Munday Daniel, Mahmood Kashifa, Dale Jeremy, King Nigel
Warwick Medical School, University of Warwick, Coventry, UK.
Fam Pract. 2007 Oct;24(5):486-94. doi: 10.1093/fampra/cmm045. Epub 2007 Aug 4.
Palliative care is an important, complex aspect of primary care, requiring a multidisciplinary approach. The Gold Standards Framework (GSF), a programme used by over 3,000 UK practices, aims to facilitate high-quality palliative care through the introduction of systematic clinical and organizational processes. Quality payments for palliative care are available to UK practices which maintain registers and hold multidisciplinary meetings.
To explore the effectiveness and sustainability of the implementation of GSF at practice level.
The study followed a qualitative comparative case study design using in-depth interviews and observational data with 15 practices participating in GSF, from three areas differing in socio-geography. Semi-structured interviews (total 45) with GPs, community nurses and practice managers were supplemented by observation of practice meetings and systems, to provide contextual insights. Transcribed interviews were analysed using a thematic matrix approach and comparisons were made within and between practices. Practices were identified on a continuum of performance (high, medium and minimal) according to the evidence of functioning in palliative care-related activity.
Considerable variation existed between practices in both the extent of palliative care-related processes and the effectiveness of inter-professional communication. High-performing practices displayed a clear-shared purpose for palliative care with effective communication, whereas minimal performing practices demonstrated little utilization of basic GSF processes and deficiencies in inter-professional communication.
Effective palliative care requires good team relationships and robust processes. While GSF can enable such improvements, quality measures focusing on processes alone are inadequate to distinguish good practice, questioning the effectiveness of current quality measures in UK general practice.
姑息治疗是初级保健中一个重要且复杂的方面，需要多学科方法。黄金标准框架（GSF）是一项被英国3000多家医疗机构采用的计划，旨在通过引入系统的临床和组织流程来促进高质量的姑息治疗。英国维持登记册并召开多学科会议的医疗机构可获得姑息治疗质量支付。
探讨在实践层面实施GSF的有效性和可持续性。
该研究采用定性比较案例研究设计，对来自社会地理不同的三个地区的15家参与GSF的医疗机构进行深入访谈和观察数据收集。通过观察医疗机构会议和系统，对全科医生、社区护士和医疗机构管理人员进行半结构化访谈（共45次），以提供背景见解。使用主题矩阵方法对转录的访谈进行分析，并在医疗机构内部和之间进行比较。根据姑息治疗相关活动的运作证据，将医疗机构分为表现连续体（高、中、低）。
各医疗机构在姑息治疗相关流程的程度和跨专业沟通的有效性方面存在很大差异。高绩效的医疗机构在姑息治疗方面有明确的共同目标，沟通有效，而低绩效的医疗机构很少利用基本的GSF流程，跨专业沟通存在缺陷。
有效的姑息治疗需要良好的团队关系和稳健的流程。虽然GSF可以实现这些改进，但仅关注流程的质量措施不足以区分良好实践，这对英国全科医疗中当前质量措施的有效性提出了质疑。
