Patient-Perceived Breakdowns in Care: Informing Physician Responses and Improvements in Healthcare Delivery

 描述(由申请人提供)：患者感知的护理故障是指从患者或家庭成员的角度来看，发生了一些本来可以防止的、对患者有重大影响的事情。从概念上讲，在患者安全和患者体验的交汇处，一些患者感知的护理故障，如可预防的溃疡，符合医疗错误的标准定义，而其他一些，包括沟通故障，可能不符合。因为患者感知的故障会造成伤害--包括身体伤害、心理痛苦和对医患关系的损害--它们是需要改善的重要目标。越来越多的研究表明，当患者报告他们对护理故障的担忧时，他们很少得到足够的回应。迫切需要干预措施，以改善医疗保健系统和提供者对患者感知的故障做出反应的能力和意愿；医生对这种努力至关重要。医生和他们工作的系统未能做出充分反应的原因尚不清楚。彻底了解影响医生对患者感知故障的反应的因素，对于开发和传播以患者为中心的干预措施以提高医疗保健的质量和安全性至关重要。在多元化的10家医院的MedStar卫生系统中工作，并利用AHRQ资助的一个正在进行的示范项目(‘检测、解决和学习患者感知的护理故障’)中的先前存在的数据，候选人建议首先对已经进行的1,148名患者访谈进行深入的定性分析，以创建住院患者报告的患者感知护理故障和相关伤害的分类(目标1)。以这一分类为参考，她将采访医生，以了解他们对患者感知的护理故障的看法，并确定影响他们对这些事件做出反应的意愿和能力的因素(目标2)。根据访谈结果，她将生成可测试的假设，以确定哪些因素有助于或阻碍对患者感知到的精神崩溃的有效反应。在最后阶段，候选人将通过调查广泛的医生样本来检验这些假设(目标3)。问卷的一部分将包含一个嵌入式实验，以测试逐字描述患者感知的故障是否比量化总结更有效地影响医生的反应。该项目将为设计和测试干预措施提供坚实的基础，使医生能够立即对患者感知的护理故障做出反应，并参与系统级的反应以防止复发。候选人金伯利·费舍尔博士是马萨诸塞大学医学院(UMMS)的医学助理教授，也是一名肺部和重症监护执业医生。她的长期职业目标是成为一名独立的临床医生调查员，开展以患者为中心的结果研究(PCOR)，以解决患者感知的护理故障，并提高医疗保健的安全性、质量和以患者为中心。她拥有独特的背景，实施质量改进计划，并进行以患者为中心的研究，检查代理决策者对重症监护病房护理的看法。她目前是AHRQ资助的示范项目的研究小组成员，该项目为本K08奖下提议的研究提供背景。在短期内，她会寻求额外的培训，以实现她的长期职业目标。她提出了一个培训计划，将为她提供高级定性分析、调查等方面的技能 设计与分析，比较有效性研究方法，医疗保健安全与质量改进的理论与实践，以及实施科学。她组建了一支模范的导师团队和顾问小组。凯萨琳·马佐博士将担任费舍尔博士的主要导师，托马斯·加拉格尔博士将担任该基金的副导师。她是家长基金“发现、解决和学习患者感知的护理故障”的PI。费舍尔博士的顾问将包括彼得·林德诺博士、托马斯·休斯顿博士和朱迪思·奥克内博士。候选人所在的机构提供了一个丰富的环境，这将促进费希尔博士的职业发展，并促进拟议研究的完成。主要的机构资源包括密歇根大学生物医学科学研究生院，该学院提供进行变革和改革研究和比较有效性研究(CER)的研究人员的科学社区，并在这些领域提供教学培训。实施科学博士后培训方案是在实施科学领域获得培训和指导的独特机会，这对复杂干预措施的开发和评估至关重要，也是CER的重要组成部分。迈耶斯初级保健研究所是一个联合研究机构，专注于基于人口的研究和CER。候选人还获得了MedStar Health领导层对这项工作的充分和热情的支持，该研究将作为临床环境，MedStar Health负责质量和安全的企业副总裁David Mayer博士证实了这一点。候选人的职业目标和预期结果与AHRQ的使命是一致的，即“提供证据，使医疗保健更安全、更高质量、更容易获得、更公平、更负担得起，并确保证据被理解和使用。”

 DESCRIPTION (provided by applicant): Patient-perceived breakdowns in care are events where something has "gone wrong" from the perspective of the patient or family member, that could have been prevented, and that has a significant impact on the patient. Conceptually at the confluence of patient safety and patient experience, some patient-perceived breakdowns in care, such as preventable ulcers, meet the standard definition of a medical error, while others, including communication breakdowns, may not. Because patient-perceived breakdowns result in harm - including physical harm, psychological distress, and damage to the patient-physician relationship - they are important targets for improvement. A growing body of research suggests that when patients report their concerns about breakdowns in care, they seldom receive an adequate response. Interventions are urgently needed to improve healthcare systems' and providers' ability and willingness to respond to patient-perceived breakdowns; physicians are critical to such efforts. The reasons that physicians and the systems they work in fail to respond adequately are not known. A thorough understanding of the factors which affect physicians' responses to patient-perceived breakdowns is critical to the development and dissemination of patient-centered interventions to improve the quality and safety of healthcare. Working within the diverse, 10-hospital MedStar Health system, and leveraging pre-existing data from an ongoing AHRQ-funded demonstration project (`Detecting, Addressing and Learning From Patient-Perceived Breakdowns in Care'), the candidate proposes to first conduct an in-depth qualitative analysis of the 1,148 patient interviews already conducted to create a taxonomy of patient-perceived breakdowns in care and associated harms reported by hospitalized patients (Aim 1). Using this taxonomy as a reference, she will interview physicians to understand their perspectives on patient-perceived breakdowns in care, and to identify the