在过去的十年中,将质量改进纳入医疗保健的机会和努力越来越多。实践促进是一种行之有效的策略,可支持重新设计和改进初级保健实践,重点是建设组织能力以持续改进。实践领导力,工作人员,和实践促进者都在支持初级保健质量改进方面发挥着重要作用。然而,他们对上下文的观点知之甚少,启用者,障碍,以及影响质量改进举措的策略。
这项研究旨在开发一个框架,以评估环境因素,挑战,以及影响实践便利化的战略,临床测量性能,以及实施质量改进干预措施。我们还使用实际案例研究说明了该框架的应用。
我们开发了TITO(任务,个人,技术,和组织)框架,方法是开展参与性利益相关者研讨会,并结合他们的观点,以确定质量改进和实践促进的促进因素和障碍。我们使用混合方法进行了案例研究,以证明该框架的使用,并描述了参与Heartland健康心脏研究的初级保健实践中的实践促进和影响质量改进的因素。
所提出的框架用于根据框架域组织和分析不同利益相关者的观点和关键因素。案例研究表明,实践领导者,工作人员,和实践促进者都影响了质量改进计划的成功。然而,这些参与者面临不同的挑战,使用不同的策略。该框架表明,障碍源于患者健康的社会决定因素,缺乏人员和时间,和非系统的便利化资源,虽然推动者包括实践文化,员工买入,实施有效的实践促进策略,实践变革的能力,并共享类似的互补资源,正在进行的项目。
我们的框架提供了一个有用的和可推广的结构来指导和支持未来实践促进项目的评估,质量改进举措,和医疗保健干预实施研究。实践领导者,工作人员,和实践促进者都看到了质量改进计划和实践促进的价值。实践促进者是帮助质量改进计划的关键联络人;他们帮助所有利益相关者朝着共同的目标努力,并利用量身定制的策略。从竞争中利用资源,但互补,作为额外支持的计划可以加速质量改进目标的有效实现。实践促进支持的质量改进计划可能是通过集中和有针对性的努力来协助初级保健实践实现护理质量提高的机会。案例研究展示了我们的框架如何支持更好地理解实践促进的环境因素,这可以为初级保健实践提供充分准备和更成功的质量改进计划。结合实施科学和信息学思想,我们的TITO框架可以促进这两个领域的跨学科研究。
The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven
strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives.
This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world
case study.
We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a
case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study.
The proposed framework was used to organize and analyze different stakeholders\' perspectives and key factors based on framework domains. The
case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients\' social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs.
Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation-supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The
case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.