Effects of Primary Care Team Social Networks on Quality of Care and Costs for Patients With Cardiovascular Disease

Mundt and colleagues' study builds on a growing literature on the importance of social-organizational factors in primary care teams (1, 2,3). Findings from the study extend this literature by showing that equally distributed communication among team members, rather than communication that is routed through a few central individuals, may lead to improved patient care.

The exploratory structural equation model analyses are interesting in how they use the social network density concept to extend prior work linking team/organizational climate to primary care team functioning. Our work has focused on the concept of relational climate as a measure of the social context in primary care that is associated with quality of care (1,4). Other work in the climate literature has shown that "strong" climates, defined as the degree to which team members share climate perceptions is important in service industries (5). The current study identifies social network density as a potentially key concept to extend this work. Dense social networks may facilitate information exchange and behavioral support among team members. Dense social networks may also promote "strong" climates.

One omitted variable may be clinic leadership style. Affiliative or coaching leaders may encourage greater interconnection among team members through practices such as daily huddles or encouraging social events to promote inter- and across-team discussions. Clinic leaders could also aim to reduce barriers that inhibit or discourage communication on the team, such as a "culture of blame" and over-emphasis on positional authority.

References
1. Benzer JK, Young G, Stolzmann K, Osatuke K, Meterko M, Caso A, White B, Mohr DC. The relationship between organizational climate and quality of chronic disease management. Health Serv Res. 2011 46(3):691-711.
2. Roblin DW, Howard DH, Junling R, & Becker ER. An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries. Med Care Res Rev, 2011; 68(2), 177-201.
3. Virtanen M, Oksanen T, Kawachi I, Subramanian S, Elovainio M, Suominen S. Linna A, Koponen A, Pentti J, Kivim?ki M, Vahtera J. Organizational justice in primary-care health centers and glycemic control in patients with type 2 diabetes. Med Care, 2012; 50(10), 831-835.
4. Mohr DC, Benzer JK, & Young, GJ. Provider workload and quality of care in primary care settings: moderating role of relational climate. Med Care 2013, 51(1), 108-114.
5. Schneider B, Salvaggio AN, & Subirats M. Climate strength: A new direction for climate research. J Appl Psycho, 2002, 87(2), 220-229.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Competing interests: None declared

We greatly appreciate your insightful read of our article. We agree that the significance of the connectedness among health care professionals in relation to patient outcomes has not been fully explored. In part, this may be due to prior efforts to improve patient care through process-improvement initiatives targeting the behavior of single individuals. Conversely, when health care practices are seen as complex adaptive systems (CASs), which are interconnected in nonlinear ways, the role of teams in patient care comes to light. We theorize that team relational connectedness allows health professionals to manage complexity effectively through coordination and shared awareness.

From the vantage point of CASs, dense face-to-face interaction networks in teams, as opposed to EHR communication, may be better suited for establishing situational awareness, sense-making, learning, improvisation, self-organization, and emergence, and for fostering the team's ability to deliver high-value cost-effective care to patients with CVD.

We believe complex systems science will provide a rich framework for studying primary care practices. Future studies utilizing CASs' analytical tools (e.g. social networks analysis, stochastic actor based modeling, etc) are greatly needed to better understand how team connectedness shapes care delivery and impacts patient outcomes in primary care. We are of the same mind that mixed methods studies that rely on qualitative methods as well as on complex systems science quantitative methods are also needed. We concur that communication is not the same thing as relationship. It is a rich area for study!

We are very grateful for your online comment to our publication.

Most Sincerely, Marlon Mundt

Competing interests: None declared