Defense Date


Document Type


Degree Name

Doctor of Philosophy


Health Related Sciences

First Advisor

Stephen Mick


A frequently cited reason for poor quality of care in the ambulatory care setting is the lack of optimally designed systems to address care for those with preventive or chronic care needs. Organizational theory suggests that culture plays an important role in the shaping of these types of programs. The purpose of this cross-sectional study is to understand through descriptive and regression analysis of secondary data, the relationship between the existence of cultural characteristics such as collegiality, quality emphasis and autonomy, and the systems employed to improve quality of care within primary care practices. The study uses an integrated theoretical framework consisting of organizational culture, social network and organizational learning theories to better understand the rationale for the relationships. The analysis is an outgrowth of a previous National Committee for Quality Assurance (NCQA) project conducted in Minnesota where 300 staff across 42 office practices were asked to answer questions on a self-report survey to assess the presence and function of clinical practice systems. To evaluate organizational culture, validated questions from the work of Kralewski and colleagues were also asked. Descriptive analysis results showed a large range in consistency of practice system use, with clinical information systems as most used and care management systems as least used. Results of the multivariate analysis showed collegiality and quality emphasis as significantly related to the use of practice systems. More specifically, both collegiality and quality emphasis were seen to positively influence the use of clinical quality evaluation and improvement systems and an emphasis of quality was seen to positively influence the use of clinician reminders and clinical information systems. A statistically significant relationship between autonomy and practice systems use was not seen. As the study shows that culture does influence the use of certain systems for care improvement, it provides an increased understanding and avenue for intervention/change in the continued quest for improved quality of care. Policymakers and practice leadership may want to focus energy on understanding primarily whether the culture of practices places an emphasis on quality and collegiality. Ultimately it may foster the use of practice systems for quality of care improvement.


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Date of Submission

May 2010