Organizational culture and physician satisfaction with dimensions of group practice

Health Services Research, June, 2007 by James L. Zazzali, Jeffrey A. Alexander, Stephen M. Shortell, Lawton R. Burns

Most physicians in the United States now work in group practice settings (Wassenaar and Thran 2003). The reasons why physicians have integrated into group practices are well known (Charns 1997; Robinson 1999). Much less is known, however, about the organizational arrangements of such groups and their effects on physician attitudes and behaviors. Given the movement of physicians into groups, and the traditional tensions between organizational requirements and professional norms of autonomy and freedom from external control, it is important to understand how these groups are organized and, perhaps more importantly, whether such factors are associated with physician satisfaction with various aspects of these organizational arrangements. From a practical standpoint, satisfaction is important because it has been demonstrated to be related to retention and turnover across a variety of organizational settings and among many different types of workers (Tett and Meyer 1993). Physician satisfaction has also been linked to patient satisfaction (Linn et al. 1985; C. Haas et al. 2000), patient adherence to medical treatment (DiMatteo et al. 1993), prescribing patterns (Melville 1980), physician performance (McGlynn 1988; Warren, Weitz, and Koulis 1998; Kerr et al. 2000), and the willingness of physicians to work with hospitals (Grumbach et al. 1998).

Because physician organizations typically lack the formalized structures that other delivery organizations (e.g., hospitals) possess, the organizational culture of physician groups may be a particularly important contextual determinant of physician satisfaction. However, the extant literature on the culture of health care organizations sheds limited light on this question because much of it: (1) is descriptive, (2) does not relate organizational culture to meaningful measures of outcomes, and/or (3) addresses the culture of only one organization. Indeed, only a handful of studies have examined either the structure or culture of physician group practices (Kralewski et al. 1996, 1998; Shortell, Alexander et al. 2001; Williams et al. 2002) and only one has considered the relationship between organizational culture and the satisfaction of physicians working in group practice settings (Williams et al. 2002). Our study is a significant departure from the previous published accounts of health care organizational culture insofar as we address the analytic question of the relationship of organizational culture and physician satisfaction with the managerial and organizational capabilities of the groups in which they work. This approach to assessing satisfaction is distinct from the more typical global measures of overall job satisfaction, as well as satisfaction with particular facets of physician's jobs, like pay and rewards, relationships with coworkers, etc. The capabilities of physician groups are assuming increased importance with the growth in the number of patients with chronic illness. Such patients often require a team-based approach to care with strong organizational supports (Wagner 2000; Shortell et al. 2004). Managerial and organizational capabilities are also growing in importance due to increased need of medical groups to implement electronic health records, and respond to financial incentives for improved quality and increased public reporting demands.

BACKGROUND

The culture of an organization consists of its norms, values, and beliefs, and is reflected by its stories, rituals and rites, symbols, and language (Daft 2000). The notion that organizations have a culture is a relatively new idea, with the concept first entering the academic literature in 1979. In 1982, two books popularized the concept, Corporate Culture by Deal and Kennedy and In Search of Excellence by Peters and Waterman. In much of the writings on culture assumptions about the importance of culture in organizational settings have been made, yet little empirical work has been conducted to support such claims.

Early research on culture focused on developing measures of culture or on empirically describing the culture of various organizational settings. Recent interest in the culture of health care organizations, however, has begun to address the importance of culture for key organizational outcomes. For example, some have argued that the culture of physician organizations is important in the care of chronic illnesses, in that culture may be related to the ability of these organizations to support quality improvement efforts and develop needed information systems to provide better patient care (Rundall et al. 2002). In a study of ICUs, "caregiver interaction" (culture, leadership, coordination, conflict management abilities, and communication) was found to be significantly related to several measures of organizational effectiveness. However, the reporting methods prevent one from distinguishing the effects of culture on clinical effectiveness from the effects of other components of caregiver interaction (Shortell et al. 1994). In a study of culture and patient outcomes for CABG, a supportive group culture was associated with shorter postoperative intubation time (a positive outcome), but also associated with longer operating room times (a negative outcome) (Shorten et al. 2000). When examining whether implementation of evidenced-based medicine in physician organizations was related to organizational culture, no significant relationships were found (Shortell, Zazzali et al. 2001). Others have examined attitudinal measures of effectiveness, like job satisfaction, as a function of group culture, and demonstrated that organizational "culture" is a determinant of physician job satisfaction (Williams et al. 2002). However, the measures of culture and satisfaction were assessed at a global level, and do not provide a fine-grained understanding of how culture and satisfaction are related. Two other studies found positive relationships between culture and organizational outcomes in mental health services settings (Morris and Bloom 2002; Morris, Bloom, and Wang 2006), using measures that jointly assessed dimensions of the organization's climate and culture.