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BMJ Qual Saf. 2017 Jun;26(6):475-483. doi: 10.1136/bmjqs-2016-005612. Epub 2016 Oct 26.

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

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Department of Medicine, University of California Los Angeles, Los Angeles, California, USA.
Veterans Affairs/Robert Wood Johnson Clinical Scholars Program, Los Angeles, California, USA.
Department of Medicine, University of California San Francisco, San Francisco, California, USA.
Department of Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA.



Organisational culture affects physician behaviours. Patient safety culture surveys have previously been used to drive care improvements, but no comparable survey of high-value care culture currently exists. We aimed to develop a High-Value Care Culture Survey (HVCCS) for use by healthcare leaders and training programmes to target future improvements in value-based care.


We conducted a two-phase national modified Delphi process among 28 physicians and nurse experts with diverse backgrounds. We then administered a cross-sectional survey at two large academic medical centres in 2015 among 162 internal medicine residents and 91 hospitalists for psychometric evaluation.


Twenty-six (93%) experts completed the first phase and 22 (85%) experts completed the second phase of the modified Delphi process. Thirty-eight items achieved ≥70% consensus and were included in the survey. One hundred and forty-one residents (83%) and 73 (73%) hospitalists completed the survey. From exploratory factor analyses, four factors emerged with strong reliability: (1) leadership and health system messaging (α=0.94); (2) data transparency and access (α=0.80); (3) comfort with cost conversations (α=0.70); and (4) blame-free environment (α=0.70). In confirmatory factor analysis, this four-factor model fit the data well (Bentler-Bonett Normed Fit Index 0.976 and root mean square residual 0.056). The leadership and health system messaging (r=0.56, p<0.001), data transparency and access (r=0.15, p<0.001) and blame-free environment (r=0.37, p<0.001) domains differed significantly between institutions and positively correlated with Value-Based Purchasing Scores.


Our results provide support for the reliability and validity of the HVCCS to assess high-value care culture among front-line clinicians. HVCCS may be used by healthcare groups to identify target areas for improvements and to monitor the effects of high-value care initiatives.


Healthcare quality improvement; Quality measurement; Safety culture

[Indexed for MEDLINE]

Conflict of interest statement

Competing interests: RG is the Director of Outreach and Evaluation and the Director of the Teaching Value in Healthcare Learning Network at Costs of Care. She is supported by the VA Office of Academic Affiliations through the VA/Robert Wood Johnson Clinical Scholars Program. CM receives royalties from McGraw Hill for the textbook ‘Understanding Value-based Healthcare’, outside of the submitted work and is the Director of Implementation at Costs of Care. RDH was supported in part by grants from the NIA (No. P30-AG021684) and the NIMHD (No. P20-MD000182). CHB is the Vice Dean for Education at the David Geffen School of Medicine at UCLA and the chair of the American Board of Internal Medicine. RW reports that he is a member of the Lucian Leape Institute of the National Patient Safety Foundation (for which he receives no compensation); is currently chairing an advisory board to England's National Health Service reviewing the NHS’ digital health strategy (no compensation); has a contract to UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley and Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill for writing/editing several books; received a stipend and stock options for having previously served on the Board of Directors of IPC Healthcare; receives stock options for serving on the board of Accuity Medical Management Systems; serves on the scientific advisory boards for, PatientSafe Solutions, QPID Health, Twine and EarlySense (for which he receives stock options); and holds the Benioff endowed chair in hospital medicine from Marc and Lynne Benioff. RG and CM had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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