Holmboe Eric S, Prince Leslie, Green Michael
American Board of Internal Medicine, Suite 1700, 510 Walnut Street, Philadelphia, PA 19160, USA.
Acad Med. 2005 Jun;80(6):571-7. doi: 10.1097/00001888-200506000-00012.
Purpose Learning and applying quality of care principles are essential to practice-based learning and improvement. The authors investigated the feasibility and effects of a self-directed curriculum in quality of care for residents. Method In 2001-02, 13 second-year residents at two community-based outpatient clinics in the Yale University primary care internal medicine residency program were asked to participate in a trial of a quality improvement curriculum (intervention group). Thirteen third-year residents in the same residency program served as the comparison group. The curriculum consisted of readings in quality of care, weekly self-reflection with a faculty member, completion of a commitment to change survey, and medical record audits. Study outcome measures were patient level quality of care measures for diabetes, satisfaction with the curriculum, and self-reported behavioral changes. Results In the follow-up, patients of the intervention group were significantly more likely to have received a monofilament foot examination and baseline electrocardiogram than were patients of the comparison group. When comparing the change between baseline and follow-up, patients for the second-year residents showed significantly more improvement in hemoglobin A1c and LDL cholesterol levels and Pneumovax administration than did patients of the comparison group. All residents in the intervention group were highly satisfied with the curriculum. Thirty-five of 54 residents' personal commitments to change were either partially or fully implemented six months after the curriculum. Conclusions A multifaceted curriculum in quality improvement led to modest improvements in the care of diabetic patients and meaningful changes in self-reported practice behaviors. Future research should include more focus on the microsystems of residency outpatient experiences.
目的 学习并应用护理质量原则对于基于实践的学习与改进至关重要。作者调查了一项针对住院医师护理质量的自主课程的可行性及效果。方法 在2001 - 2002年，耶鲁大学初级保健内科住院医师项目中两家社区门诊诊所的13名二年级住院医师被要求参与一项质量改进课程试验（干预组）。同一住院医师项目中的13名三年级住院医师作为对照组。该课程包括护理质量方面的阅读材料、每周与教员进行自我反思、完成一份改变承诺调查以及病历审核。研究结果指标为糖尿病患者层面的护理质量指标、对课程的满意度以及自我报告的行为改变。结果 在随访中，干预组患者比对照组患者更有可能接受单丝足部检查和基线心电图检查。在比较基线与随访之间的变化时，二年级住院医师的患者在糖化血红蛋白和低密度脂蛋白胆固醇水平以及肺炎球菌疫苗接种方面的改善明显大于对照组患者。干预组的所有住院医师对该课程高度满意。在课程结束六个月后，54名住院医师中有35人的个人改变承诺部分或全部得到了落实。结论 一项多方面的质量改进课程在糖尿病患者护理方面带来了适度改善，并在自我报告的实践行为方面产生了有意义的变化。未来的研究应更多地关注住院医师门诊体验的微观系统。
