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

Alison Cuellar; Alex H. Krist; Len M. Nichols; Anton J. Kuzel

doi:10.1370/afm.2198

Article Figures & Data

Tables

Additional Files

View popup

Table 1

Survey Respondent and Practice Sample Characteristics

Characteristic	All Practices^a	Independent	Hospital Owned	Federally Qualified Health Center
Total responding	1,973	690	910	373
Clinicians responding	467	170	239	58
Staff responding	1,506	520	671	315
Outcome
Culture of learning, mean score (95% CI)^b	3.0 (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 work	3.6 (3.5–3.7)	3.5 (3.3–3.6)	3.7 (3.6–3.9)^c	3.4 (3.3–3.6)
Place of joy and hope	3.5 (3.4–3.6)	3.4 (3.2–3.6)	3.6 (3.5–3.7)^c	3.4 (3.2–3.6)
Psychological safety, mean score (95% CI)^b	3.5 (3.4–3.6)	3.4 (3.2–3.5)	3.7 (3.6–3.9)^d	3.2 (3.0–3.3)
Burnout scale, mean score (95% CI)^b	2.1 (2.00–2.14)	2.2 (2.1–2.3)	2.0 (1.9–2.1)^d	2.1 (2.0–2.2)
Burnout indicator, mean score (95% CI)^e	0.24 (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
1–5	38.9 (30.9–47.5)	27.5 (17.4–40.6)	49.4 (36.3–62.6)	34.7 (17.9–56.9)
6–10	32.1 (24.0–41.5)	30.6 (18.4–46.2)	30.4 (19.8–43.6)	40.3 (19.2–65.7)
≥11	29.0 (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 specialty	60.7 (50.4–70.2)	76.6 (58.8–88.3)	62.4 (47.1–75.5)	21.5 (8.8–43.9)^f
Multispecialty	39.3 (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)^d	83.0 (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.	189	61	104	24

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

Characteristic	Culture of Learning^a β (95% CI)	Enjoyment With Work^a β (95% CI)	Place of Joy and Hope^a β (95% CI)	Psychological Safety^a β (95% CI)	Burnout^a β (95% CI)
Practice ownership
Independent	Reference	Reference	Reference	Reference	Reference
Hospital	0.062 (−0.141 to 0.265)	0.273 (0.014 to 0.533)^b	0.194 (−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 category^a	Difference	Difference	Difference	Difference	Difference

Level 1	−0.011	−0.017	−0.011	−0.027	0.098
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 4	0.014	0.039	0.033	0.052	−0.023
Level 5	0.009	0.061	0.043	0.085	−0.020
Total number	1,989	1,988	1,988	1,992	1,984

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

Characteristic	Culture of Learning^a β (95% CI)	Enjoyment With Work^a β (95% CI)	Place of Joy and Hope^a β (95% CI)	Psychological Safety^a β (95% CI)	Burnout^a β (95% CI)
Practice ownership
Independent	Reference	Reference	Reference	Reference	Reference
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)^c	0.219 (−0.317 to 0.755)
Incremental difference between FQHC and independent practices by response category

Response category^a	Difference	Difference	Difference	Difference	Difference

Level 1	0.108	0.033	0.045	0.088	−0.055
Level 2	0.071	0.088	0.081	0.122	−0.021
Level 3	−0.009	0.083	0.089	0.060	0.033
Level 4	−0.109	−0.117	−0.129	−0.153	0.019
Level 5	−0.061	−0.088	−0.086	−0.116	0.024
No. of respondents	467	466	466	467	466

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

Characteristic	Culture of Learning^a β (95% CI)	Enjoyment With Work^a β (95% CI)	Place of Joy and Hope^a β (95% CI)	Psychological Safety^a β (95% CI)	Burnout^a β (95% CI)
Ownership
Independent	Reference	Reference	Reference	Reference	Reference
Hospital-owned	0.111 (−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 category^a	Difference	Difference	Difference	Difference	Difference

Level 1	−0.020	−0.020	−0.017	−0.030	0.116
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 4	0.044	0.044	0.045	0.060	−0.026
Level 5	0.061	0.061	0.062	0.082	−0.021
No. of respondents	1,503	1,503	1,503	1,506	1,472

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.