Feifer Chris, Nemeth Lynne, Nietert Paul J, Wessell Andrea M, Jenkins Ruth G, Roylance Loraine, Ornstein Steven M
Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif 90033, USA.
Ann Fam Med. 2007 May-Jun;5(3):233-41. doi: 10.1370/afm.697.
Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes.
This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies.
Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet's improvement model.
Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.
基层医疗实践在追求高质量医疗服务时采用不同方法。实践伙伴研究网络（PPRNet）之前的研究发现，改善结果与以下策略相关：优先考虑绩效、让员工参与、重新设计服务提供系统的要素、使患者成为遵循指南的积极伙伴以及使用电子病历中嵌入的工具。本研究的目的是调查在取得最佳结果的医疗机构中改进措施采用情况的差异。
本研究采用观察性案例研究设计。使用一种针对临床指南遵循情况的实践层面衡量方法，在参与一项全国示范项目的内科和家庭医学实践网络中识别表现最佳的实践。我们分析了从项目文件、实地记录和评估问卷中获取的定性和定量信息，以制定和比较案例研究。
描述了九个案例。所有案例都采用了许多相同的改进策略。改进措施组织方式的差异定义了三种不同的原型：技术爱好者型、积极团队型和关怀型企业。没有单一的方法能解释表现最佳的实践的卓越表现，尽管它们都采用了PPRNet改进模式的不同变体。
在通往高质量医疗服务的道路上，不同实践会有所不同。这些原型可能会成为其他选择整体质量改进方法的实践的有用指南。