factors which influence their willingness and ability to respond to these events (Aim 2). Informed by the interview findings, she will generate testable hypotheses about what factors facilitate or hinder effective responses to patient-perceived breakdowns. In the final phase, the candidate will test these hypotheses by surveying a broad sample of physicians (Aim 3). One section of the questionnaire will contain an embedded experiment to test whether verbatim patient narrative descriptions of patient-perceived breakdowns are more effective than quantitative summaries in influencing physicians' responses. This project will provide a strong foundation for designing and testing an intervention that enables physicians to respond immediately to patient- perceived breakdowns in care, and to participate in system-level responses to prevent recurrence. The candidate, Dr. Kimberly Fisher, is an Assistant Professor of Medicine at the University of Massachusetts Medical School (UMMS), and a practicing pulmonary and critical care physician. Her long-term career goal is to become an independent clinician investigator conducting patient centered outcomes research (PCOR) to address patient-perceived breakdowns in care, and improve the safety, quality, and patient- centeredness of healthcare. She has a unique background with experience implementing quality improvement initiatives, and conducting patient-centered research examining surrogate decision maker's perceptions of care in the intensive care unit. She is currently a member of the research team on the AHRQ-funded demonstration project that provides the context for the research proposed under this K08 award. In the short-term, she seeks additional training to achieve her long-term career goals. She has proposed a training plan that will provide her with skills in advanced qualitative analysis, survey design and analysis, comparative effectiveness research methods, the theory and practice of healthcare safety and quality improvement, and implementation science. She has assembled an exemplary mentorship team and advisory panel. Dr. Kathleen Mazor, PI of the parent grant `Detecting, Addressing, and Learning from Patient-Perceived Breakdowns in Care', will serve as Dr. Fisher's primary mentor and Dr. Thomas Gallagher, co-investigator on the same grant, will serve as secondary mentor. Advisors to Dr. Fisher will include Drs. Peter Lindenauer, Thomas Houston and Judith Ockene. The candidate's institution provides a rich environment which will enhance Dr. Fisher's career development and facilitate completion of the proposed research. Key institutional resources include the Graduate School of Biomedical Sciences at UMMS which provides a scientific community of researchers conducting PCOR and comparative effectiveness research (CER), and offers didactic training in these areas. The Post-doctoral Training in Implementation Science program is a unique opportunity to obtain training and mentorship in the field of Implementation Science, which is critical to the development and evaluation of complex interventions and an important component of CER. The Meyers Primary Care Institute is a joint research endeavor with a focus on population-based research, and CER. The candidate has also garnered full and enthusiastic support for this work from leadership at MedStar Health, which will serve as the clinical setting for the research, as confirmed by Dr. David Mayer, Corporate Vice President for Quality and Safety at MedStar Health . The candidate's career goals and expected findings are consistent with AHRQ's mission "to produce evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable, and to...make sure that the evidence is understood and used."