van Bokhoven Marloes A, Koch Hèlen, Dinant Geert-Jan, Bindels Patrick Je, Grol Richard Ptm, van der Weijden Trudy
Department of General Practice/Centre for Quality of Care Research (WOK), Care and Public Health Research Institute, Maastricht University, PO Box 616, NL-6200 MD, Maastricht.
Fam Pract. 2008 Jun;25(3):139-45. doi: 10.1093/fampra/cmn022. Epub 2008 Jun 5.
The effects of quality improvement strategies are sometimes limited in spite of a systematic development approach. What elements play a role in the change process is not yet fully understood.
To explore this 'black box' of change, by analysing the barriers and facilitators GPs perceive during the change process.
Qualitative study among GPs who participated in the quality improvement strategy arm of a randomized clinical trial on blood test ordering for unexplained complaints (UCs). The strategy was based on a national guideline that advocates delayed test ordering in patients presenting with UCs. Each GP's change process was assessed by means of a semi-structured interview about barriers to and facilitators of change.
Twenty-four interviews were analysed. Important themes identified in the interviews were lack of problem awareness, the time and effort it takes to change, influence of patients and the pros and cons of the changed behaviour.
The themes can be summarized into one comprehensive issue: the GPs lack a sense of urgency to change. An important explanation seems to be that two questions from the problem analysis prior to the development of the strategy had not been adequately answered: "Is the GPs' current behaviour a problem and does the problem have consequences for patients?" and if so, "What is the extent of the problem?." As a result, insufficient attention was given to applicability issues, such as time investment, costs and patient and practitioner satisfaction and anxiety.
尽管采用了系统的开发方法，但质量改进策略的效果有时仍然有限。变革过程中哪些因素发挥作用尚未完全明了。
通过分析全科医生在变革过程中所感知到的障碍和促进因素，探究这一变革的“黑匣子”。
对参与一项关于不明原因投诉（UC）血液检查医嘱开具的随机临床试验质量改进策略组的全科医生进行定性研究。该策略基于一项国家指南，该指南提倡对出现UC的患者延迟开具检查医嘱。通过关于变革障碍和促进因素的半结构化访谈对每位全科医生的变革过程进行评估。
对24次访谈进行了分析。访谈中确定的重要主题包括缺乏问题意识、变革所需的时间和精力、患者的影响以及变革后行为的利弊。
这些主题可归纳为一个综合问题：全科医生缺乏变革的紧迫感。一个重要的解释似乎是，在制定策略之前的问题分析中的两个问题没有得到充分解答：“全科医生目前的行为是一个问题吗？这个问题对患者有影响吗？”如果是，“问题的严重程度如何？”结果，对适用性问题，如时间投入、成本以及患者和从业者的满意度与焦虑等关注不足。
