在一家退伍军人事务部（VA）医院促使住院医师参与综合质量改进课程的教育系统因素：一项现实主义评价
Educational system factors that engage resident physicians in an integrated quality improvement curriculum at a VA hospital: a realist evaluation.
作者信息
Ogrinc Greg, Ercolano Ellyn, Cohen Emily S, Harwood Beth, Baum Karyn, van Aalst Robertus, Jones Anne C, Davies Louise
机构信息
Dr. Ogrinc is senior scholar, White River Junction VA Medical Center, and associate professor of community and family medicine and of medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Ms. Ercolano is senior value measurement analyst, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Dr. Cohen is associate program director and assistant professor of medicine, White River Junction VA Medical Center and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Ms. Harwood is research associate, White River Junction VA Medical Center and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Baum is associate chair of clinical quality and professor of medicine, University of Minnesota Medical School, Minneapolis, Minnesota. Mr. van Aalst is industrial engineer, White River Junction VA Medical Center, White River Junction, Vermont. Dr. Jones is VA Quality Scholar, White River Junction VA Medical Center, and instructor of community and family medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. Dr. Davies is assistant professor of surgery, Department of Surgery-Otolaryngology, Geisel School of Medicine at Dartmouth, VA Outcomes Group, White River Junction VA Medical Center, Hanover, New Hampshire.
出版信息
Acad Med. 2014 Oct;89(10):1380-5. doi: 10.1097/ACM.0000000000000389.
PURPOSE
Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum-including real QI work-into the routine work of inpatient internal medicine teams.
METHOD
A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts.
RESULTS
Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge.
CONCLUSIONS
Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.
目的
在住院医师培训中，有关质量改进（QI）的学习通常被归入选修或非核心临床活动。作者将QI的教学、学习和实践融入了一家退伍军人事务（VA）医院内科住院团队的日常临床工作中。本研究描述了促进和阻碍将QI课程（包括实际的QI工作）融入内科住院团队日常工作的设计因素。
方法
采用现实主义评价框架，使用了三个数据源：QI教员的现场记录；对住院医师的半结构化访谈；以及对QI教员和工作人员的小组访谈。2011年4月至2012年7月，白河汇合处VA医疗中心的住院医师团队在其QI工作中使用了改进模型，并使用统计过程控制图分析数据。
结果
三个领域影响了QI课程的实施以及住院医师参与QI工作的程度：环境、学习者和教师。在团队工作室的公共空间持续展示QI材料是环境方面的一个促进机制。向下一个住院医师团队明确交接QI工作，在学习者领域实现了交接的正规化。身为受尊敬的临床领导者且具备QI专业知识的QI教师提供了榜样示范和当地系统知识。
结论
将QI教学融入住院服务的日常临床和教育系统具有挑战性。在环境、学习者和教师领域中可识别的具体策略有助于将QI融入临床和教育系统。
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