Association of Implementation and Social Network Factors With Patient Safety Culture in Medical Homes: A Coincidence Analysis

Abstract

Objectives: The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture.

Methods: This was a cross-case analysis study in 25 diverse U.S. PCMHs. Data sources included interviews of a clinician and an administrator in each PCMH, surveys of clinicians and staff, and existing data on the PCMHs' characteristics. We used coincidence analysis, a novel method based on set theory and Boolean logic, to evaluate relationships between factors and the implementation outcome of patient safety culture.

Results: The coincidence analysis identified 5 equally parsimonious solutions (4 factors), accounting for all practices with higher safety culture. Three solutions contained the same core minimally sufficient condition: the implementation factor leadership priority for patient safety and the social network factor reciprocity in advice-seeking network ties (advice-seeking relationships). This minimally sufficient condition had the highest coverage (5/7 practices scoring higher on the outcome) and best performance across solutions; all included leadership priority for patient safety. Other key factors included self-efficacy and job satisfaction and quality improvement climate. The most common factor whose absence was associated with the outcome was a well-functioning process for behavioral health.

Conclusions: Our findings suggest that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists. Interventions to improve patient safety should consider measuring and addressing these key factors.

Figure 1a.. Illustration of Solution 1 from Coincidence Analysis

This figure shows the two minimally sufficient conditions (MSCs) for Solution 1 and illustrates the concepts of consistency and coverage. In Solution 1, the MSC of “Reciprocity in advice-seeking and prioritized patient safety among leadership” has a consistency of 1, meaning that the co-presence of those two terms was only true when the outcome (high patient safety culture) was present. This MSC covered 5 of the 7 practices (or 71%) that had the outcome. The second MSC is Adult-only practice and Agreement that a well-functioning system exists for managing patient relationships and communication, This MSC had a consistency of 1, meaning that the co-presence of those two terms was only true when the outcome was present. This MSC covered 2 of the 7 practices (or 29%) that had the outcome.

Figure 1b.. Illustration of Solution 4 from Coincidence Analysis

In Solution 4, the MSC of “Climate for quality improvement and Job satisfaction and self-efficacy” has a consistency of 1, meaning that the co-presence of those two terms was only true when the outcome (high patient safety culture) was present. This MSC covered 4 of the 7 practices (or 57%) that had the outcome. The second MSC is Agreement that a well-functioning system exists for behavioral health and prioritized patient safety among leadership. This MSC had a consistency of 1, meaning that the co-presence of those two terms was only true when the outcome was present. This MSC covered 3 of the 7 practices (or 43%) that had the outcome.