $260000. 42 Turnover of nonphysician staff members also generates substantial organizational costs and training needs. 43 Of note, we did find evidence of financial stress during the 3-year follow-up period of the RCT following this study; 4 of the original 44 practices went bankrupt. Equally important, the degree of clinician turnover found in this study may impede the provision of a medical home for children, which by definition requires a physician who is known to the child and the family and who can develop a partnership of mutual responsibility and trust with the family over time. 44 Finally, although there is little research in this area, high clinician turnover rates may affect other aspects of the quality of care in primary care practices. 45
The overestimation of preventive service rates by clinicians also deserves special comment. An important stimulus for improving the quality of care is the recognition of a gap between desired and actual levels of performance. 1,40,46 In this study, we found that only 9% of practices had measured their immunization rates in the previous year. It is likely that fewer practices measured other preventive service rates, given the emphasis on immunizations in pediatric practice. 16 Failure to monitor preventive service performance inhibits the recognition of a gap in performance for a practice. Therefore, until private practices have the tools and resources to monitor their own preventive service performance, we speculate that a key factor for improving preventive service delivery will continue to be missing.
There are several limitations to this study. Where possible, we used existing instruments with demonstrated validity and reliability. In general, however, there were sparse data and/or existing measures on which to build. 47 Therefore, some of the measures we used to address organizational characteristics might have been inadequate. For example, it might be necessary to measure in more detail how staff members work together, rather than simply measuring numbers of staff members and staff ratios. In addition, we might have omitted potentially important organizational characteristics.
A strength of the study is the inclusion of both family medicine and pediatric practices. However, because of preventive service sample size requirements, we included only family medicine and pediatric practices that care for a substantial number of children. Although the study practices may be representative of practices that care for the majority of children in the United States (because of the volume of children they care for), they are likely larger than typical private practices that care for children. Other selection criteria, including practice selection within 2 discrete geographic areas, the need for practices to agree to participate in an improvement project, and the overselection of Medicaid patients in 1 of the geographic regions, also might have decreased the generalizability of the results of this study to other private practices. Finally, although community health centers, academic centers, health departments, and other public providers are important components of the health care system, we excluded them to reduce practice heterogeneity for the RCT. Therefore, our results cannot be generalized to these providers.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study suggests a growing need for research that examines the impact of organizational characteristics on the quality of care in private practices. We found striking variation in organizational characteristics among North Carolina private practices serving children. In general, these private practices had high rates of physician and staff member turnover, wide variation in staffing levels, widespread lack of systems for prevention, lack of practice-wide agreement on the timing of preventive services, and low rates of successful preventive service delivery, with tremendous variation across practices. We speculate that this low level of performance for the 4 preventive services and the marked practice-level variation with respect to organizational characteristics are largely unintentional.
Because of the high volume of children's preventive services and their effectiveness in improving child health, we think that engaging private practices in improving preventive service delivery is paramount. 16 The organizational features we observed, such as high staff turnover rates, lack of systems for prevention, and overestimation of preventive service performance, should be considered in preventive service quality improvement efforts among private practices in the future.
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ACKNOWLEDGMENTS |
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This study was supported by US Agency for Healthcare Research and Quality grant RO1-HS08509, US Bureau of Maternal and Child Health grant RO1-HS08509, the North Carolina Division of Medical Assistance, and the National Research Service Award Training Program of the US Health Resources and Services Administration (grant 5 T32 PE 14001-12).
We thank the dedicated physicians, nurses, and staff members in all of the Partners in Prevention practices. We also thank Lynette Keyes-Elstein, DrPH, for technical assistance with data management and statistical analyses and Clay Williams, BA, and Haley Yates, BA, for technical assistance with manuscript preparation.
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FOOTNOTES |
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Accepted Nov 9, 2004.
Address correspondence to Greg D. Randolph, MD, MPH, Center for Children's Healthcare Improvement, University of North Carolina, 201 Timberhill Place, CB 7226, Chapel Hill, NC 27599–7226. E-mail: randolph{at}unc.edu
No conflict of interest declared.
Ms Loeding's current address is: Center for Care Innovation and Research, Children's Hospitals and Clinics, Minneapolis, MN 55404.
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