BACKGROUND/RATIONALE:
Many VA teaching clinics struggle to be efficient, effective, and patient-centered. Patients, trainees, faculty, and administrators value various elements of clinic activity differently, and this causes recurring problems and barriers to implementation of ‘best practice’. Understanding these value differences is an extremely important first step in ameliorating these common, recurring problems and barriers.

OBJECTIVE(S):
Our previous study (PCC 98-101) has validated a Cultural Consensus Analysis (CCA) of local patients, faculty, and trainees. The specific objectives of this study are to: 1) To test the exportability of this CCA tool for detecting site-specific operational problems in individual clinics; 2) To create a conceptual model to explain clinic preferences; and 3) to evaluate the ability of this CCA tool to predict standard performance measure scores.

METHODS:
The CCA was studied at four other VA teaching clinics using a cross-sectional, correlation design. For each site, a working group of key clinic informants brainstormed a list of problems, and then used modified Delphi to prioritize this list. The CCA is independently performed on 50 subjects (10 each of faculty, residents, faculty patients, resident patients, administrators). CCA results were compared with the site’s problems using graphical, factor and correspondence analysis.

The conceptual model was iteratively developed from all CCA and observational data. Four analysts met regularly and proposed conceptual models. Discrepancies were adjudicated by discussion and reformulation of the models, and by triangulation with all available data. The final model was validated using correspondence analysis and convergent/discriminant analysis.

SHEP total quality and wait time scores and VSSC data on budget and # of unique patients were obtained for comparison to CCA performance.

FINDINGS/RESULTS:
All site visits have been completed. The CCA detected systematic, group-specific preference differences at each site. These were moderately to strongly associated with the problems independently identified by the workgroups. The CCA proved to be a useful tool for exploring the problems in depth and for detecting previously unrecognized problems.

A conceptual model of clinic preferneces was developed. Our final model, the Perception of Care Map, is a pentagram with five critical perspectives of the clinic visit. These five perspectives are structured care, educational care, relationship-based care, algorithmic care and efficient care. Each group emphasizes one or more of these perspectives, and group locations on the conceptual map explain the observed tensions between groups and the problems independently identified by the workgroups at each site.

We are just completing the evaluation of the ability of CCA to predict performance measures.

IMPACT:
This study continues to support the importance of CCA as a method for clinic improvement. CCA may be able to bridge the critical gap between guidelines and performance measures, and the specif elements and context of implementing these in a given site.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Smith CS, Morris M, Hill W, Francovich C, Christiano J. Developing and validating a conceptual model of recurring problems in teaching clinic. Advances in health sciences education : theory and practice. 2006 Aug 1; 11(3):279-88. [view]
2. Smith CS, Morris M, Hill W, Francovich C, McMullin J, Christiano J, Chavez L, Roth C, Vo A, Wheeler S, Milne C. Testing the exportability of a tool for detecting operational problems in VA teaching clinics. Journal of general internal medicine. 2006 Feb 1; 21(2):152-7. [view]

Conference Presentations

1. Smith C, Hill W, Morris M, Francovich C, McMullin J. Cultural consensus analysis successfully identifies specific problems for remediation at five VA teaching clinics. Paper presented at: Society of General Internal Medicine Annual Meeting; 2005 May 14; New Orleans, LA. [view]
2. Smith C. Important communication elements: Differences of opinion between U.S. war veterans and their doctors. Paper presented at: Association for Medical Education in Europe Annual Meeting; 2004 Sep 1; Edinburgh, Scotland. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Diagnosis, Treatment - Observational, Technology Development and Assessment
Keywords: Management
MeSH Terms: none