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Author List:
Smith CS (Boise VAMC)
Morris M (Boise VAMC)
Hill W (Boise VAMC)
Francovich C (Boise VAMC)
McMullin J (UC Riverside)
Objectives:
Cultural Consensus Analysis (CCA) is a method used by anthropologists to determine groups with shared values. This study examined the ability of CCA to identify value differences between patients, residents, faculty, and administrators that correlate with major problems in teaching clinics.
Methods:
CCA was performed at five clinics by asking residents, faculty, patients and administrators to rank order 16 statements about things that might happen during a clinic visit by order of importance. A matrix of matches between subjects was factor analyzed, and “correct” answers for each group were calculated a posteriori using Bayes’ theorem. A workgroup was also systematically created at each site. Each workgroup independently identified and prioritized a list of clinic problems using brainstorm and Delphi. The relationship between the CCA results and problems was examined in a three-step process using graphical analysis, factor analysis, and then correspondence analysis.
Results:
Four of the CCA statements had between-group differences of greater than five points across all sites. For instance, “Have the same doctor for more than one year” was ranked number one out of sixteen for patients, while it was ranked number 10, 10, and 11 for residents, faculty, and administrators respectively. Individually, the CCA statement corresponding to a site’s major problem (for instance, “Use the computer” at a site where the major problem involved CPRS) was always ranked in the top four (out of sixteen) greatest differences at that site. Correspondence analysis revealed five competing models of the clinic visit: technical care, education-based care, humanistic care, guideline-based care, and efficient care. Specific CCA statements were closely linked with each model; and patients, residents, faculty, and administrators had very different preferences for each.
Implications:
This study had three important findings: 1) Some problems, such as continuity in teaching clinic, are system-wide; 2) CCA is a sensitive indicator of more site-specific problems, and 3) competing models of the clinic visit explain many between-group and site-specific tensions that correlate with recurring problems.
Impacts:
No site was particularly close to the patients’ ideal model. Specific patient-centered improvements for each site, and for the system as a whole, are suggested.
