title: What's in a setting?: Influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use.
abstract: BACKGROUND
  Organizational culture is an important but underinvestigated feature of the work environment that can impact provider behavior, including adherence to clinical practice guidelines. There is substantial evidence that physician assistance to smokers can produce significant reductions in tobacco use. However, this evidence has not been well translated into practice, as only a small proportion of smokers receive recommended treatment during medical visits.
  
  
  OBJECTIVE
  This study examines organizational culture as a contextual feature of primary care clinics and its impact on adherence to evidence-based guidelines for treating tobacco use.
  
  
  METHODS
  Cross-sectional survey data were collected from 500 primary care providers in 60 community clinics located in New York City. Relationships between provider adherence to "5A" clinical guidelines, as recommended by the U.S. Public Health Service, and both provider and organizational covariates were described. We used hierarchical linear modeling to examine the associations between clinic culture and provider treatment patterns.
  
  
  RESULTS
  Providers in clinics with stronger "group/clan," "hierarchical," and "rational" culture types, as compared with a "developmental" culture, reported greater adherence to 5A guidelines (p < .05). System-level structures and care processes were positively associated (p < .01), whereas number of ongoing quality initiatives was negatively associated with 5A delivery (p < .05). Provider familiarity with guidelines (p < .01), confidence with cessation counseling (p < .05), and perceived effectiveness in helping smokers quit were associated with more frequent 5A intervention (p < .01).
  
  
  CONCLUSIONS
  Findings suggest that organizational culture can influence provider adherence to cessation treatment guidelines, even when controlling for other factors known to affect practice patterns. Specifically, cultures that emphasize human resources and performance standards are conducive to integrating 5A guidelines into routine practice. Understanding the role of organizational culture enables healthcare managers and practitioners to be strategic when implementing, and also sustaining, use of evidence-based guidelines.
authors: Dorothy Y. Hung, PhD, MA, MPH, is Assistant Investigator, Department of Health Policy Research, Palo Alto Medical Foundation Research Institute, Mountain View, California, and Institute for Health Policy Studies, University of California, San Francisco. E-mail: hungd@pamfri.org. Robynn Leidig, MPH, is Research Fellow, Department of Health Policy Research, Palo Alto Medical Foundation Research Institute, Mountain View, California. E-mail: leidigr@pamfri.org. Donna R. Shelley, MD, MPH, is Associate Professor, Division of General Internal Medicine, New York University Medical Center. E-mail: donna.shelley@nyumc.org.
authors: Dorothy Y
authors: DY
authors: Hung
authors: Robynn
authors: R
authors: Leidig
authors: Donna R
authors: DR
authors: Shelley
mesh_terms: D000328:Adult; D003151:Community Health Centers / Q000458:organization & administration / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D005260:Female; D019983:Guideline Adherence / Q000458:organization & administration* / Q000706:statistics & numerical data; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D009519:New York City / Q000453:epidemiology; D015279:Organizational Culture; D011320:Primary Health Care / Q000458:organization & administration / Q000706:statistics & numerical data; D016540:Smoking Cessation / Q000706:statistics & numerical data*