Creating Healthy Workplaces: Improving Outcomes for Providers and Patients

描述(由申请人提供)：提供初级保健的背景很少作为质量改进倡议或研究项目的一部分进行评估。我们备忘录研究的数据(最小化错误，最大化结果)证实了工作环境、提供者反应和患者护理之间的关系。时间压力与医生满意度、压力、职业倦怠、离职意向以及高血压患者较低质量的护理有关。医生和领导之间缺乏价值观一致性与医生满意度、压力、职业倦怠和离职意图以及较差的糖尿病护理和较少的预防活动有关。因此，在不利的工作条件下，面临风险的不仅仅是供应商。一个重要的共存因素是即将到来的初级保健医生短缺。不理想的工作条件与医生的离职意向和医学生对初级保健的兴趣降低有关。这项随机研究将评估应用一种新的质量改进战略的影响，该战略旨在创建“健康的工作场所”。我们假设，解决不利的初级保健工作条件(工作流程、工作控制、组织文化)将导致临床医生更多地参与改善卫生保健提供的计划。作为备忘录的一部分，我们开发了办公室和工作生活(OWL)测量工具。OWL评估初级保健工作场所，并确定影响提供者结果和护理质量的特定工作条件。目前的应用程序将评估OWL和重点QI过程的能力，以促进工作环境的变化并改善提供者和患者的结果。将在纽约市和中西部北部招募34家初级保健诊所。将对医生、医生助理和护士从业者(n=238)进行调查，以收集有关提供者结果、组织结构和文化的OWL数据。管理人员将提供有关诊所结构、政策和程序的信息。将对每个提供者(n=1904)的8名高血压和/或糖尿病患者进行健康素养、生活质量、服药依从性、满意度和信任度的调查。将对患者病历进行审计，以评估高血压和糖尿病的管理。然后，这些数据将被汇编成每个诊所的OWL测量。这34家诊所将被随机安排。17家干预诊所的当地领导、提供者和工作人员将接受他们的猫头鹰测量，并讨论数据显示的护理成功和挑战。在研究团队的协助下，他们将制定QI计划，重点关注我们发现对护理质量有贡献的工作场所变量：时间压力、工作控制、工作节奏(混乱)和组织文化。12个月后，OWL数据将被收集到所有34家诊所并进行比较。新的OWL数据将反馈给17个干预诊所的人员，以正式确定其在连续QI过程中的作用。对照诊所将在研究结束时收到OWL数据。将对数据子集进行分析，以确定改善工作环境的最佳方式，以改善代表不足的群体(妇女和少数群体提供者和少数群体患者)的结果。

DESCRIPTION (provided by applicant): The context in which primary care is delivered is rarely evaluated as part of quality improvement initiatives or research projects. Data from our MEMO Study (Minimizing Error, Maximizing Outcome) confirm a relationship between the work environment, provider reactions, and patient care. Time pressure is associated with physician satisfaction, stress, burnout, and intent to leave as well as lower quality care for hypertensive patients. Lack of values alignment between physicians and leaders is associated with physician satisfaction, stress, burnout, and intent to leave as well as poorer diabetes care and fewer prevention activities. Thus, providers are not the only ones at risk in adverse work conditions. An important coexisting factor is the impending primary care physician shortage. Less than optimal work conditions are associated with physician intent to leave and with reduced medical student interest in primary care. This randomized study will assess the impact of applying a novel quality improvement strategy designed to create "healthy workplaces". We hypothesize that addressing adverse primary care work conditions (workflow, work control, organizational culture) will lead to greater clinician participation in programs to improve health care delivery. As part of MEMO, we developed the Office and Work Life (OWL) measurement tool. The OWL assesses the primary care workplace and identifies specific working conditions that impact provider outcomes and quality of care. The current application will assess the ability of the OWL and a focused QI process to facilitate changes in the work environment and improve outcomes for providers and patients. Thirty-four primary care clinics will be recruited in New York City and the upper Midwest. Physicians, physician assistants, and nurse practitioners (n=238) will be surveyed to collect OWL data on provider outcomes, and organizational structure and culture. Managers will provide information on clinic structure, policies and procedures. Eight patients per provider (n=1904) with hypertension and /or diabetes will be surveyed on health literacy, quality of life, medication compliance, satisfaction, and trust. Patient charts will be audited to assess hypertension and diabetes management. The data will then be compiled into an OWL measure for each clinic. The 34 clinics will be randomized. Local leaders, providers, and staff in 17 intervention clinics will receive their OWL measure and discuss the successes and challenges to care illustrated by the data. Assisted by the study team, they will develop QI plans focusing on workplace variables that we've found contribute to care quality: time pressure, work control, work pace (chaos), and organizational culture. Twelve months later, OWL data will be recollected in all 34 clinics and compared. New OWL data will be fed back to personnel in the 17 intervention clinics to formalize its role in continuous QI processes. Control clinics will receive their OWL data at study end. Subsets of data will be analyzed to determine the best ways to modify the work environment to improve outcomes for underrepresented groups (women and minority providers and minority patients).