影响基层医疗质量改进实施的背景因素：组织、团队和个人的作用。
Contextual factors that influence quality improvement implementation in primary care: The role of organizations, teams, and individuals.
机构信息
Christopher M. Shea, PhD, MPA, is Assistant Professor, Department of Health Policy and Management, University of North Carolina at Chapel Hill. E-mail:
出版信息
Health Care Manage Rev. 2018 Jul/Sep;43(3):261-269. doi: 10.1097/HMR.0000000000000194.
BACKGROUND
Recent emphasis on value-based health care has highlighted the importance of quality improvement (QI) in primary care settings. QI efforts, which require providers and staff to work in cross-functional teams, may be implemented with varying levels of success, with implementation being affected by factors at the organizational, teamwork, and individual levels.
PURPOSE
The purpose of our study was to (a) identify contextual factors (organizational, teamwork, and individual) that affect implementation effectiveness of QI interventions in primary care settings and (b) compare perspectives about these factors across roles (health care administrators, physician and nonphysician clinicians, and administrative staff).
METHODS/APPROACH: We conducted semistructured interviews with 24 health care administrators, physician and nonphysician primary care providers, and administrative staff representing 10 primary care practices affiliated with one integrated delivery system.
RESULTS
Participants across all roles identified similar organizational- and team-level factors that influence QI implementation including organizational capacity to take on new initiatives (e.g., time availability of physicians), technical capability for QI (e.g., data analysis skills), and team climate (e.g., how well staff work together). There was greater variation in terms of individual-level factors, particularly perceived meaning and purpose of QI. Perceptions about value of QI ranged from positive impacts on patient care and practice competitiveness to decreased efficiency and distractions from patient care, but differences did not appear attributable to role.
CONCLUSIONS
Successful QI implementation requires effective collaboration within cross-functional teams. Additional research is needed to assess how best to employ implementation strategies that promote cross-understanding of QI among team members and, ultimately, effective implementation of QI programs.
PRACTICE IMPLICATIONS
Health care managers in primary care settings should strive to create a strong teamwork climate, reinforced by opportunities for staff in various roles to discuss QI as a collective.
背景
最近对基于价值的医疗保健的重视强调了在初级保健环境中提高质量（QI）的重要性。QI 工作需要提供者和工作人员在跨职能团队中工作，其实施可能会取得不同程度的成功，实施受到组织、团队和个人层面因素的影响。
目的
我们研究的目的是：(a) 确定影响初级保健环境中 QI 干预措施实施效果的背景因素（组织、团队和个人）；(b) 比较不同角色（医疗保健管理人员、医师和非医师临床医生以及行政人员）对这些因素的看法。
方法/方法：我们对 10 个与一个综合交付系统相关的初级保健实践中代表 24 名医疗保健管理人员、医师和非医师初级保健提供者以及行政人员进行了半结构化访谈。
结果
所有角色的参与者都确定了影响 QI 实施的类似组织和团队层面的因素，包括组织承担新举措的能力（例如，医生的时间可用性）、QI 的技术能力（例如，数据分析技能）和团队氛围（例如，员工之间的合作程度）。在个人层面的因素方面存在更大的差异，特别是对 QI 的感知意义和目的。对 QI 的价值的看法从对患者护理和实践竞争力的积极影响到降低效率和分散患者护理注意力不等，但差异似乎不是归因于角色。
结论
成功的 QI 实施需要跨职能团队的有效协作。需要进一步研究如何最好地采用实施策略，以促进团队成员之间对 QI 的交叉理解，并最终有效实施 QI 计划。
实践意义
初级保健环境中的医疗保健管理人员应努力营造强烈的团队合作氛围，并为不同角色的员工提供机会，共同讨论 QI。
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