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The roles of practice systems and individual effort in quality performance
  1. Hoangmai H Pham1,
  2. Elizabeth C Bernabeo2,3,
  3. Benjamin J Chesluk2,
  4. Eric S Holmboe2
  1. 1Center for Studying Health System Change Washington DC, USA
  2. 2American Board of Internal Medicine, Philadelphia, Pennsylvania, USA
  3. 3Bryn Mawr College Graduate School of Social Work and Social Research, Bryn Mawr, Pennsylvania, USA
  1. Correspondence to Elizabeth C. Bernabeo, MPH PhD candidate, Bryn Mawr College Graduate School of Social Work Research Associate, American Board of Internal Medicine 510 Walnut Street, Suite 1700 Philadelphia, PA 19106, USA; ebernabeo{at}


Introduction Individual effort and practice systems contribute to quality performance, but the nature of their contributions remains unclear.

Methods This study assessed the roles of individual attributes and behaviours versus practice attributes in quality performance by assessing general internists' perceptions of factors that drive their engagement in quality improvement (QI). The authors interviewed 20 physicians in two distinct categories from diverse practice settings who had the greatest discordance between their ranked scores on standardised measures of individual quality performance and practice ‘systems’ performance.

Results Findings suggest that there are subtle but important differences between high-scoring physicians practising in low-scoring practice systems, and low-scoring physicians practising in high-scoring practice systems with regards to quality performance and improvement. Physicians with high individual and low systems scores contributed a greater individual effort in quality improvement (QI), exhibited greater internal drivers to change, and reported a greater number and broader list of QI activities than physicians with low individual scores and high systems scores. Physicians with high individual scores also tended to be more reflective. There was a lack of consensus between categories on the relative usefulness of different systems resources, including electronic information systems. Our findings also suggest that physicians practice in isolation and autonomously, and highly independent of each other, and perceive a tension between pursuing technical quality and patient satisfaction at the same time. Both categories were skeptical of performance measurement more generally.

Conclusion QI efforts may be more effective if they foster both specific individual attitudes and capabilities, as well as improve practice-level systems.

  • Quality improvement
  • performance measurement
  • practice systems
  • medical home
  • healthcare quality improvement
  • qualitative research

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  • Funding American Board of Internal Medicine Foundation.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the New England IRB.

  • Provenance and peer review Not commissioned; externally peer reviewed.