Primary care practice transformation is hard work: insights from a 15-year developmental program of research.
Primary care practice transformation is hard work: insights from a 15-year developmental program of research.
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DOI：
10.1097/mlr.0b013e3181cad65c
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发表时间：
2011-12
期刊：
影响因子：
3
通讯作者：
Stewart E
中科院分区：
文献类型：
--
作者：
Crabtree BF;Nutting PA;Miller WL;McDaniel RR;Stange KC;Jaen CR;Stewart E
严重的缺点仍然在美国的临床护理，尽管广泛使用的改进策略，以提高临床表现的基础上知识转移的方法。最近呼吁将初级保健实践转变为以患者为中心的医疗之家，这带来了更大的挑战，需要更有效的方法。我们的研究团队进行了一系列美国国立卫生研究院资助的描述性和干预性项目，以了解初级保健实践环境中的组织变革，强调复杂性科学的观点。其结果是开展了一项发展研究工作，确定了与促成实践变革有关的关键经验教训。一项为期15年的研究计划的结果摘要强调了从机械的角度看待初级保健实践的局限性，这些机械的术语是当前或传统的质量改进方法的基础。一个理论的角度来看，认为初级保健的做法是动态的复杂的适应性系统与“代理人”谁有能力学习，并以不可预测的方式采取行动的自由提供了一个更好的框架接地质量改进策略。该框架强调，质量改进干预措施不仅应该使用复杂系统的观点，而且还需要不断反思，精心定制干预措施，并不断关注实践中代理商之间的互动质量。如果没有更强有力的指导理论基础，目前的质量改进战略不太可能成功地将目前的初级保健实践转变为以患者为中心的医疗之家。我们的工作表明，复杂性科学指导的理论框架可以帮助质量改进策略的发展，这将更有效地促进实践的变化。
Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with “agents” who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.