背景:理论和相关研究表明,组织领导力和气候对于在医疗机构中成功实施循证实践(EBP)很重要;但是,缺乏实验证据。我们使用WISDOM(实施和维持数字结果措施)混合III型有效性实施试验的数据解决了这一差距。WISDOM的主要结果表明,领导力和组织变革实施(LOCI)策略提高了青年心理健康服务中基于测量的护理(MBC)的保真度。在这项研究中,我们测试了LOCI假设的变化机制,即:(1)LOCI将改善实施和变革型领导,这反过来将(2)调解LOCI对实施气候的影响,这反过来将(3)介导LOCI对MBC保真度的影响。
方法:21个为青年服务的门诊精神卫生诊所被随机分配到LOCI加MBC培训和技术援助或仅MBC培训和技术援助。临床医生评价他们的领导人“实施领导”,变革型领导,和MBC在五个时间点的临床实施气候(基线,4-,8-,12-,和基线后18个月)。使用电子元数据对在MBC训练后12个月内开始治疗的青年门诊患者评估MBC保真度。使用纵向混合效应模型和多层次中介分析对假设进行了检验。
结果:LOCI在4-从基线到后续行动显着改善了实施领导和实施氛围。8-,12-,和基线后18个月(所有ps<0.01),产生大的效果(ds=0.76到1.34的范围)。LOCI对变革型领导的影响在4个月时较小(d=0.31,p=0.019),此后不显著(ps>.05)。LOCI从基线到12个月的临床实施气候的改善是通过从基线到4个月的实施领导的改善来介导的(介导的比例[pm]=0.82,p=.004)。变革型领导没有调解LOCI对实施气候的影响(p=0.136)。从基线到12个月,临床实施气候的改善介导了LOCI对同期MBC保真度的影响(pm=0.71,p=0.045)。
结论:LOCI通过改善临床实施氛围,改善了青年心理健康服务中的MBC保真度,这本身通过加强执行领导而得到了改善。通过培养组织领导者和强大的实施环境,可以提高医疗保健环境中EBP的保真度。
背景:ClinicalTrials.gov标识符:NCT04096274。2019年9月18日注册。
BACKGROUND: Theory and correlational research indicate organizational leadership and climate are important for successful implementation of evidence-based practices (EBPs) in healthcare settings; however, experimental evidence is lacking. We addressed this gap using data from the WISDOM (Working to Implement and Sustain Digital Outcome Measures) hybrid type III effectiveness-implementation trial. Primary outcomes from WISDOM indicated the Leadership and Organizational Change for Implementation (
LOCI) strategy improved fidelity to measurement-based care (MBC) in youth mental health services. In this study, we tested
LOCI\'s hypothesized mechanisms of change, namely: (1)
LOCI will improve implementation and transformational leadership, which in turn will (2) mediate LOCI\'s effect on implementation climate, which in turn will (3) mediate
LOCI\'s effect on MBC fidelity.
METHODS: Twenty-one outpatient mental health clinics serving youth were randomly assigned to LOCI plus MBC training and technical assistance or MBC training and technical assistance only. Clinicians rated their leaders\' implementation leadership, transformational leadership, and clinic implementation climate for MBC at five time points (baseline, 4-, 8-, 12-, and 18-months post-baseline). MBC fidelity was assessed using electronic metadata for youth outpatients who initiated treatment in the 12 months following MBC training. Hypotheses were tested using longitudinal mixed-effects models and multilevel mediation analyses.
RESULTS: LOCI significantly improved implementation leadership and implementation climate from baseline to follow-up at 4-, 8-, 12-, and 18-month post-baseline (all ps < .01), producing large effects (range of ds = 0.76 to 1.34). LOCI\'s effects on transformational leadership were small at 4 months (d = 0.31, p = .019) and nonsignificant thereafter (ps > .05). LOCI\'s improvement of clinic implementation climate from baseline to 12 months was mediated by improvement in implementation leadership from baseline to 4 months (proportion mediated [pm] = 0.82, p = .004). Transformational leadership did not mediate
LOCI\'s effect on implementation climate (p = 0.136). Improvement in clinic implementation climate from baseline to 12 months mediated LOCI\'s effect on MBC fidelity during the same period (pm = 0.71, p = .045).
CONCLUSIONS: LOCI improved MBC fidelity in youth mental health services by improving clinic implementation climate, which was itself improved by increased implementation leadership. Fidelity to EBPs in healthcare settings can be improved by developing organizational leaders and strong implementation climates.
BACKGROUND: ClinicalTrials.gov identifier: NCT04096274. Registered September 18, 2019.