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Comparative Study
, 35 (9), 457-66

How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care

Comparative Study

How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care

Holly J Lanham et al. Jt Comm J Qual Patient Saf.


Background: Understanding the role of relationships health care organizations (HCOs) offers opportunities for shaping health care delivery. When quality is treated as a property arising from the relationships within HCOs, then different contributors of quality can be investigated and more effective strategies for improvement can be developed.

Methods: Data were drawn from four large National Institutes of Health (NIH)-funded studies, and an iterative analytic strategy and a grounded theory approach were used to understand the characteristics of relationships within primary care practices. This multimethod approach amassed rich and comparable data sets in all four studies, which were all aimed at primary care practice improvement. The broad range of data included direct observation of practices during work activities and of patient-clinician interactions, in-depth interviews with physicians and other key staff members, surveys, structured checklists of office environments, and chart reviews. Analyses focused on characteristics of relationships in practices that exhibited a range of success in achieving practice improvement. Complex adaptive systems theory informed these analyses.

Findings: Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes.

Discussion: Although this model of practice relationships was developed from data collected in primary care practices, which differ from other HCOs in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties.


Figure 1
Figure 1. Model-Development Process
The figure illustrates the model-development process. DOPC, Direct Observation of Primary Care (DOPC) study; P&CD, Prevention and Competing Demands in Primary Care study; STEP-UP, Study to Enhance Prevention by Understanding Practice; ULTRA, Using Learning Teams for Reflective Adaptation study.
Figure 2
Figure 2. Conceptual Model Depicting the Relationship Between Seven Characteristics of Practice Relationships, Reflection, Sensemaking and Learning, and Practice Outcomes†
This figure represents work underlying Figure 2 published in Safran D.G., Miller W., Beckman H.: Organizational dimensions of relationship-centered care: Theory, evidence, and practice. J Gen Intern Med 21(suppl. 1):S9–S15, Jan. 2006. The original work is acknowledged there. Model building occurred iteratively through the identification of relationship characteristics. Although secondary analysis of P&CD and STEP-UP data was performed before primary analysis of ULTRA data, both primary and secondary data analyses informed model building. Ex, example.

Comment in

  • Why Healing Relationships Matter in Primary Care Practice
    RM Epstein. Jt Comm J Qual Patient Saf 35 (9), 456, 437. PMID 19769205.
    Defining a language of relationships in clinical practices challenges health care to determine the role of such relationships in achieving patient safety.

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