Silver Samuel A, McQuillan Rory, Harel Ziv, Weizman Adam V, Thomas Alison, Nesrallah Gihad, Bell Chaim M, Chan Christopher T, Chertow Glenn M
Division of Nephrology and.
Division of Nephrology, University Health Network-Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
Clin J Am Soc Nephrol. 2016 May 6;11(5):916-924. doi: 10.2215/CJN.11501015. Epub 2016 Mar 25.
To achieve sustainable change, quality improvement initiatives must become the new way of working rather than something added on to routine clinical care. However, most organizational change is not maintained. In this next article in this Moving Points in Nephrology feature on quality improvement, we provide health care professionals with strategies to sustain and support quality improvement. Threats to sustainability may be identified both at the beginning of a project and when it is ready for implementation. The National Health Service Sustainability Model is reviewed as one example to help identify issues that affect long-term success of quality improvement projects. Tools to help sustain improvement include process control boards, performance boards, standard work, and improvement huddles. Process control and performance boards are methods to communicate improvement results to staff and leadership. Standard work is a written or visual outline of current best practices for a task and provides a framework to ensure that changes that have improved patient care are consistently and reliably applied to every patient encounter. Improvement huddles are short, regular meetings among staff to anticipate problems, review performance, and support a culture of improvement. Many of these tools rely on principles of visual management, which are systems transparent and simple so that every staff member can rapidly distinguish normal from abnormal working conditions. Even when quality improvement methods are properly applied, the success of a project still depends on contextual factors. Context refers to aspects of the local setting in which the project operates. Context affects resources, leadership support, data infrastructure, team motivation, and team performance. For these reasons, the same project may thrive in a supportive context and fail in a different context. To demonstrate the practical applications of these quality improvement principles, these principles are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis).
为实现可持续变革，质量改进举措必须成为新的工作方式，而非常规临床护理之外额外添加的内容。然而，大多数组织变革都未能持续下去。在《肾脏病学质量改进要点》系列的下一篇文章中，我们为医疗保健专业人员提供维持和支持质量改进的策略。在项目启动之初以及准备实施时，都可能识别出对可持续性的威胁。我们以英国国家医疗服务体系可持续性模型为例进行审视，以帮助识别影响质量改进项目长期成功的问题。有助于维持改进的工具包括过程控制板、绩效看板、标准作业流程和改进碰头会。过程控制板和绩效看板是向员工和领导层传达改进结果的方法。标准作业流程是某项任务当前最佳实践的书面或可视化概述，并提供一个框架，以确保改善患者护理的变革能始终如一地、可靠地应用于每一次患者诊疗过程。改进碰头会是员工之间定期召开的简短会议，用于预测问题、审查绩效并支持改进文化。这些工具中的许多都依赖于可视化管理原则，这些系统透明且简单，以便每个员工都能迅速区分正常与异常工作状况。即使质量改进方法得到正确应用，项目的成功仍取决于背景因素。背景是指项目开展所处当地环境的各个方面。背景会影响资源、领导支持、数据基础设施以及团队动力和团队绩效。出于这些原因，同一个项目在支持性环境中可能蓬勃发展，而在不同环境中可能失败。为展示这些质量改进原则的实际应用，我们将这些原则应用于一项旨在推广家庭透析（家庭血液透析和腹膜透析）的假设性质量改进举措。
