A Review of the Evidence: The Effect of Healthcare Providers' Working Conditions on Patient Care

A large body of evidence shows clear linkages between workplace conditions and employee satisfaction. In the healthcare industry, increasing interest in understanding these linkages stems from the idea that healthcare providers' working environments also affect important patient outcomes, including safety, quality of care, and satisfaction. Moreover, meeting objectives of current healthcare reform to increase quality of care includes increasing the availability of primary care providers. Results from this review may inform policymakers as they endeavor to implement aspects of healthcare reform related to increasing the supply of primary care providers and improving patient outcomes.

Recently, investigators at the VA Evidence-Based Synthesis Program site in Minneapolis, MN conducted a systematic review of the literature to examine the role of primary care providers' workplace conditions in influencing patient outcomes, with a focus on patient satisfaction, safety, and quality of care. Building on a 2003 report from the Agency for Healthcare Research and Quality, the investigators reviewed the literature from 2000 through September 2011 to help answer the following three key questions.

Question #1
How are human resources practices, such as skill levels, training, workload, hours worked, autonomy, and electronic medical records/systems, associated with patient outcomes?

Using data from 3 randomized clinical trials, 7 longitudinal studies, and 17 cross-sectional studies that met this review's inclusion criteria, the evidence suggests:

• More training (two studies), shorter hours (two studies), and computerized systems (three studies) lead to better quality of care.
• There was mixed evidence on the effect of provider skill levels and workload on patient satisfaction.
• No studies were identified that examined how electronic medical records or computerized systems affect patient satisfaction.

Question #2
How are other working conditions, such as organizational culture or physical environment, associated with patient outcomes?

Using data from 9 studies on organizational culture and/or team-based care that met this review's inclusion criteria, the evidence suggests:

• Two studies found a positive effect of provider teams on patient quality of care, though one study found no effect.
• Two studies that examined the effect of implementing patient-centered medical homes (PCMH) found positive effects on quality of care.
• One study found that organizations with a culture that emphasized the importance of information sharing had high quality of care.

Question #3
In studies that report provider outcomes, how are working conditions associated with provider outcomes (e.g., job satisfaction, productivity, pay)?

Using data from studies used to answer the first two questions in this review, in addition to systematic reviews pertaining to provider outcomes in primary care, the evidence suggests:

• Greater workloads and less control over work tasks resulted in greater provider stress, burnout, and less job satisfaction.
• One study found that electronic medical records did not result in greater provider stress.

Conclusions:
Overall, the studies that were 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; and
• Provider training and work hours have no effect on patient satisfaction.

Future Research:
Investigators note that there is little research that investigates the effects of working conditions on patient safety. Also, the development of, or more consistent use of valid measures of both working conditions and patient or provider outcomes in the primary care settings is needed to make comparisons across studies easier.

This report is a product of the HSR&D Evidence-based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference
Kapinos K, Fitzgerald P, Greer N, Rutks I, and Wilt T. The Effect of Working Conditions on Patient Care: A Systematic Review. VA-ESP Project #09-009;2012.

View the full report (**VA Intranet only**):
http://www.hsrd.research.va.gov/publications/esp/reports.cfm

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Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

See the full reports online.