Fernald Douglas H, Deaner Nicole, O'Neill Caitlin, Jortberg Bonnie T, degruy Frank Verloin, Dickinson W Perry
Department of Family Medicine, University of Colorado Denver, Aurora, CO 80045, USA.
Fam Med. 2011 Jul-Aug;43(7):503-9.
Residency programs face inevitable challenges as they redesign their practices for higher quality care and resident training. Identifying and addressing early barriers can help align priorities and thereby augment the capacity to change.
Evaluation of the Colorado Family Medicine Residency PCMH Project included iterative qualitative analysis of field notes, interviews, and documents to identify early barriers to change and strategies to overcome them.
Nine common but not universal barriers were identified: (1) a practice's history reflected some negative past experiences with quality improvement or routines incompatible with transformative change, (2) leadership gaps were evident in unprepared practice leaders or hierarchical leadership, (3) resistance and skepticism about change were expressed through cynicism aimed at change or ability to change, (4) unproductive team processes were reflected in patterns of canceled meetings, absentee leaders, or lack of accountability, (5) knowledge gaps about the Patient-centered Medical Home (PCMH) were apparent from incomplete dissemination about the project or planned changes, (6) EHR implementation distracted focus or stalled improvement activity, (7) sponsoring organizations' constraints emerged from staffing rules and differing priorities, (8) insufficient staff participation resulted from traditional role expectations and structures, and (9) communication was hampered by ineffective methods and part-time faculty and residents. Early barriers responded to varying degrees to specific interventions by practice coaches.
Some barriers that interfere with practices getting started with cultural and structural transformation can be addressed with persistent attention and reflection from on-site coaches and by realigning the talents, leaders, and priorities already in these residency programs.
住院医师培训项目在为提供更高质量的医疗服务和住院医师培训而重新设计其实践时面临不可避免的挑战。识别并尽早解决障碍有助于明确优先事项，从而增强变革能力。
对科罗拉多家庭医学住院医师以患者为中心的医疗之家（PCMH）项目的评估包括对现场记录、访谈和文件进行迭代定性分析，以确定变革的早期障碍及克服这些障碍的策略。
识别出九个常见但并非普遍存在的障碍：（1）一种实践的历史反映出过去在质量改进方面有一些负面经历或存在与变革性变化不相容的常规做法；（2）在准备不足的实践领导者或层级式领导中明显存在领导力差距；（3）对变革的抵制和怀疑通过对变革或变革能力的冷嘲热讽表现出来；（4）无效的团队流程体现在会议取消、领导缺席或缺乏问责制的模式中；（5）由于对该项目或计划变革的传播不完整，对以患者为中心的医疗之家（PCMH）的知识差距明显；（6）电子健康记录（EHR）的实施分散了注意力或使改进活动停滞不前；（7）赞助组织的限制源于人员配备规则和不同的优先事项；（8）由于传统的角色期望和结构导致员工参与不足；（9）沟通因无效的方法以及兼职教员和住院医师而受到阻碍。实践教练的特定干预措施在不同程度上应对了早期障碍。
一些妨碍实践开始文化和结构转型的障碍可以通过现场教练的持续关注和反思，以及重新调整这些住院医师培训项目中已有的人才、领导者和优先事项来解决。
