Gerrish Kate, Keen Carol, Palfreyman Judith
Emeritus Professor of Nursing, School of Nursing and Midwifery, University of Sheffield, Sheffield, UK.
Lead Therapist, Pulmonary Vascular Diseases Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
Prim Health Care Res Dev. 2018 Aug 23;20:e62. doi: 10.1017/S1463423618000567.
To identify learning from a clinical microsystems (CMS) quality improvement initiative to develop a more integrated service across a falls care pathway spanning community and hospital services.
Falls present a major challenge to healthcare providers internationally as populations age. A review of the falls care pathway in Sheffield, United Kingdom, identified that pathway implementation was constrained by inconsistent co-ordination and integration at the hospital-community interface.
The initiative utilised the CMS quality improvement approach and comprised three phases. Phase 1 focussed on developing a climate for change through engaging stakeholders across the existing pathway and coaching frontline teams operating as microsystems in quality improvement. Phase 2 involved initiating change by working at the mesosystem level to identify priorities for improvement and undertake tests of change. Phase 3 engaged decision makers at the macrosystem level from across the wider pathway in achieving change identified in earlier phases of the initiative.
The initiative was successful in delivering change in relation to key aspects of the pathway, engaging frontline staff and decision makers from different services within the pathway, and in building quality improvement capability within the workforce. Viewing the pathway as a series of interrelated CMS enabled stakeholders to understand the complex nature of the pathway and to target key areas for change. Particular challenges encountered arose from organisational reconfiguration and cross-boundary working.
CMS quality improvement methodology may be a useful approach to promoting integration across a care pathway. Using a CMS approach contributed towards clinical and professional integration of some aspects of the service. Recognition of the pathway operating at meso- and macrosystem levels fostered wider stakeholder engagement with the potential of improving integration of care across a range of health and care providers involved in the pathway.
通过一项临床微系统（CMS）质量改进计划来学习经验，以在涵盖社区和医院服务的跌倒护理路径中开发更综合的服务。
随着人口老龄化，跌倒对全球医疗服务提供者构成重大挑战。对英国谢菲尔德市跌倒护理路径的一项审查发现，该路径的实施受到医院与社区接口处协调和整合不一致的限制。
该计划采用了CMS质量改进方法，包括三个阶段。第一阶段专注于通过让现有路径中的利益相关者参与并指导作为微系统运作的一线团队进行质量改进，来营造变革氛围。第二阶段通过在中观系统层面开展工作来启动变革，以确定改进重点并进行变革测试。第三阶段让来自更广泛路径的宏观系统层面的决策者参与进来，以实现该计划早期阶段确定的变革。
该计划成功地在路径的关键方面带来了变革，让路径内不同服务的一线工作人员和决策者参与进来，并在员工队伍中建立了质量改进能力。将路径视为一系列相互关联的CMS，使利益相关者能够理解路径的复杂性质，并确定关键变革领域。遇到的特殊挑战来自组织重组和跨界合作。
CMS质量改进方法可能是促进护理路径整合的有用方法。采用CMS方法有助于实现服务某些方面的临床和专业整合。认识到路径在中观和宏观系统层面的运作，促进了更广泛的利益相关者参与，有可能改善参与该路径的一系列健康和护理提供者之间的护理整合。
