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Research ArticleOriginal Research

Effect of Practice Ownership on Work Environment, Learning Culture, Psychological Safety, and Burnout

Alison Cuellar, Alex H. Krist, Len M. Nichols and Anton J. Kuzel
The Annals of Family Medicine April 2018, 16 (Suppl 1) S44-S51; DOI: https://doi.org/10.1370/afm.2198
Alison Cuellar
1Department of Health Administration and Policy, George Mason University, Washington, DC
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Alex H. Krist
2Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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Len M. Nichols
1Department of Health Administration and Policy, George Mason University, Washington, DC
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Anton J. Kuzel
2Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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    Table 1

    Survey Respondent and Practice Sample Characteristics

    CharacteristicAll PracticesaIndependentHospital OwnedFederally Qualified Health Center
    Total responding1,973690910373
    Clinicians responding46717023958
    Staff responding1,506520671315
    Outcome
    Culture of learning, mean score (95% CI)b3.0 (2.9–3.0)2.9 (2.8–3.1)3.0 (2.9–3.1)2.9 (.2.7–3.0)
    Work environment, mean score (95% CI)b
     Enjoyment with work3.6 (3.5–3.7)3.5 (3.3–3.6)3.7 (3.6–3.9)c3.4 (3.3–3.6)
     Place of joy and hope3.5 (3.4–3.6)3.4 (3.2–3.6)3.6 (3.5–3.7)c3.4 (3.2–3.6)
    Psychological safety, mean score (95% CI)b3.5 (3.4–3.6)3.4 (3.2–3.5)3.7 (3.6–3.9)d3.2 (3.0–3.3)
    Burnout scale, mean score (95% CI)b2.1 (2.00–2.14)2.2 (2.1–2.3)2.0 (1.9–2.1)d2.1 (2.0–2.2)
    Burnout indicator, mean score (95% CI)e0.24 (0.21–0.28)0.28 (0.24–0.34)0.20 (0.15–0.26)0.27 (0.22–0.33)
    Practice
    No. of clinicians, mean % (95% CI)a
     1–538.9 (30.9–47.5)27.5 (17.4–40.6)49.4 (36.3–62.6)34.7 (17.9–56.9)
     6–1032.1 (24.0–41.5)30.6 (18.4–46.2)30.4 (19.8–43.6)40.3 (19.2–65.7)
     ≥1129.0 (19.2–41.1)41.9 (25.7,−60.0)20.2 (8.5–40.9)24.9 (7.7–56.7)
    Specialty mix, mean % (95% CI)
     Single specialty60.7 (50.4–70.2)76.6 (58.8–88.3)62.4 (47.1–75.5)21.5 (8.8–43.9)f
     Multispecialty39.3 (29.8–40.6)23.4 (11.7–41.2)37.6 (24.5–52.9)78.4 (56.1–91.2)
    Medically underserved area, mean % (95% CI)69.3 (59.7–77.4)51.9 (35.6–67.9)78.0 (67.7–85.7)d83.0 (53.6–95.3)
    Patients with Medicare, mean % (95% CI)28.1 (24.2–32.0)29.1 (21.6–36.6)30.9 (25.5–36.3)18.9 (13.4–24.4)c
    Patients with Medicaid/uninsured, mean % (95% CI)24.1 (19.1–29.1)14.9 (10.0–19.8)19.6 (14.6–24.7)56.8 (45.5–68.0)f
    Total practices, No.1896110424
    • Note: P values generated by comparison with independent practices using t tests for differences in means, and χ2 tests of independence for proportions, adjusted for the survey design.

    • ↵a Estimates adjusted for practice-level nonresponse.

    • ↵b Scored on a scale from 1 to 5, where higher scores indicate higher levels; see text for response categories.

    • ↵c P <.05.

    • ↵d P <.01

    • ↵e Scored on an indicator of burnout defined by a rating of 3 or higher.

    • ↵f P <.001.

    • View popup
    Table 2

    Association of Practice Ownership With Work Environment, Learning Culture, Psychological Safety, and Burnout, All Survey Respondents

    CharacteristicCulture of Learninga
    β (95% CI)
    Enjoyment With Worka
    β (95% CI)
    Place of Joy and Hopea
    β (95% CI)
    Psychological Safetya
    β (95% CI)
    Burnouta
    β (95% CI)
    Practice ownership
     IndependentReferenceReferenceReferenceReferenceReference
     Hospital0.062 (−0.141 to 0.265)0.273 (0.014 to 0.533)b0.194 (−0.057 to 0.446)0.363 (0.118 to 0.609)c−0.287 (−0.509 to −0.063)b
    FQHC−0.106 (−0.385 to 0.172)−0.171 (−0.505 to 0.162)−0.191 (−0.536 to 0.155)−0.264 (−0.549 to 0.021)−0.048 (−0.364 to 0.268)
    Incremental difference between hospital-owned and independent practices by response category
    Response categoryaDifferenceDifferenceDifferenceDifferenceDifference
    Level 1−0.011−0.017−0.011−0.0270.098
    Level 2−0.012−0.041−0.028−0.054−0.010
    Level 3−0.001−0.042−0.037−0.055−0.045
    Level 40.0140.0390.0330.052−0.023
    Level 50.0090.0610.0430.085−0.020
    Total number1,9891,9881,9881,9921,984
    • FQHC = federally qualified health center.

