Relationship Quality and Patient-Assessed Quality of Care in VA Primary Care Clinics: Development and Validation of the Work Relationships Scale

Erin P. Finley; Jacqueline A. Pugh; Holly Jordan Lanham; Luci K. Leykum; John Cornell; Poornachand Veerapaneni; Michael L. Parchman

doi:10.1370/afm.1554

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Figure 1
Person-item map for 15-item Work Relationships Scale.

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Table 1

Final Item-Fit Statistics for the Work Relationships Scale

Item	χ²	df	P Value	Out-fit Mean Square	In-fit Mean Square
1. This clinic encourages nursing staff (ie, RN, LVN, MA, CMA) input for making changes.	459.6	353	<.001	1.30	1.02
2. Most people in this clinic are willing to change how they do things in response to feedback from others.	351.9	353	.507	0.99	1.03
3. Most people in this clinic actively seek new ways to improve how we do things.	335.3	353	.743	0.95	0.97
4. Most people in this clinic are comfortable voicing their opinion even though it may be unpopular.	487.4	353	<.001	1.38	1.33
5. Most people in this clinic pay attention to how their actions affect others in the clinic.	376.5	353	.186	1.06	1.10
6. After making a change, we usually discuss what worked and what didn’t.	268.7	353	>.999	0.76	0.76
7. Most people in this clinic get together to talk about their work.	339.8	353	.684	0.96	0.96
8. This clinic values people who have different points of view.	327.7	353	.829	0.93	0.83
9. Difficult problems in this clinic are usually solved through face-to-face discussion.	303.7	353	.973	0.86	0.79
10. We regularly take time to consider ways to improve how we do things.	367.8	353	.283	1.04	0.84
11. When there is a conflict in this clinic, the people involved are encouraged to talk about it.	249.0	353	>.999	0.70	0.71
12. Most people in this clinic understand how their job fits into the rest of the clinic.	451.9	353	<.001	1.28	1.34
13. This clinic usually encourages everybody’s input for making changes.	250.7	353	>.999	0.71	0.67
14. My opinion is valued by others in this clinic.	271.3	353	>.999	0.77	0.84
15. The leadership in this clinic usually makes sure that we have the time and space necessary to discuss changes to improve care.	409.1	353	.021	1.16	1.02

CMA = certified medical assistant; LVN = licensed vocational nurse; MA = medical assistant; RN = registered nurse.

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Table 2

Work Relationships Scale Scores by Clinic

Clinic	No.^a	Mean Score (SD)^b	Range
1^c	41	39.2 (11.0)	19.0–58.0
2^c	44	41.7 (10.0)	15.0–58.0
3^c	20	43.6 (12.4)	19.0–61.0
4	13	44.3 (10.8)	29.0–60.0
5	19	45.4 (11.7)	28.0–71.0
6	19	46.2 (11.1)	21.0–62.5
7	41	46.4 (12.1)	20.0–75.0
8	10	48.7(11.6)	31.0–66.0
9	32	50.8 (7.6)	34.0–72.0
10	58	50.9 (11.6)	18.0–75.0
11	32	51.3 (12.16)	20.0–75.0
12	20	51.5 (10.0)	28.5–65.0
13	36	51.9 (9.7)	32.0–72.0
14	11	53.4 (11.6)	27.0–72.0
15^c	25	57.1 (7.5)	38.0–72.0
16^c	15	57.5 (4.2)	51.0–68.0
17^c	9	60.1 (6.09)	48.0–67.0

↵a Number of respondents from each clinic.
↵b Scored on a range from 15 to 90, with higher scores indicating higher quality relastionships.
↵c Selected as representing high-scoring and low-scoring clinics.

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Table 3

Survey of Health Care Experiences of Patients Variable Data for Participating Clinics, FY2010–2011, and Mean Work Relationships Scale Scores by Clinic

Variable	Overall Rating of Health Care, r²	Overall Rating of Doctor/Nurse, r²	Getting Care Quickly, r²	Clinician Wait Time, r²	Mean Clinic WRS, r²
Overall rating of health care	1.00	0.81^a	0.28	0.55^b	0.50^b
Overall rating of personal doctor/nurse	…	1.00	0.71^a	0.45	0.53^b
Getting care quickly	…	…	1.00	0.24	0.19
Clinician wait time	…	…	…	1.00	0.08

SHEP = Survey of Health Care Experiences of Patients; WRS = Work Relationships Scale.
Note: Data are based on information for 17 clinics, with the exception of the variable getting care quickly (n=15), for which 2 clinics were missing from the FY2010–2011 SHEP data set.
↵a P <.01, based on Spearman rank-order correlations.
↵b P <.05, based on Spearman rank-order correlations.

