Primary Care Networks and Team Effectiveness: The Case of a Large-Scale Quality Improvement Disparity Reduction Program

Abstract

Background: Growing evidence on the difficulty in achieving quality improvement (QI) and reducing health and health care disparities in diverse populations, has led to increased attention to the role of health care teams. It has long been established that effective teamwork leads to higher-quality decision making and medical intervention and, in turn, to better patient outcomes. The current study investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale quality improvement disparity reduction intervention. Methods: The study was conducted in Israel's largest insurer and provider of services, operating a primary-care-based quality improvement disparity reduction program to reduce gaps between disadvantaged and general member populations. We used a mixed-method design of Social Network Analysis and qualitative data collection. We performed 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units. We also collected information on the organizational ties, analyzing density and centrality. Pearson correlations examined the association between network measures and perceived team effectiveness. Results: Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE (r=0.406 p<0.05; r=0.464 p<0.05). and reported by primary care teams as central to the implementation of the program. Clinic indegree centrality was also positively associated with perceived TE (r=0.482 p<0.05). Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. Findings show that conflicts between team members about their roles within the disparity reduction initiative resulted in low cohesiveness and a sense of low ability to reach the organizational goal. Conclusions: The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts.