Rubenstein Lisa V, Danz Marjorie S, Crain A Lauren, Glasgow Russell E, Whitebird Robin R, Solberg Leif I
RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.
Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, 91343, USA.
Implement Sci. 2014 Dec 2;9:173. doi: 10.1186/s13012-014-0173-1.
Depression is a major cause of morbidity and cost in primary care patient populations. Successful depression improvement models, however, are complex. Based on organizational readiness theory, a practice's commitment to change and its capability to carry out the change are both important predictors of initiating improvement. We empirically explored the links between relative commitment (i.e., the intention to move forward within the following year) and implementation capability.
The DIAMOND initiative administered organizational surveys to medical and quality improvement leaders from each of 83 primary care practices in Minnesota. Surveys preceded initiation of activities directed at implementation of a collaborative care model for improving depression care. To assess implementation capability, we developed composites of survey items for five types of organizational factors postulated to be collaborative care barriers and facilitators. To assess relative commitment for each practice, we averaged leader ratings on an identical survey question assessing practice priorities. We used multivariable regression analyses to assess the extent to which implementation capability predicted relative commitment. We explored whether relative commitment or implementation capability measures were associated with earlier initiation of DIAMOND improvements.
All five implementation capability measures independently predicted practice leaders' relative commitment to improving depression care in the following year. These included the following: quality improvement culture and attitudes (p = 0.003), depression culture and attitudes (p <0.001), prior depression quality improvement activities (p <0.001), advanced access and tracking capabilities (p = 0.03), and depression collaborative care features in place (p = 0.03). Higher relative commitment (p = 0.002) and prior depression quality improvement activities appeared to be associated with earlier participation in the DIAMOND initiative.
The study supports the concept of organizational readiness to improve quality of care and the use of practice leader surveys to assess it. Practice leaders' relative commitment to depression care improvement may be a useful measure of the likelihood that a practice is ready to initiate evidence-based depression care changes. A comprehensive organizational assessment of implementation capability for depression care improvement may identify specific barriers or facilitators to readiness that require targeted attention from implementers.
抑郁症是基层医疗患者群体发病和成本的主要原因。然而，成功的抑郁症改善模式很复杂。基于组织准备度理论，医疗机构对变革的承诺及其实施变革的能力都是启动改善工作的重要预测因素。我们通过实证研究了相对承诺（即在次年推进变革的意愿）与实施能力之间的联系。
“钻石计划”（DIAMOND initiative）对明尼苏达州83家基层医疗诊所的医疗和质量改进负责人进行了组织调查。调查在启动旨在实施改善抑郁症护理的协作护理模式的活动之前进行。为了评估实施能力，我们针对假定为协作护理障碍和促进因素的五种组织因素编制了调查项目综合指标。为了评估每家诊所的相对承诺，我们对评估诊所优先事项的同一调查问题上负责人的评分进行了平均。我们使用多变量回归分析来评估实施能力对相对承诺的预测程度。我们探讨了相对承诺或实施能力指标是否与更早启动“钻石计划”的改进措施相关。
所有五项实施能力指标均独立预测了诊所负责人次年对改善抑郁症护理的相对承诺。这些指标包括：质量改进文化和态度（p = 0.003）、抑郁症文化和态度（p <0.001）、先前的抑郁症质量改进活动（p <0.001）、提前预约和跟踪能力（p = 0.03）以及现有的抑郁症协作护理特征（p = 0.03）。更高的相对承诺（p = 0.002）和先前的抑郁症质量改进活动似乎与更早参与“钻石计划”相关。
该研究支持组织准备度以改善护理质量的概念以及使用诊所负责人调查来评估这一概念。诊所负责人对改善抑郁症护理的相对承诺可能是衡量诊所准备好启动循证抑郁症护理变革可能性的有用指标。对抑郁症护理改善实施能力进行全面的组织评估可能会识别出准备度方面需要实施者有针对性关注的具体障碍或促进因素。
