Contextual Factors Associated with Implementation Effectiveness within a QIColla

描述(由申请人提供)：在美国，改善医院护理的质量和安全的必要性是公认的。质量改进协作是指来自不同医院的多学科团队围绕一个共同的改进目标联合起来，这是一种在美国和国外都很受欢迎的加速改进努力的方法。医院通过合作，分享将临床创新转化为常规实践的方法方面的知识。虽然协作在直觉上是有道理的，但实施起来代价高昂，而且其益处的证据也有限。最重要的是，对于参与同一协作的医院之间业绩差异的来源，或者参与者可以采取哪些策略来增加他们成功的可能性，我们知之甚少。Premier Healthcare联盟最近推出了Quest，这是一个为期3年的合作项目，已经从全国550多家医院的网络中招募了160多家医院。Quest的目标是在多个质量领域提高医院绩效，包括增加对循证护理的坚持、降低成本、提高患者满意度和降低并发症发生率。这项合作任务最雄心勃勃的目标之一是降低风险调整后的医院死亡率。为了实现这一目标，合作参与者正试图实施十几种临床实践，从“脓毒症捆绑”到快速反应小组，旨在提高患有脓毒症和呼吸衰竭等高风险临床疾病的患者的存活率。这项研究的主要目的是通过应用一个理论框架来分析实施有效性，该框架在商业上是众所周知的，但在医疗保健领域相对较新，从而调查协作参与者实施推荐临床实践时的差异来源。为了实现这一点，我们将对Quest医院的临床和行政领导进行调查，以评估对协作推荐临床实践的看法以及医院实施环境和战略如何影响成功实施协作推荐实践的机会(目标1)。然后，我们将研究参与医院实施推荐的临床实践与并发症和死亡率变化之间的联系(目标2)。最后，我们将通过检查参与和非参与医院的并发症和风险调整死亡率随时间的变化，对合作医院的总体影响进行严格评估(目标3)。更好地了解协作方法的好处，以及使一些医院脱颖而出的背景因素和战略，将为当前和未来的协作参与者和组织者提供可操作的信息，并将提高质量改进工作的有效性。 公共卫生相关性：在美国，提高医院护理质量和安全的一种常见方法是将来自不同医院的医生和护士团队聚集在一起，共同努力实现共同的改善目标。虽然这个概念是有意义的，但质量改进协作的运行成本很高，而且其好处的证据有限。更重要的是，人们几乎不知道为什么在同一个协作体中，一些医院比其他医院更成功。通过对医院高级领导和质量改进人员的调查，这项研究将检查对新临床实践的看法以及其他医院因素如何有助于成功实施工作。此外，这项研究还将评估以减少医院并发症和死亡率为重点的大规模质量改进协作的效果。

DESCRIPTION (provided by applicant): The need to improve the quality and safety of hospital care in the United States is well-recognized. Quality improvement collaboratives, in which multi-disciplinary teams from different hospitals unite around a common improvement goal, are a popular method for accelerating improvement efforts, both in the United States and abroad. Working collaboratively, hospitals share knowledge about methods to translate clinical innovations into routine practice. Although collaboratives make intuitive sense, they are costly to carry out, and evidence of their benefit is limited. Most significantly, little is known about the sources of performance variation among hospitals participating in the same collaborative, or about the strategies that participants can engage in to increase the likelihood that they will be successful. The Premier healthcare alliance recently launched QUEST, a 3 year collaborative that has enrolled more than 160 hospitals from a network of more than 550 hospitals nationwide. QUEST aims to improve hospital performance across multiple domains of quality, including increasing adherence to evidence based care, reducing costs, improving patient satisfaction, and decreasing rates of complications. One of the most ambitious goals of the QUEST collaborative is to reduce risk-adjusted hospital mortality rates. To accomplish this, collaborative participants are attempting to implement more than a dozen clinical practices, ranging from "sepsis bundles" to rapid response teams, intended to improve survival for patients with high-risk clinical conditions like sepsis and respiratory failure. The primary aim of this study is to investigate the sources of variation in the implementation of recommended clinical practices by collaborative participants by applying a theoretical framework for analyzing implementation effectiveness that is well known in business but relatively new to healthcare. To accomplish this we will survey clinical and administrative leaders at QUEST hospitals in order to assess how perceptions of collaborative-recommended clinical practices, together with the hospital implementation climate and strategies, influence the chances of successful implementation of collaborative recommended practices (Aim 1). We will then examine the association between the implementation of recommended clinical practices and change in complication and mortality rates at participating hospitals (Aim 2). Finally, we will conduct a rigorous evaluation of the overall impact of the collaborative by examining changes in complication and risk-adjusted mortality rates over time at participating and non-participating hospitals (Aim 3). Developing a greater understanding of the benefits of the collaborative approach, and of the contextual factors and strategies that enable some hospitals to excel, will provide actionable information to current and future collaborative participants and organizers, and will increase the effectiveness of quality improvement efforts. PUBLIC HEALTH RELEVANCE: A common approach for improving the quality and safety of hospital care in the United States involves bringing teams of doctors and nurses together from different hospitals to work collaboratively towards a common improvement goal. While the concept makes sense, quality improvement collaboratives are costly to run, and evidence of their benefit is limited. More importantly, little is known about why, within the same collaborative, some hospitals are more successful than others. Through surveys of senior hospital leaders and quality improvement staff, this study will examine how perceptions of new clinical practices, together with other hospital factors, contribute to successful implementation efforts. Additionally, this study will evaluate the effects of a large quality improvement collaborative focused on reducing hospital complication and death rates.