Kreindler Sara Adi
Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
Health Systems Performance, George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada.
BMJ Qual Saf. 2017 May;26(5):388-394. doi: 10.1136/bmjqs-2016-005438. Epub 2016 Jul 27.
Although well-established principles exist for improving the timeliness and efficiency of care, many organisations struggle to achieve more than small-scale, localised gains. Where care processes are complex and include segments under different groups' control, the elegant solutions promised by improvement methodologies remain elusive. This study sought to identify common design flaws that limit the impact of flow initiatives.
This qualitative study was conducted within an explanatory case study of a Canadian regional health system in which multitudinous flow initiatives had yielded no overall improvement in system performance. Interviews with 62 senior, middle and departmental managers, supplemented by ∼700 documents on flow initiatives, were analysed using the constant comparative method.
Findings suggested that smooth flow depends on linking a defined to appropriate by means of an efficient ; flawed initiatives reflected failure to consider one or more of these essential elements. Many initiatives focused narrowly on process, failing to consider that the intended population was poorly defined or the needed capacity inaccessible; some introduced capacity for an intended population, but offered no process to link the two. Moreover, interveners were unable to respond effectively when a bottleneck moved to another part of the system. Errors of population, capacity and process, in different combinations, generated six 'formulae for failure'.
Typically, flawed initiatives focused on too small a segment of the patient journey to properly address the impediments to flow. The proliferation of narrowly focused initiatives, in turn, reflected a decentralised system in which responsibility for flow improvement was fragmented. Thus, initiatives' specific design flaws may have their roots in a deeper problem: the lack of a coherent system-level strategy.
尽管已有完善的原则来提高医疗服务的及时性和效率，但许多组织仍难以实现大规模、全面的改善。在医疗流程复杂且涉及不同群体控制的环节时，改善方法所承诺的精妙解决方案仍然难以捉摸。本研究旨在识别限制流程改进举措影响的常见设计缺陷。
本定性研究是在对加拿大一个区域卫生系统的解释性案例研究中进行的，在该系统中，众多流程改进举措并未使系统性能得到整体提升。通过对62名高级、中级和部门经理进行访谈，并辅以约700份关于流程改进举措的文件，采用持续比较法进行分析。
研究结果表明，顺畅的流程依赖于通过高效的[具体内容缺失]将明确的[具体内容缺失]与适当的[具体内容缺失]相联系；有缺陷的举措反映出未能考虑到这些基本要素中的一个或多个。许多举措狭隘地聚焦于流程，未考虑目标人群定义不明确或所需能力无法实现；一些举措为目标人群引入了能力，但没有提供将两者联系起来的流程。此外，当瓶颈转移到系统的另一部分时，干预者无法有效应对。人群、能力和流程方面的错误，以不同组合形式，产生了六种“失败公式”。
通常，有缺陷的举措关注的患者就医旅程部分过小，无法妥善解决流程障碍。反过来，狭隘聚焦的举措大量涌现，反映出一个分散的系统，其中流程改进的责任分散。因此，举措的具体设计缺陷可能源于一个更深层次的问题：缺乏连贯的系统层面战略。
