title: How improving practice relationships among clinicians and nonclinicians can improve quality in primary care.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Information, Risk and Operations Management, McCombs School of Business, University of Texas, Austin, USA. holly.lanham@phd.mccombs.utexas.edu
authors.forename: Holly J
authors.initials: HJ
authors.lastname: Lanham
authors.forename: Reuben R
authors.initials: RR
authors.lastname: McDaniel
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Crabtree
authors.forename: William L
authors.initials: WL
authors.lastname: Miller
authors.forename: Kurt C
authors.initials: KC
authors.lastname: Stange
authors.forename: Alfred F
authors.initials: AF
authors.lastname: Tallia
authors.forename: Paula
authors.initials: P
authors.lastname: Nutting
mesh_terms: D003695:Delivery of Health Care / Q000379:methods*; D006801:Humans; D007400:Interprofessional Relations; D017146:Models, Organizational; D015279:Organizational Culture; D009936:Organizational Innovation; D011320:Primary Health Care / Q000458:organization & administration / Q000592:standards*; D011787:Quality of Health Care; D014481:United States