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  • Publication # 13-RA008

Perceptions of quality and safety decline as the size of medical practices increases

Patient Safety and Quality

Most studies of patient safety culture are conducted at the inpatient level in hospitals. However, most care is provided in office-based and ambulatory care settings. To promote more understanding of patient safety culture in medical offices, AHRQ developed the Medical Office Survey on Patient Safety. A new study that used the 51-item survey found that smaller medical office practices have higher overall quality and safety of care compared to larger practices. In addition, a direct relationship was found between increasing practice size and declines in quality and safety perceptions. 

The study surveyed 6,534 clinicians and staff working at 306 primary care medical practices about practice size and the use of health information technology (electronic appointment scheduling, medication, test ordering, and electronic access to test results) to determine the impact of these factors on perceptions of care quality and safety. Practice sizes varied from 2 to 15 clinicians. There was a good range of urban, suburban, and rural practices as well as a variety of patient populations served. The survey asked participants to provide overall ratings on quality and patient safety.

Perceptions of quality were significantly associated with practice size but not associated with practice ownership, while the relationship to the level of health IT implementation was complex. Small offices had the highest rankings of overall quality; larger practices had the lowest. This effect was consistent across all quality components such as patient centeredness and effectiveness, timeliness, and efficiency of care. Small offices also had more positive responses regarding the perceived safety of office systems. Interestingly, the highest quality ratings were found in practices with the lowest health IT implementation. However, those practices with full health IT implementation scored intermediate on ratings of overall quality. The study was supported in part by AHRQ (Contract No. 290-07-10016). 

See "The relationship of self-report of quality to practice size and health information technology," by Paul N. Gorman, M.D., Jean P. O’Malley, M.P.H., and Lyle J. Fagnan, M.D., in the September-October 2012 issue of the Journal of the American Board of Family Practice 25(5), pp. 614-624.


Page last reviewed May 2013
Internet Citation: Perceptions of quality and safety decline as the size of medical practices increases: Patient Safety and Quality. May 2013. Agency for Healthcare Research and Quality, Rockville, MD.


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