Scalia Peter, Elwyn Glyn, Durand Marie-Anne
The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 1 Medical Center Drive 5th floor, Lebanon, NH, 03756, USA.
BMC Med Inform Decis Mak. 2017 Aug 18;17(1):124. doi: 10.1186/s12911-017-0517-2.
Implementing patient decision aids in clinic workflow has proven to be a challenge for healthcare organizations and physicians. Our aim was to determine the organizational strategies, motivations, and facilitating factors to the routine implementation of Option Grid™ encounter decision aids at two independent settings.
Case studies conducted by semi-structured interview, using the Normalization Process Theory (NPT) as a framework for thematic analysis. Twenty three interviews with physicians, nurses, hospital staff and stakeholders were conducted at: 1) CapitalCare Medical Group in Albany, New York; 2) HealthPartners Clinics in Minneapolis, Minnesota.
'Coherent' motivations were guided by financial incentives at CapitalCare, and by a 'champion' physician at HealthPartners. Nurses worked 'collectively' at both settings and played an important role at sites where successful implementation occurred. Some physicians did not understand the perceived utility of Option Grid™, which led to varying degrees of implementation success across sites. The appraisal work (reflexive monitoring) identified benefits, particularly in terms of information provision. Physicians at both settings, however, were concerned with time pressures and the suitability of the tool for patients with low levels of health literacy.
Although both practice settings illustrated the mechanisms of normalization postulated by the theory, the extent to which Option Grid™ was routinely embedded in clinic workflow varied between sites, and between clinicians. Implementation of new interventions will require attention to an identified rationale (coherence), and to the collective action, cognitive participation, and assessment of value by organizational members of the organization.
事实证明，在临床工作流程中应用患者决策辅助工具对医疗保健机构和医生来说是一项挑战。我们的目的是确定在两个独立机构中常规实施Option Grid™诊疗决策辅助工具的组织策略、动机和促进因素。
采用半结构化访谈进行案例研究，以规范化过程理论（NPT）作为主题分析的框架。在以下机构对医生、护士、医院工作人员和利益相关者进行了23次访谈：1）纽约奥尔巴尼的CapitalCare医疗集团；2）明尼苏达州明尼阿波利斯的HealthPartners诊所。
在CapitalCare，“一致的”动机受经济激励的引导，而在HealthPartners则受一位“带头”医生的引导。护士在这两个机构都进行“集体”工作，并且在成功实施的机构中发挥了重要作用。一些医生不理解Option Grid™的预期效用，这导致了各机构在实施成功程度上存在差异。评估工作（反思性监测）发现了益处，特别是在信息提供方面。然而，两个机构的医生都担心时间压力以及该工具对健康素养较低患者的适用性。
尽管这两个实践机构都展示了该理论所假定的规范化机制，但Option Grid™在临床工作流程中常规嵌入程度在不同机构之间以及不同临床医生之间存在差异。新干预措施的实施将需要关注明确的基本原理（一致性），以及组织成员的集体行动, 认知参与和对价值的评估。
