van Deventer Claire, Robert Glenn, Wright Anne
Department of Family Medicine and Rural Health, University of the Witwatersrand, Phillip Tobias Building, York Road, Parktown, Johannesburg, South Africa.
Health Care Quality & Innovation, Florence Nightingale Faculty of Nursing & Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
BMC Health Serv Res. 2016 Aug 5;16(a):358. doi: 10.1186/s12913-016-1574-4.
A significant proportion of children admitted to a hospital in a South African sub-district in 2010 were severely malnourished and - when concurrently HIV positive - were not correctly initiated on antiretroviral therapy. Audit data over a subsequent four year period revealed that 60 % of malnourished children admitted to the hospital were HIV positive. To supplement an ongoing local quality improvement (QI) intervention addressing poor nutritional outcomes in children in this setting, Experience-based Co-design (EBCD) was used to enhance previously low levels of mother, carer and staff engagement.
EBCD was implemented over an 8 month period. Non-participant observation was conducted comprising a total of 10 h in 5 different clinical locations. Semi-structured interviews were undertaken with 14 purposively selected staff members as well as 10 mothers/caregivers. The staff interviews were audio-taped whilst the mothers/caregiver interviews were filmed; both sets of experiences were analysed for key 'touchpoints'. Mothers/caregivers and staff participated in separate feedback events and then came together to identify their shared priorities for improving the service. Participants worked together in 3 smaller co-design teams to implement improvements.
There was overlap in staff and mother/carer views as to their priorities for QI. However, whilst staff typically highlighted pragmatic issues, mothers/caregivers were more likely to identify experiential and relational issues. A total of 38 QI interventions were proposed after the priorities had been discussed and delegated to the 3 co-design teams; 25 of these changes had been implemented or were being planned for by the end of the study period. Examples included: a point of care blood machine being bought to shorten the time in the emergency department whilst waiting for laboratory results; a play area being organised for children attending the HIV clinic; the development of three standard operating procedures to improve clinical handover and waiting times; and privacy screens installed to improve privacy in reception.
The impact of EBCD was noted both in practical improvements focused on a better experience for mothers/caregivers and children within the system and in reflections from stakeholders as to the value added to the ongoing QI intervention by the co-design process.
2010年，南非一个分区医院收治的很大一部分儿童严重营养不良，同时感染艾滋病毒的儿童未正确开始接受抗逆转录病毒治疗。随后四年的审计数据显示，入院的营养不良儿童中有60%感染了艾滋病毒。为了补充正在进行的旨在改善该地区儿童营养不良状况的当地质量改进（QI）干预措施，采用了基于经验的协同设计（EBCD）来提高此前较低的母亲、护理人员和工作人员参与度。
EBCD在8个月的时间内实施。进行了非参与性观察，在5个不同的临床地点共观察10小时。对14名经过有目的挑选的工作人员以及10名母亲/照顾者进行了半结构化访谈。工作人员访谈进行了录音，而母亲/照顾者访谈进行了录像；对两组经历都分析了关键的“接触点”。母亲/照顾者和工作人员分别参加了反馈活动，然后共同确定他们改善服务的共同优先事项。参与者在3个较小的协同设计团队中共同努力实施改进措施。
工作人员与母亲/照顾者在质量改进优先事项上的看法存在重叠。然而，工作人员通常强调实际问题，而母亲/照顾者更有可能指出体验和关系方面的问题。在讨论了优先事项并将其分配给3个协同设计团队后，共提出了38项质量改进干预措施；到研究期结束时，其中25项变更已实施或正在计划中。示例包括：购买一台即时检测血液机器，以缩短在急诊科等待实验室结果的时间；为参加艾滋病毒诊所的儿童组织一个游乐区；制定三项标准操作程序以改善临床交接和等待时间；安装隐私屏风以改善候诊区的隐私。
EBCD的影响不仅体现在为系统内的母亲/照顾者和儿童提供更好体验的实际改进中，还体现在利益相关者对协同设计过程为正在进行的质量改进干预措施所增加价值的反思中。