    • Note: Multivariate ordered probit models adjusted for practice-level nonresponse and clustering at practice level and controlling for ownership (independent, hospital system, or federally qualified health center), whether practice is located in a medical underserved area, practice size, single- or multispecialty practice, percentage of patients with Medicare coverage, and percentage of patients with Medicaid coverage or uninsured.

    • ↵a Scored on a scale from 1 to 5, where higher scores indicate higher levels; see text for response categories.

    • ↵b P <.05.

    • ↵c P <.01.

    • View popup
    Table 3a

    Association of Practice Ownership With Work Environment, Learning Culture, Psychological Safety, and Burnout, Clinician Respondents

    CharacteristicCulture of Learninga
    β (95% CI)
    Enjoyment With Worka
    β (95% CI)
    Place of Joy and Hopea
    β (95% CI)
    Psychological Safetya
    β (95% CI)
    Burnouta
    β (95% CI)
    Practice ownership
     IndependentReferenceReferenceReferenceReferenceReference
     Hospital−0.131 (−0.409 to 0.146)0.094 (−0.243 to 0.430)−0.063 (−0.403 to 0.276)0.100 (−0.242 to 0.443)−0.192 (−0.545 to 0.161)
    FQHC−0.470 (−0.919 to −0.021)b−0.552 (−0.996 to −0.109)b−0.567 (−1.089 to −0.045)b−0.723 (−1.194 to −0.252)c0.219 (−0.317 to 0.755)
    Incremental difference between FQHC and independent practices by response category
    Response categoryaDifferenceDifferenceDifferenceDifferenceDifference
    Level 10.1080.0330.0450.088−0.055
    Level 20.0710.0880.0810.122−0.021
    Level 3−0.0090.0830.0890.0600.033
    Level 4−0.109−0.117−0.129−0.1530.019
    Level 5−0.061−0.088−0.086−0.1160.024
    No. of respondents467466466467466
    • FQHC = federally qualified health center.

    • Note: Multivariate ordered probit models adjusted for practice-level nonresponse and clustering at the practice level and controlling for ownership (independent, hospital system, or federally qualified health center), whether practice is located in a medical underserved area, practice size, single or multispecialty practice, percentage of patients with Medicare coverage, and percentage of patients with Medicaid coverage or uninsured.

    • ↵a Scored on a scale from 1 to 5, in which higher scores indicate higher levels; see text for response categories.

    • ↵b P < .05.

    • ↵c P < .01.

    • View popup
    Table 3b

    Association of Practice Ownership With Work Environment, Learning Culture, Psychological Safety and Burnout, Staff Respondents

    CharacteristicCulture of Learninga
    β (95% CI)
    Enjoyment With Worka
    β (95% CI)
    Place of Joy and Hopea
    β (95% CI)
    Psychological Safetya

    β (95% CI)
    Burnouta
    β (95% CI)
    Ownership
     IndependentReferenceReferenceReferenceReferenceReference
     Hospital-owned0.111 (−0.157 to 0.378)0.282 (−0.007 to 0.571)0.275 (−0.012 to 0.562)0.372 (0.131 to 0.613)b−0.328 (−0.608 to −0.049)c
    FQHC−0.018 (−0.367 to 0.331)−0.063 (−0.446 to 0.321)−0.085 (−0.443 to 0.274)−0.157 (−0.456 to 0.141)−0.066 (−0.411 to 0.280)
    Incremental difference between hospital-owned and independent practices by response category
    Response categoryaDifferenceDifferenceDifferenceDifferenceDifference
    Level 1−0.020−0.020−0.017−0.0300.116
    Level 2−0.044−0.044−0.040−0.056−0.018
    Level 3−0.041−0.041−0.049−0.057−0.051
    Level 40.0440.0440.0450.060−0.026
    Level 50.0610.0610.0620.082−0.021
    No. of respondents1,5031,5031,5031,5061,472
    • FQHC = federally qualified health center.

    • Note: Multivariate ordered probit models adjusted for practice-level nonresponse and clustering at the practice level and controlling for ownership (independent, hospital system, or federally qualified health center), whether practice is located in a medical underserved area, practice size, single or multispecialty practice, percentage of patients with Medicare coverage, and percentage of patients with Medicaid coverage or uninsured.

    • ↵a Scored on a scale from 1 to 5, in which higher scores indicate higher levels; see text for response categories.

    • ↵b P <.01.

    • ↵c P <.05.

Additional Files

  • Tables
  • Supplemental Table

    Supplemental Table

    Files in this Data Supplement:

    • Supplemental data: Table - PDF file
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The Annals of Family Medicine: 16 (Suppl 1)
The Annals of Family Medicine: 16 (Suppl 1)
Vol. 16, Issue Suppl 1
April 2018
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Effect of Practice Ownership on Work Environment, Learning Culture, Psychological Safety, and Burnout
Alison Cuellar, Alex H. Krist, Len M. Nichols, Anton J. Kuzel
The Annals of Family Medicine Apr 2018, 16 (Suppl 1) S44-S51; DOI: 10.1370/afm.2198

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Effect of Practice Ownership on Work Environment, Learning Culture, Psychological Safety, and Burnout
Alison Cuellar, Alex H. Krist, Len M. Nichols, Anton J. Kuzel
The Annals of Family Medicine Apr 2018, 16 (Suppl 1) S44-S51; DOI: 10.1370/afm.2198
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