Effect of care management program structure on implementation: a normalization process theory analysis.
Effect of care management program structure on implementation: a normalization process theory analysis.
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DOI：
10.1186/s12913-016-1613-1
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发表时间：
2016-08-15
影响因子：
2.8
通讯作者：
Green LA
中科院分区：
文献类型：
--
作者：
Holtrop JS;Potworowski G;Fitzpatrick L;Kowalk A;Green LA
初级保健中的护理管理可以有效地帮助慢性病患者改善健康状况，然而，初级保健实践往往在实施方面受到挑战。此外，有不同的方式来构建护理管理，可能会使实施或多或少成功。规范化过程理论（NPT）提供了一种理解新的复杂干预如何在实践中成为常规（规范化）的方法。在这项研究中，我们使用NPT来了解护理管理结构如何影响护理管理在实践中成为常规。数据收集涉及半结构化的访谈和观察，在25个做法在美国密歇根州的五个医生组织。选择的做法，以反映医生组织的变化，类型的护理管理计划，和规范化程度。数据进行转录，定性编码和分析，最初使用的编辑方法，然后模板的方法与NPT作为指导框架。完成了70次访谈和25次观察。护理管理组织出现了两个关键结构：基于实践的护理管理，其中护理管理人员作为实践团队的一部分嵌入实践中;和集中式护理管理，其中护理管理人员独立于实践工作流程工作，并位于实践之外。有不同的做法，在正常化的护理管理。与集中式护理管理相比，基于实践的护理管理通常更好地规范化。《不扩散条约》，特别是集体行动构想很好地解释了正常化方面的差异。当护理经理有多种和灵活的机会进行沟通（实习工作性），有必要的知识，技能和个人特征（技能集工作性），和组织的支持和资源（上下文整合），信任的专业关系（关系整合）之间的实践提供者和工作人员和护理经理。当任何这些要素缺失，护理管理的实施似乎受到负面影响。虽然护理管理可以引入许多新的变化到临床实践的交付，成功地实施它作为一个新的复杂的干预是可能的。NPT有助于解释实施新的护理管理计划的差异，以便在实施规划期间解决这些差异。本文的在线版本（doi：10.1186/s12913-016-1613-1）包含补充材料，可供授权用户使用。
Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice. Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework. Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively. Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning. The online version of this article (doi:10.1186/s12913-016-1613-1) contains supplementary material, which is available to authorized users.