Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation

Abstract

BackgroundOrganisational 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.MethodsWe 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.ResultsTwenty-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.ConclusionsOur 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.

A new instrument to measure high value, cost-conscious care attitudes among healthcare stakeholders: development of the MHAQ

“…Because the initial 21 items focused primarily on costs, new items focused on value (e.g., risks and benefits of treatment, consideration of patient values) given the importance of value in HVCCC. These items were based on items described in the context of validated surveys on high-value originating from experts in the field [10,23,39,47].…”

“…Learning environments are complex, involving personal, social, organizational, physical, and virtual components [18]. Multiple individuals from different stakeholder groups contribute to the creation of workplace environments, and the attitudes of these individuals may influence an organizations' culture regarding how and what residents learn [19][20][21][22][23]. Attitudes are also important (albeit imperfect) predictors of individual behavior [24], as evidenced by multiple studies showing associations between physician attitudes and beliefs and their utilization of healthcare services [25][26][27][28].…”

“…While different stakeholders can have different preferences regarding the provision of HVCCC, measuring all stakeholders' attitudes can give insight in the resident's workplace environment regarding the different dimensions of providing HVCCC. Prior studies have tried to measure the attitudes of particular stakeholder groups with respect to specific dimensions of HVCCC [8,10,23,[32][33][34][35][36][37][38][39]. However, a single reliable instrument to measure the individual attitudes of all these stakeholder groups toward multiple dimensions of providing HVCCC has not yet been developed.…”

Emerging principles for health system value improvement programmes

“…In addition to providing the structure for a systemic value improvement programme, addressing these key elements also is likely to contribute to creating an overall high-value care culture within the organisation 23 24…”

Prospective Observational Study on High-Value Care Topics Discussed on Multidisciplinary Rounds

“…Although physicians play a critical role in the rise of health care use, 8 implementing and sustaining an HVC culture also requires multidisciplinary collaboration and education with role modeling of HVC practices. 9,10 Pharmacists, 11,12 nurses and nurse practitioners, 13 trainees, [14][15][16][17] and patients 18,19 may all influence and model HVC practices.…”