Slack resources and quality of primary care

Med Care. 2012 Mar;50(3):203-9. doi: 10.1097/MLR.0b013e318241e3e6.


Background: Research generally shows that greater resource utilization fails to translate into higher-quality healthcare. Organizational slack is defined as extra organizational resources needed to meet demand. Divergent views exist on organizational slack in healthcare. Some investigators view slack negatively because it is wasteful, inefficient, and costly, whereas others view slack positively because it allows flexibility in work practices, expanding available services, and protecting against environmental changes.

Objective: We tested a curvilinear relationship between organizational slack and care quality.

Methods: The study setting was primary care clinics (n=568) in the Veterans Health Administration. We examined organizational slack using the patient panel size per clinic capacity ratio and support staff per provider ratio staffing guidelines developed by the Veterans Health Administration. Patient-level measures were influenza vaccinations, continuity of care, and overall quality of care ratings. We obtained 2 independent patient samples with approximately 28,000 and 62,000 observations for the analysis. We used multilevel modeling and examined the linear and quadratic terms for both organizational slack measures.

Results: We found a significant curvilinear effect for panel size per clinic capacity for influenza vaccinations and overall quality of care. We also found support staff per provider exhibited a curvilinear effect for continuity of care and influenza vaccinations. Greater available resources led to better care, but at a certain point, additional resources provided minimal quality gains.

Conclusions: Our findings highlight the importance of primary care clinic managers monitoring staffing levels. Healthcare systems managing a balanced provider workload and staff-mix may realize better patient care delivery and cost management.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Continuity of Patient Care / organization & administration
  • Continuity of Patient Care / standards
  • Female
  • Health Resources / organization & administration
  • Health Resources / standards*
  • Humans
  • Influenza Vaccines / therapeutic use
  • Male
  • Middle Aged
  • Patient Satisfaction
  • Primary Health Care / organization & administration
  • Primary Health Care / standards*
  • Quality of Health Care* / organization & administration
  • Quality of Health Care* / standards
  • Resource Allocation / organization & administration
  • Resource Allocation / standards
  • United States
  • United States Department of Veterans Affairs / organization & administration
  • United States Department of Veterans Affairs / standards


  • Influenza Vaccines