Explaining Matching Michigan: an ethnographic study of a patient safety program
Explaining Matching Michigan: an ethnographic study of a patient safety program
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DOI：
10.1186/1748-5908-8-70
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发表时间：
2013-06-20
影响因子：
7.2
通讯作者：
Bion, Julian
中科院分区：
文献类型：
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作者：
Dixon-Woods, Mary;Leslie, Myles;Bion, Julian
背景：医疗保健领域的质量和安全改进举措通常会产生两种令人不安的影响。第一个是未能超越长期趋势。第二种是衰退效应，即最初有希望的干预措施在尝试在新的环境中复制时，似乎不会产生同样成功的结果。匹配密歇根州，一个病人安全计划，旨在减少中心线感染在200多个重症监护病房（ICU）在英格兰，可能是一个例子。我们的目的是解释为什么这些明显的影响可能已经happened.Methods：我们进行了采访，98名工作人员和非参与观察19个ICU，这些单位中有17个参加匹配密歇根州。我们进行了进一步的电话采访，29名工作人员谁参加了计划的培训活动，我们分析了相关documents.Results：一个匹配密歇根州的单位改变了其做法和文化，以应对该计划，五个提升现有的努力，和11个几乎没有改变。与密歇根州的影响相匹配可能受到程序设计和执行的限制;它不是原始项目的精确复制品。外部和内部环境强烈地改变了程序的效果。外部环境包括以前为解决中心静脉感染问题所做的努力，这些努力被一些人视为自上而下和惩罚性的国家感染控制政策。这破坏了参与该计划，使其难以说服参与者，该计划是必要的。个别ICU的历史和当地背景也是非常重要的：他们过去的质量改进经验，他们能够开发高质量数据收集和反馈系统的程度，以及当地领导人在发展共识和联盟方面的成功，都影响了该计划对当地实践的影响。改进程序性良好做法的实施可以通过许多不同的途径实现，参与计划只是其中之一。因此，顺从性的“表型”可能通过不同的“基因型”产生。“在设计和实施干预措施以提高质量和安全性时，可以通过更好地理解项目机制和实施背景来避免下降效应的风险和难以证明长期趋势的附加值。
Background: Quality and safety improvement initiatives in healthcare often display two disconcerting effects. The first is a failure to outperform the secular trend. The second is the decline effect, where an initially promising intervention appears not to deliver equally successful results when attempts are made to replicate it in new settings. Matching Michigan, a patient safety program aimed at decreasing central line infections in over 200 intensive care units (ICUs) in England, may be an example of both. We aimed to explain why these apparent effects may have occurred.Methods: We conducted interviews with 98 staff and non-participant observation on 19 ICUs; 17 of these units were participating in Matching Michigan. We undertook further telephone interviews with 29 staff who attended program training events and we analyzed relevant documents.Results: One Matching Michigan unit transformed its practices and culture in response to the program; five boosted existing efforts, and 11 made little change. Matching Michigan's impact may have been limited by features of program design and execution; it was not an exact replica of the original project. Outer and inner contexts strongly modified the program's effects. The outer context included previous efforts to tackle central line infections superimposed on national infection control policies that were perceived by some as top-down and punitive. This undermined engagement in the program and made it difficult to persuade participants that the program was necessary. Individual ICUs' histories and local context were also highly consequential: their past experience of quality improvement, the extent to which they were able to develop high quality data collection and feedback systems, and the success of local leaders in developing consensus and coalition all influenced the program's impact on local practices.Conclusions: Improved implementation of procedural good practice may occur through many different routes, of which program participation is only one. The 'phenotype' of compliance may therefore arise through different 'genotypes.' When designing and delivering interventions to improve quality and safety, risks of decline effects and difficulties in demonstrating added value over the secular trend might be averted by improved understanding of program mechanisms and contexts of implementation.