Hospital ownership of medical practices was associated with positive perceptions of practice work environment and lower burnout for staff compared with independent ownership. Conversely, clinicians practicing at federally qualified health centers (FQHCs) had a more negative, less joyful work environment and more burnout, according to the results of a study published in the Annals of Family Medicine.

Alison Cuellar, PhD, of the Department of Health Administration and Policy at George Mason University in Washington, DC, and colleagues, used cross-sectional data from staff surveys of small- and medium-sized practices that participated in EvidenceNOW, a multiyear pragmatic trial to investigating differences in work environment, culture of learning, psychological safety, and burnout by practice type. Researchers used weighted multivariate linear regression of outcomes on ownership, controlling for practice size, specialty mix, payer mix, and whether the practice was located in a medically underserved area. They also analyzed clinician and staff responses separately.

The investigators included 2005 questionnaires with complete responses on all relevant items in the analysis. These questionnaires came from 61 independent practices, 104 hospital system practices, and 25 FQHCs.

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For the question of culture of learning, the average score was 3.0, or neutral. Differences between practice types were not significant. As for work environment, staff reported a mean rating of 3.6 (weakly positive) for enjoyment of work and a mean of 3.5 for “this practice is a place of joy and hope.” Working in a hospital-owned practice was associated with a higher rating of enjoyment with work relative to independent practices. However, differences in ratings of the practice as a place of joy and hope between hospital-owned and independent practices were not significant, nor were differences in work environment between independent practices and FQHCs.

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Psychologic safety was rated at 3.5 on average, with higher ratings reported in hospital-owned practices than in independent practices. FQHCs, however, were associated with lower psychologic safety than independent practices, though differences were not statistically significant after adjusting for covariates. Overall, burnout was rated at 2.1 on average. Being in a hospital-owned practice was associated with lower burnout values relative to independent practices. Differences between FQHCs and independent practices were not statistically significant.

Responses from clinicians, which included physicians, nurse practitioners, and physician assistants, showed no statistically significant differences across independent and hospital-owned practices in ratings across culture of learning, work environment, psychologic safety, or burnout. However, clinicians working in FQHCs reported lower ratings of culture of learning, work environment, and the practice as a place of joy. Clinicians in these practices also reported lower psychologic safety. As for staff, no differences between FQHCs and independent practices occurred for any of the variables. However, staff employed by hospital-owned practices reported greater psychologic safety than those in independent practices and lower burnout.

The authors argue that their findings suggest that staff may be critical to building overall practice adaptive reserve and for providing the energy for continuing quality improvement.


Cuellar A, Krist AH, Nichols LM, Kuzel AJ. Effect of practice ownership on work environment, learning culture, psychological safety and burnout. Ann Fam Med. 2018;16(Suppl 1):S44-S51.