Using systems thinking to support clinical system transformation
Using systems thinking to support clinical system transformation
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DOI：
10.1108/jhom-12-2014-0206
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发表时间：
2016-01-01
影响因子：
1.4
通讯作者：
Millar, John
中科院分区：
文献类型：
--
作者：
Best, Allan;Berland, Alex;Millar, John
目的-将不列颠哥伦比亚省卫生部的临床护理管理计划用作案例研究，以更好地了解不列颠哥伦比亚省卫生系统内的大规模变革（LSC）。使用一个复杂的系统框架，本文的目的是检查机制，使和限制在各种临床setting.Design/方法/途径的实施临床指南-研究人员采用了一个一般模型的复杂适应系统加上两个具体的概念框架（现实主义的评价和系统动力学映射）来定义和研究使能和约束。焦点小组会议和采访的临床医生，行政人员，管理人员和董事会成员进行了验证，通过网上survey.Findings -管理大规模的临床变化的功能主题包括：创造一个环境，准备临床医生的卫生系统转型举措，促进共享的临床领导，加强知识管理，战略沟通和机会网络;通过一个多层次的，动态的system.Research限制/影响的复杂性和清除路径-行动研究方法的目的是指导实施的持续改进。选择了一些举措作为样本，并不是要比较和对比所有举措和区域的促进因素和障碍。同样，评价准则执行的结果或进程也不在范围之内;这些方法旨在促成在政策、管理和实践等多个层面就如何改进执行情况进行对话。该研究最好被视为LSC的案例研究，为其他人复制提供了一个可能的模型，并为进一步对话提供了一个工具。实际影响-建议的以行动为导向的战略包括让当地冠军参与;支持当地适应临床指南的实施;加强当地团队指导实施;减少变革疲劳;确保足够的资源;提供一致的沟通，特别是对一线护理提供者;和支持当地团队证明他们的同事的指导方针的临床价值。独创性/价值-将复杂的系统视角引入临床指南实施，使人们清楚地了解了LSC所涉及的挑战。
Purpose - The British Columbia Ministry of Health's Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC's health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings.Design/methodology/approach - Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey.Findings - The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system.Research limitations/implications - The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels - policy, management and practice - about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue.Practical implications - Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues.Originality/value - Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.