Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes
Tailoring an intervention to the context and system redesign related to the intervention: A case study of implementing shared medical appointments for diabetes
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DOI：
10.1186/1748-5908-3-34
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发表时间：
2008-06-04
影响因子：
7.2
通讯作者：
Aron, David C.
中科院分区：
文献类型：
--
作者：
Kirsh, Susan R.;Lawrence, Renee H.;Aron, David C.
背景：将共享医疗预约 (SMA) 或小组就诊纳入临床实践以改善护理和提高效率已成为一种流行的干预措施，但实施和维持这些措施的流程尚未得到很好的描述。本研究的目的是描述随着时间的推移在当地初级保健诊所实施 SMA 的过程。方法：研究地点是退伍军人健康管理局城市学术医疗中心的初级保健诊所。我们利用创新框架和嵌套系统框架方法进行了深入的案例分析。该分析有助于组织和总结实施和可持续性问题，特别是： SMA 之前的当地背景；干预措施的定制和实施过程；结果：改进干预措施和当地环境在实施过程中共同适应和演变，确保了可持续性。最重要的推动因素是致力于质量和改进的核心团队的形成，以及得到团队成员大力支持的诊所领导层。定制还必须考虑到关键的创新阻碍因素，包括有限的资源（例如空间）、改变长期患者与提供者关系的可能性，以及核心团队成员向不同主管报告的组织孤岛（脱节的群体）。结论：尽管干预措施的设计必须满足实施地点的需求，但缺乏针对实践环境的具体指导。 SMA 需要复杂的变革，这些变革会影响护理常规、协作和各个组织级别。尽管 SMA 最初并未被设想为一种会改变其实施环境的系统重新设计形式，但很明显，单独调整干预措施并不能确保可持续性，因此需要对系统进行调整。这项创新需要重新配置初级保健诊所本身以及患者和团队所源自的其他服务的某些方面。此外，系统不同部分之间的关系也发生了变化。
Background: Incorporating shared medical appointments (SMAs) or group visits into clinical practice to improve care and increase efficiency has become a popular intervention, but the processes to implement and sustain them have not been well described. The purpose of this study was to describe the process of implementation of SMAs in the local context of a primary care clinic over time.Methods: The setting was a primary care clinic of an urban academic medical center of the Veterans Health Administration. We performed an in-depth case analysis utilizing both an innovations framework and a nested systems framework approach. This analysis helped organize and summarize implementation and sustainability issues, specifically: the pre-SMA local context; the processes of tailoring and implementation of the intervention; and the evolution and sustainability of the intervention and its context.Results: Both the improvement intervention and the local context co-adapted and evolved during implementation, ensuring sustainability. The most important promoting factors were the formation of a core team committed to quality and improvement, and the clinic leadership that was supported strongly by the team members. Tailoring had to also take into account key innovation-hindering factors, including limited resources (such as space), potential to alter longstanding patient-provider relationships, and organizational silos (disconnected groups) with core team members reporting to different supervisors.Conclusion: Although interventions must be designed to meet the needs of the sites in which they are implemented, specific guidance tailored to the practice environment was lacking. SMAs require complex changes that impact on care routines, collaborations, and various organizational levels. Although the SMA was not envisioned originally as a form of system redesign that would alter the context in which it was implemented, it became clear that tailoring the intervention alone would not ensure sustainability, and therefore adjustments to the system were required. The innovation necessitated reconfiguring some aspects of the primary care clinic itself and other services from which the patients and the team were derived. In addition, the relationships among different parts of the system were altered.