Rangachari Pavani, Madaio Michael, Rethemeyer R Karl, Wagner Peggy, Hall Lauren, Roy Siddharth, Rissing Peter
Pavani Rangachari, PhD, is Associate Professor and MPH Program Director, Department of Health Management and Informatics, Georgia Regents University, Augusta. E-mail:
Health Care Manage Rev. 2015 Jan-Mar;40(1):65-78. doi: 10.1097/HMR.0000000000000001.
Many hospitals are unable to consistently implement evidence-based practices. For example, implementation of the central line bundle (CLB), known to prevent catheter-related bloodstream infections (CRBSIs), is often challenging. This problem is broadly characterized as "change implementation failure."
The theoretical literature on organizational change has suggested that periodic top-down communications promoting tacit knowledge exchanges across professional subgroups may be effective for enabling learning and change in health care organizations. However, gaps remain in understanding the mechanisms by which top-down communications enable practice change at the unit level. Addressing these gaps could help identify evidence-based management strategies for successful practice change at the unit level. Our study sought to address this gap.
A prospective study was conducted in two intensive care units within an academic health center. Both units had low baseline adherence to CLB and higher-than-expected CRBSIs. Periodic top-down quality improvement communications were conducted over a 52-week period to promote CLB implementation in both units. Simultaneously, the study examined (a) the content and frequency of communication related to CLB through weekly "communication logs" completed by unit physicians, nurses, and managers and (b) unit outcomes, that is, CLB adherence rates through weekly chart reviews.
Both units experienced substantially improved outcomes, including increased adherence to CLB and statistically significant (sustained) declines in both CRBSIs and catheter days (i.e., central line use). Concurrently, both units indicated a statistically significant increase in "proactive" communications-that is, communications intended to reduce infection risk-between physicians and nurses over time. Further analysis revealed that, during the early phase of the study, "champions" emerged within each unit to initiate process improvements.
The study helps identify evidence-based management strategies for successful practice change at the unit level. For example, it underscores the importance of (a) screening each unit for change champions and (b) enabling champions to emerge from within the unit to foster change implementation.
许多医院无法始终如一地实施循证实践。例如，实施已知可预防导管相关血流感染（CRBSI）的中心静脉导管集束干预措施（CLB）往往具有挑战性。这个问题被广泛描述为“变革实施失败”。
关于组织变革的理论文献表明，定期进行自上而下的沟通以促进专业子群体之间的隐性知识交流，可能有助于医疗保健组织实现学习和变革。然而，在理解自上而下的沟通在单位层面促成实践变革的机制方面仍存在差距。填补这些差距有助于确定在单位层面成功实现实践变革的循证管理策略。我们的研究旨在填补这一差距。
在一家学术医疗中心的两个重症监护病房进行了一项前瞻性研究。两个病房对CLB的基线依从性都很低，且CRBSI高于预期。在52周的时间里定期进行自上而下的质量改进沟通，以促进两个病房实施CLB。同时，该研究通过单位医生、护士和管理人员填写的每周“沟通日志”，考察了（a）与CLB相关的沟通内容和频率，以及（b）单位结果，即通过每周的病历审查得出的CLB依从率。
两个病房的结果都有显著改善，包括CLB依从性提高，CRBSI和导管使用天数（即中心静脉导管使用）在统计学上均显著（持续）下降。同时，两个病房医生和护士之间“主动”沟通（即旨在降低感染风险的沟通）在统计学上显著增加。进一步分析表明，在研究的早期阶段，每个病房都出现了“倡导者”来启动流程改进。
该研究有助于确定在单位层面成功实现实践变革的循证管理策略。例如，它强调了（a）在每个单位筛选变革倡导者以及（b）使倡导者从单位内部涌现以促进变革实施的重要性。
