Ginsburg Liane, Easterbrook Adam, Berta Whitney, Norton Peter, Doupe Malcolm, Knopp-Sihota Jennifer, Anderson Ruth A, Wagg Adrian
Jt Comm J Qual Patient Saf. 2018 Sep;44(9):526-535. doi: 10.1016/j.jcjq.2018.04.009. Epub 2018 Jul 7.
Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker-led QI program was implemented in nursing homes.
Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants-35 health care aides, health professionals, and managers.
Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program.
Health care aide-led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation.
尽管出现了质量改进（QI）实施框架，但对于实施过程如何运作知之甚少，尤其是在养老院环境中。本研究旨在描述一个复杂的由一线工作人员主导的QI项目在养老院中的“实施方式”。
2017年2月，对加拿大曼尼托巴省七家养老院参加为期一年的多组件单元级QI干预的参与者进行了六次焦点小组访谈。采用持续比较分析法，考察QI项目不同参与者群体（35名医疗护理员、卫生专业人员和管理人员）的观点。
确定了对实施过程至关重要的五个主题：（1）“QI项目结构的支持要素”，（2）“应对工作场所”，（3）“协商人际关系”，（4）“培养个人技能”，以及（5）“可观察到的项目影响”。主题整合数据表明，“QI项目结构的支持要素”（主题1）、“培养个人技能”（主题4）和“可观察到的项目影响”（对居民、医疗护理员和领导者而言；主题5）作为强化反馈回路的一部分发挥作用，增强了团队成员应对工作场所、协商人际关系和实施QI项目的能力。
由医疗护理员主导的QI团队是可行的。然而，存在一种领导悖论，即由工作人员主导的QI项目还必须纳入具体机制，以促进强有力的领导并获得赞助方对团队的支持。研究结果还指出，医疗护理员与专业人员之间人际关系对QI实施的影响尚未得到充分探索。
