title: Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.
abstract: BACKGROUND
  Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care.
  
  
  METHODS
  We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation.
  
  
  RESULTS
  Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores.
  
  
  CONCLUSIONS
  Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.
authors: Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.|Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, Los Angeles, California, USA.
authors: Reshma
authors: R
authors: Gupta
authors: Department of Medicine, University of California San Francisco, San Francisco, California, USA.|Department of Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.
authors: Christopher
authors: C
authors: Moriates
authors: Department of Medicine, University of California San Francisco, San Francisco, California, USA.
authors: James D
authors: JD
authors: Harrison
authors: Department of Medicine, University of California San Francisco, San Francisco, California, USA.|Department of Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.
authors: Victoria
authors: V
authors: Valencia
authors: Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
authors: Michael
authors: M
authors: Ong
authors: Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
authors: Robin
authors: R
authors: Clarke
authors: Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
authors: Neil
authors: N
authors: Steers
authors: Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
authors: Ron D
authors: RD
authors: Hays
authors: Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
authors: Clarence H
authors: CH
authors: Braddock
authors: Department of Medicine, University of California San Francisco, San Francisco, California, USA.
authors: Robert
authors: R
authors: Wachter
mesh_terms: D000046:Academic Medical Centers / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D003697:Delphi Technique; D004777:Environment; D005260:Female; D017721:Hospital Costs; D020445:Hospitalists / Q000523:psychology; D006801:Humans; D007388:Internal Medicine / Q000193:education; D007396:Internship and Residency / Q000458:organization & administration; D007857:Leadership; D008297:Male; D008875:Middle Aged; D015279:Organizational Culture; D061214:Patient Safety; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration*; D015203:Reproducibility of Results
keywords: Healthcare quality improvement; Quality measurement; Safety culture