Solberg Leif I, Hroscikoski Mary C, Sperl-Hillen JoAnn M, O'Connor Patrick J, Crabtree Benjamin F
HealthPartners Research Foundation, Minneapolis, USA.
Jt Comm J Qual Saf. 2004 Jan;30(1):15-24. doi: 10.1016/s1549-3741(04)30002-x.
The 2001 Institute of Medicine (IOM) report highlighted the need for transformation of the U.S. health care system. This rigorous qualitative evaluation of transformational change for patient access in one large multispecialty group practice identifies the major issues facing organizations addressing the IOM challenge.
Semistructured depth interviews were conducted with the medical and administrative leaders at all levels, physicians, and nurses from 17 primary care clinics in one integrated medical group two years after they began to transform their approach to primary care patient appointment access.
The mean time to third-next-available appointment was reduced by 76% during one year, from 17.8 days to 4.2 days. Nine important issues related to the change process were identified from clinic interviews. When combined with issues identified by central leaders, 13 themes stood out as lessons in transformational change. A major issue is the tension between physician autonomy and both effective organizational function and putting patients first. Physician autonomy is also diminished by the need to standardize and systematize care.
Transformational change in care delivery is possible in large and complex group practices. Changes that directly affect care delivery and physician autonomy present particular challenges to physicians that need to be attended to if the changes are to be successful.
2001年医学研究所（IOM）的报告强调了美国医疗保健系统进行变革的必要性。这项针对一个大型多专科集团诊所中改善患者就医机会的变革性变化进行的严格定性评估，确定了应对IOM挑战的组织所面临的主要问题。
在一个综合医疗集团的17家基层医疗诊所开始改变其基层医疗患者预约就医方式两年后，对各级医疗和行政领导、医生及护士进行了半结构化深度访谈。
在一年时间里，第三次可预约的平均等待时间从17.8天减少到4.2天，降幅达76%。通过诊所访谈确定了与变革过程相关的九个重要问题。与中央领导确定的问题相结合后，有13个主题凸显出来，成为变革性变化中的经验教训。一个主要问题是医生自主权与有效的组织功能以及将患者放在首位之间的矛盾。标准化和系统化护理的需求也削弱了医生的自主权。
在大型复杂的集团诊所中，提供护理的变革性变化是可能的。直接影响护理提供和医生自主权的变革给医生带来了特殊挑战，若要变革取得成功，这些挑战需要得到关注。