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Table 4

Quotes Related to Lanham et al’s Relationship Characteristics in Clinics with High and Low WRS Scores

Rich communication
Communication through face-to-face conversation; most effective when messages are unclear or ambiguous
Low WRS score clinics	“I think that some days we should just sit down and say, ‘Okay, this is what’s going on. What do you know—how do you perceive this is supposed to be done?’ …[S]ometimes the hurdles that we run into are just, they could have been easily avoided if there had been a little bit better communication.”
High WRS score clinics	“Well, you know we have what’s called huddle every morning and any problems from the day before are discussed in huddle with all the team members and the clerical staff, social workers, the pharmacist. So we all get to know anything that’s going on at that time.”
Heedful interrelating
Individuals are attentive to their work tasks and sensitive to how their roles and actions affect and intersect with those around them
Low WRS score clinics	“…[T]here’s a whole lot of tension and a lot of it has to do with, ‘That ain’t my job and you’re messing in my area and you don’t belong in my area and you need to back out and just stay in your own business.’”
High WRS score clinics	“I think the teamwork here is just excellent. You know we really pitch in and try and help. Everyone’s attitude basically is that if one person’s working hard, we’re all working hard.”
Trust
Individuals feel safe in making themselves vulnerable to others
Low WRS score clinics	“Some people are probably not going to verbalize a lot, because they’re afraid it might get back to their boss or… because they don’t want to rock the boat.”
High WRS score clinics	“So, I have learned so much about medicine itself from these people; they’re wonderful…I’m not afraid to approach them for whatever the patient needs, because the goal is to provide the best and safest patient care.”
Respectful interaction
Honest, appreciative, and self-confident interaction between individuals
Low WRS score clinics	“That’s one of the things that kind of has me down on the clinic, just lack of communication, for coordination, lack of respect in my opinion, professionalism, and so, and your opinion about things, how things should run.”
High WRS score clinics	“The camaraderie among the team members, among the teams, among the different disciplines, that we work so cohesively together. So, ideal.”
Mindfulness
Demonstrating openness to diverse ideas and perspectives
Low WRS score clinics	“…I don’t even make suggestions anymore. I mean, you get tired after a while. I mean, you know, you really want to make a difference, but it doesn’t go anywhere and people get tired and frustrated….”
High WRS score clinics	“We have a really great chain of command that empowers us to make decisions and then also when we have problems to voice those concerns and tell them what our hurdles are and so they can help us on their end or help us with ideas about how to overcome the hurdles that we’re encountering.”

WRS=Work Relationships Scale.
Note: Relationship characteristics from Lanham HJ, McDaniel RR Jr, Crabtree BF, et al.⁷

Additional Files

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Tables

Supplemental Appendix, Figure, & Table

Supplemental Appendix. Sample Questions From Semistructured Clinic Member Interviews; Supplemental Figure. Person-Item map for original 19-item Work Relationship Scale; Supplemental Table. Initial Item-Fit Statistics for the Work Relationship Scale (WRS) (n = 457)

Files in this Data Supplement:

Supplemental data: Appendix - PDF file, 1 page, 79 KB
Supplemental data: Figure - PDF file, 1 page, 984 KB
Supplemental data: Table - PDF file, 2 pages, 131KB
The Article in Brief

Relationship Quality and Patient-Assessed Quality of Care in VA Primary Care Clinics: Development and Validation of the Work Relationships Scale

Erin P. Finley , and colleagues

Background High-quality relationships among clinicians and staff is an essential component of improving delivery of primary care. This study set out to develop and validate a scale to assess staff and clinician relationships in primary care settings.

What This Study Found A 15-item Work Relationships Scale (WRS) was developed. The WRS has excellent internal reliability and identified significant variation in relationship quality across participating practices. Practices with lower WRS scores received poorer patient quality ratings for both individual clinicians and overall healthcare.

Implications

This is one of the first studies to demonstrate that relationships within a care organization affect patient satisfaction.
Relationships between primary care staff and clinicians appear to have a significant impact on patient perceptions of care and should be assessed in efforts to improve health care delivery.