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Motivation to Improve Chronic Disease Care in Three Quality Improvement Collaboratives
Michael Lin, Jill A. Marsteller, Stephen Shortell, Peter Mendel, Majorie L. Pearson, Mayde Rosen, Shinyi Wu, Health Care Manage Rev, 2005, 30(2), 139-156.

Research Objectives: To examine the motivation of health care professionals to improve the quality of chronic illness care through implementation of the Chronic Care Model (CCM) and use of Plan-Do-Study-Act (PDSA) rapid feedback cycles.

Study Design: Using data from three quality improvement collaboratives, the paper explores contextual factors associated with individual motivation. The selected measure of motivation is process-based, and utilizes Vroom's Expectancy Theory of motivation. Motivational effort is comprised of valence, instrumentality, and expectancy components, with two separate composites for motivation to implement CCM and run PDSA cycles. The key study variables include the disease addressed by the collaborative efforts, the type of organization to which the individual belongs, the dominant organizational culture as measured by the Competing Values Framework, the organization's commitment to quality improvement as measured by the Malcolm Baldrige National Quality Award criteria, the individual's perception of a supportive managerial climate, and whether the individual is involved directly in the provision of care to patients.

Population Studied: Respondents were surveyed from 44 organizations participating in three Chronic Illness Care Collaboratives addressing care for asthma, congestive heart failure, depression, and diabetes patients during the period of 1998 to 2003. A total of 359 respondents are included in the final analysis, with 38% focusing on diabetes care, 29% on asthma, 27% on CHF, and 6% on depression. In terms of the dominant organizational culture to which the individuals belong, 39% of respondents report a group culture, 34% a hierarchical culture, 19% a rational culture, and 7% a developmental culture. Seventy percent of these individuals are classified as care providers.

Principal Findings: The results of Ordinary Least Squares regression analysis suggest that several measures in the analytic models are significantly related to motivation to implement CCM and run PDSA cycles. These results are reinforced by supplementary analyses using Generalized Estimating Equations to account for the correlation among individuals from the same sites. At the organizational level, both the disease treated and type of organization are statistically significant at the alpha=0.05 level in models for the composite measures of motivation related to CCM implementation and PDSA cycles. At the individual level, assessments of climate, and organizational commitment to quality improvement are most strongly associated (p<0.001) with these motivation measures. Of the measures of organizational culture employed in the study, the only statistically significant predictor is a dominant developmental culture (p<0.05) for increased motivation to implement CCM. Individuals who are direct care providers report 15% less motivation (p<0.001) to run PDSA cycles, with supplementary analyses revealing that this may be explained by lower expectancy and instrumentality.

Conclusions: Motivating individuals to implement CCM and run PDSA cycles is a complex process that necessitates consideration of situational constraints, individual perceptions, and roles.

Implications for Policy, Delivery, and Practice: These findings suggest that organizational attempts to redesign care for chronic disease patients may be strengthened by visible organizational support for activities initiated by practitioners and managers, and a high overall organizational commitment to quality improvement. Provision of extra time and resources are among the factors likely to have a positive influence on efforts to improve chronic disease care.

Presented at the AcademyHealth meeting by: Michael Lin, University of California, Berkeley, at a student poster panel 4:00 - 5:30 pm, June 7,Chair: Lucy Savitz, RTI International