Accounting for variation in technical quality and patient satisfaction: the contribution of patient, provider, team, and medical center.

BACKGROUND The delivery of healthcare depends on individual providers, coordination within teams, and the structure of the work setting. We analyzed the amount of variation in technical quality and patient satisfaction accounted for at the patient, provider, team, and medical center level. METHODS Data abstracted from Veterans Health Administration patient medical records for 2007 were used to calculate measures of technical quality based on adherence to best practice guidelines in 5 domains. Outpatient satisfaction was obtained from a 2007 standardized national mail survey. Hierarchical linear models that accounted for the clustering of patients within providers, providers within teams, and teams within medical centers were used to partition the variation in technical quality and satisfaction across patients and components of the system (ie, providers, teams, and medical centers). RESULTS Providers accounted for the largest percent of system-level variance for all technical quality domains, ranging from 46.5% to 71.9%. For the single-item measure of patient satisfaction, medical centers, teams, and providers accounted for about the same percent of system-level variance (31%-34%). For the doctor/patient interaction scale providers explained 59.9% of system-level variance, more than double that of teams and medical centers. For all the measures, the residual variance (composed of patient-level and random error) explained the largest proportion of the total variance. CONCLUSIONS Providers explained the greatest amount of system-level variation in technical quality and patient satisfaction. However, in both of these domains, differences between patients were the predominant source of nonrandom variance.