Primary care networks and team effectiveness: the case of a large-scale quality improvement disparity reduction program.

Documentation of primary care teams' involvement in disparity reduction efforts exists, yet little is known about how teams interact or perceive their effectiveness. We investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale disparity reduction intervention in Israel's largest insurer and provider of services. A mixed-method design of Social Network Analysis and qualitative data collection was employed. 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units were performed and information on the organizational ties, analyzing density and centrality, collected. Pearson correlations examined association between network measures and perceived TE. Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE. Clinic in-degree centrality was also positively associated with perceived TE. Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts. List of abbreviations Team Effectiveness (TE); Clalit Health Services (Clalit); Social Network Analysis (SNA); Quality Improvement (QI); National Health Care Collaborative (NHPC); Tampa Bay Community Cancer Network (TBCCN).

Can non-clinical community placements enhance medical students' understanding of the social determinants of ill health?

OBJECTIVES: Teaching the social determinants of health using classroom methods and medical settings is not effectual, yet few institutions require students to undertake placements in non-clinical settings. We sought to understand through qualitative investigation how non-clinical community placements contributed to students' understanding of health disparities. STUDY DESIGN: Qualitative methods. METHODS: Semistructured interviews with eight purposively selected students and a focus group were conducted by an independent, non-medical and non-religiously affiliated researcher. A thematic analysis elicited key themes and findings. RESULTS: On analysis, students valued the placements, reporting a greater understanding of and empathy for the needs of people from marginalised socio-economic, cultural and ethnic groups. Some believed this was better gained in non-clinical settings where doctor-patient barriers were absent. CONCLUSIONS: Non-clinical community placements may provide a special opportunity to teach health determinants and cultural competence to medical students.

Reducing inequity in primary care clinics treating low socioeconomic Jewish and Arab populations in Israel.

Background: An organization-wide inequity-reduction quality improvement (QI) initiative was implemented in primary care clinics serving disadvantaged Arab and Jewish populations. Using the Chronic Care Model (CCM), this study investigated the types of interventions associated with success in inequity reduction. Methods: Semi-structured interviews were conducted with 80 staff members from 26 target clinics, and information about intervention types was coded by CCM and clinical domains (e.g. diabetes, hypertension and lipid control; performance of mammography tests). Relationships between type and number of interventions implemented and inequity reduction were assessed. Results: Target clinics implemented 454 different interventions, on average 17.5 interventions per clinic. Interventions focused on Decision support and Community linkages were positively correlated with improvement in the composite quality score (P < 0.05). Conversely, focusing on a specific clinical domain was not correlated with a higher quality score. Conclusions: Focusing on training team members in selected QI topics and/or tailoring interventions to meet community needs was key to the interventions' success. Such findings, especially in light of the lack of association between QI and a focus on a specific clinical domain, support other calls for adopting a systems approach to achieving wide-scale inequity reduction.