Main Deborah S, Graham Deborah, Nutting Paula A, Nease Donald E, Dickinson W Perry, Gallagher Kaia
Department of Family Medicine, University of Colorado, Denver, USA.
Jt Comm J Qual Patient Saf. 2009 Jul;35(7):351-7. doi: 10.1016/s1553-7250(09)35049-7.
Primary care practices would benefit from improved understanding of how to make and sustain fundamental changes in their delivery systems. An improvement collaborative project was conducted in 2005 to not only improve the quality of depression care but help participating practices adopt and adapt more effective change processes to implement improved depression care. In a follow-up to an article on the project's impact in terms of measurable, sustained improvements in depression care, an exploratory qualitative study was conducted to examine primary care practices' adoption of effective change processes.
Qualitative data were collected from 16 primary care practices participating in the National Depression Management Leadership Initiative's Improving Depression Care project. A multistep process of qualitative analysis was used to identify exemplar practices, and a constant comparative method was applied to identify salient features that influenced adoption of change processes associated with improvements in depression care during the course of the 18-month project.
The participating practices showed considerable variability in terms of the improvements they made in depression care and corresponding adoption of change processes to help make these and other improvements. Nearly all practices that showed the greatest improvements in depression care also adopted more effective processes for change, with several features associated with exemplar practices able to improve depression care and change processes.
These findings support the thesis that successful quality improvement efforts should address both clinical content and change processes. They also add to the literature on the impact of improvement collaborative projects, which to date have demonstrated mixed effects in a variety of chronic diseases, including depression.
初级保健机构若能更好地理解如何在其服务体系中做出并维持根本性变革，将从中受益。2005年开展了一项改进合作项目，不仅旨在提高抑郁症护理质量，还帮助参与项目的机构采用并适应更有效的变革流程，以实施改进后的抑郁症护理。在一篇关于该项目对抑郁症护理产生可衡量的持续改善影响的文章后续研究中，进行了一项探索性定性研究，以考察初级保健机构对有效变革流程的采用情况。
从参与国家抑郁症管理领导力倡议组织的改善抑郁症护理项目的16家初级保健机构收集定性数据。采用多步骤定性分析流程来确定典范机构，并运用持续比较法来识别在为期18个月的项目过程中影响与抑郁症护理改善相关的变革流程采用情况的显著特征。
参与项目的机构在抑郁症护理改善程度以及相应采用有助于实现这些及其他改善的变革流程方面存在很大差异。几乎所有在抑郁症护理方面改善最大的机构也采用了更有效的变革流程，与典范机构相关的几个特征能够改善抑郁症护理和变革流程。
这些发现支持了这样一个论点，即成功的质量改进工作应兼顾临床内容和变革流程。它们还丰富了关于改进合作项目影响的文献，迄今为止，这些项目在包括抑郁症在内的多种慢性病中显示出好坏参半 的效果。
