Matchar David B, Patwardhan Meenal B, Samsa Gregory P, Haley William E
Duke Center for Clinical Health Policy Research, Durham, NC, USA.
Am J Kidney Dis. 2006 Mar;47(3):528-38. doi: 10.1053/j.ajkd.2005.11.016.
Two common strategies for guideline implementation are preformed practice improvement tools, such as flowcharts, and process reengineering by total quality management (TQM) teams. Prespecified tools fail to accommodate local circumstances, TQM requires an unrealistic level of local commitment, and neither has a proven track record for success.
We describe an alternative approach termed facilitated process improvement (FPI), a systematic exploration of potential modifications to systems of care, and its application to the implementation of an evidence-based chronic kidney disease (CKD) guideline, focusing on individuals not yet requiring renal replacement therapy. The FPI steps followed by the implementation work group to develop a set of implementation tools for the Renal Physicians Association Advanced CKD Guideline included: (1) developing functional specifications of processes, including actions and prerequisites required; (2) investigating processes of care in a variety of site types to understand processes and reasons for failures; (3) developing practical tools corresponding to root causes of failures of processes and subprocesses; and (4) developing a meta-tool to tailor local selection of tools.
Formal needs assessment identified processes of care related to 3 major tasks: identify patients, develop and communicate patient-specific management plan, and implement plan. Subtasks were identified to address root causes of failures, and, for each, tools were modified from existing or developed de novo by the work group, which further developed an organized management approach that uses 4 categories of tools: (1) assessment tools identify opportunities for improvements; (2) tailoring tools, a unique feature of this approach, determine which tools are applicable; (3) implementation tools identify patients and communicate and implement management plan; and (4) evaluation tools assess the impact of implementation.
The work group, in collaboration with community clinicians, patients, and CKD and tool experts, developed and used FPI to provide a range of tools in a fashion that supports and simplifies local assessment, tailoring, implementation, and evaluation. With the formative work completed, practitioners whose practice improvement experience level and other resources may be limited will find it more feasible and practical to provide optimal advanced CKD management without the demands of conventional TQM or continuous quality improvement.
指南实施的两种常见策略是预先制定的实践改进工具，如流程图，以及由全面质量管理（TQM）团队进行的流程再造。预先指定的工具无法适应当地情况，TQM需要不切实际的当地投入水平，而且两者都没有成功的记录。
我们描述了一种称为促进流程改进（FPI）的替代方法，这是一种对护理系统潜在改进的系统探索，及其在实施基于证据的慢性肾脏病（CKD）指南中的应用，重点关注尚未需要肾脏替代治疗的个体。实施工作组为肾脏内科医师协会晚期CKD指南开发一套实施工具所遵循的FPI步骤包括：（1）制定流程的功能规范，包括所需的行动和先决条件；（2）调查各种场所类型的护理流程，以了解流程及失败原因；（3）开发与流程和子流程失败的根本原因相对应的实用工具；（4）开发一种元工具，用于根据当地情况选择工具。
正式的需求评估确定了与3项主要任务相关的护理流程：识别患者、制定并传达针对患者的管理计划以及实施计划。确定了子任务以解决失败的根本原因，并且对于每个子任务，工作组从现有工具修改或重新开发工具，进一步开发了一种有组织的管理方法，该方法使用4类工具：（1）评估工具识别改进机会；（2）定制工具（此方法的独特特征）确定哪些工具适用；（3）实施工具识别患者并传达和实施管理计划；（4）评估工具评估实施的影响。
工作组与社区临床医生、患者以及CKD和工具专家合作，开发并使用FPI以支持和简化当地评估、定制、实施和评估的方式提供一系列工具。随着形成性工作的完成，实践改进经验水平和其他资源可能有限的从业者将发现，在没有传统TQM或持续质量改进要求的情况下，提供最佳的晚期CKD管理更加可行和实际。
