Grant Suzanne, Checkland Katherine, Bowie Paul, Guthrie Bruce
Population Health Sciences, School of Medicine, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
Health Policy, Politics and Organisation (HiPPO) Research Group, Centre for Primary Care, Institute of Population Health, University of Manchester, 5th Floor, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
Implement Sci. 2017 Apr 27;12(1):56. doi: 10.1186/s13012-017-0586-8.
The handling of laboratory, imaging and other test results in UK general practice is a high-volume organisational routine that is both complex and high risk. Previous research in this area has focused on errors and harm, but a complementary approach is to better understand how safety is achieved in everyday practice. This paper ethnographically examines the role of informal dimensions of test results handling routines in the achievement of safety in UK general practice and how these findings can best be developed for wider application by policymakers and practitioners.
Non-participant observation was conducted of high-volume organisational routines across eight UK general practices with diverse organisational characteristics. Sixty-two semi-structured interviews were also conducted with the key practice staff alongside the analysis of relevant documents.
While formal results handling routines were described similarly across the eight study practices, the everyday structure of how the routine should be enacted in practice was informally understood. Results handling safety took a range of local forms depending on how different aspects of safety were prioritised, with practices varying in terms of how they balanced thoroughness (i.e. ensuring the high-quality management of results by the most appropriate clinician) and efficiency (i.e. timely management of results) depending on a range of factors (e.g. practice history, team composition). Each approach adopted created its own potential risks, with demands for thoroughness reducing productivity and demands for efficiency reducing handling quality. Irrespective of the practice-level approach adopted, staff also regularly varied what they did for individual patients depending on the specific context (e.g. type of result, patient circumstances).
General practices variably prioritised a legitimate range of results handling safety processes and outcomes, each with differing strengths and trade-offs. Future safety improvement interventions should focus on how to maximise practice-level knowledge and understanding of the range of context-specific approaches available and the safeties and risks inherent in each within the context of wider complex system conditions and interactions. This in turn has the potential to inform new kinds of proactive, contextually appropriate approaches to intervention development and implementation focusing on the enhanced deliberation of the safety of existing high-volume routines.
在英国的全科医疗中，处理实验室检查、影像学检查及其他检查结果是一项量大且复杂、高风险的组织性日常工作。此前该领域的研究聚焦于错误和危害，但一种补充性方法是更好地理解日常工作中如何实现安全。本文采用人种志研究方法，考察了检查结果处理流程中非正式维度在英国全科医疗安全实现中的作用，以及如何将这些研究结果更好地拓展，以供政策制定者和从业者更广泛地应用。
对英国8家具有不同组织特征的全科医疗机构的大量组织性日常工作进行了非参与式观察。还与关键的执业人员进行了62次半结构化访谈，并对相关文件进行了分析。
虽然在8个研究机构中，正式的结果处理流程描述相似，但在实践中如何执行该流程的日常结构却是通过非正式方式理解的。结果处理的安全性呈现出多种当地形式，这取决于如何对安全的不同方面进行优先排序，各机构在平衡彻底性（即确保由最合适的临床医生对结果进行高质量管理）和效率（即及时管理结果）方面存在差异，这取决于一系列因素（如机构历史、团队构成）。每种采用的方法都有其自身潜在的风险，对彻底性的要求会降低生产率，对效率的要求会降低处理质量。无论采用何种机构层面的方法，工作人员还会根据具体情况（如结果类型、患者情况），经常对个别患者采取不同的处理方式。
全科医疗机构对一系列合理的结果处理安全流程和结果的优先排序各不相同，每种都有不同的优势和权衡。未来的安全改进干预措施应侧重于如何在更广泛的复杂系统条件和相互作用的背景下，最大限度地提高机构层面对于可用的一系列针对具体情况的方法以及每种方法所固有的安全性和风险的认识和理解。这反过来有可能为新的、针对具体情况的主动干预措施的制定和实施提供信息，这些措施侧重于加强对现有大量日常工作安全性的审慎考虑。
