Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care
Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women's health primary care
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DOI：
10.1007/s13142-017-0501-5
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发表时间：
2017-09-01
影响因子：
3.6
通讯作者：
Yano, Elizabeth M.
中科院分区：
文献类型：
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作者：
Hamilton, Alison B.;Brunner, Julian;Yano, Elizabeth M.
退伍军人健康管理局（VHA）已经根据以患者为中心的医疗之家（PCMH）原则进行了初级保健转型。VHA PCMH模型是专为主要是男性退伍军人群体，并需要定制，以满足妇女退伍军人的需求。我们使用循证质量改进（EBQI），一个企业主驱动的实施策略，在12个站点（8个EBQI，4个对照）的集群随机对照试验中，这些站点是基于实践的研究网络的成员。EBQI涉及多层次、跨专业的领导者和工作人员作为利益相关者参与审查证据和设定QI优先级。这项分析的目的是检查参与早期实施EBQI的利益攸关方的过程，以调整VHA的妇女医疗之家。举行了四次专业间区域利益攸关方规划会议;这些会议通过提供关于退伍军人护理经历中性别差异的区域数据，让利益攸关方参与。在每次会议之后，对87个主要利益攸关方（领导人和工作人员）进行了定性访谈。利益攸关方被要求描述QI的努力和使用数据来改变护理的各个方面，包括妇女的保健。访谈记录进行了总结和编码使用混合演绎/归纳分析方法。介绍区域一级关于性别差距的数据，提高了人们对以妇女健康为重点的质量合格指标的认识，利益攸关方也更愿意接受和作出决策。访谈显示，利益相关者熟悉QI，区域和设施领导人了解跨学科委员会和促进组织变革的努力，包括PCMH转型。这些努力通常不注重妇女的健康，尽管也作出了一些非正式的努力。从事QI的障碍包括缺乏跨临床服务线的沟通，人员流动性，以及缺乏保护时间。跨专业、多层次的利益攸关方需要尽早参与实施，并提供数据和讨论，以传达新举措的重要性和相关性。利益攸关方对体制规范的看法（例如，性别规范）和人群特异性QI的准备是旨在改变临床亚群护理的临床倡议的有用驱动力。
The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four interprofessional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.