Long Janet C, Winata Teresa, Debono Deborah, Phan-Thien Kim-Chi, Zhu Christine, Taylor Natalie
Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia.
Centre for Health Services Management, Faculty of Health, University of Technology, Sydney, NSW, 2007, Australia.
BMC Health Serv Res. 2019 Mar 20;19(1):180. doi: 10.1186/s12913-019-3985-5.
This retrospective process evaluation reports on the application of a 1-year implementation program to increase identification and management of patients at high risk of a hereditary cancer syndrome. The project used the Theoretical Domains Framework Implementation (TDFI) approach, a promising implementation methodology, used successfully in the United Kingdom to address patient safety issues. This Australian project run at two large public hospitals aimed to increase referrals of patients flagged as being at risk of Lynch syndrome on the basis of a screening test to genetic services. At the end of the project, the pathologists' processes had changed, but the referral rate remained inconsistent and low.
Semi-structured interviews explored participants' perceptions of the TDFI approach and Health services researchers wrote structured reflections. Interview transcripts and reflections were coded initially against implementation outcomes for the various TDFI approach activities: acceptability, appropriateness, feasibility, value for time cost, and adoption. On a second pass, themes were coded around challenges to the approach.
Interviews were held with nine key project participants including pathologists, oncologists, surgeons, genetic counsellors and an administrative officer. Two health services researchers wrote structured reflections. The first of two major themes was 'Theory-related challenges', with subthemes of accessibility of theory underpinning the TDFI, commitment to that theory-based approach, and the problem of complexity. The second theme was 'Practical challenges' with subthemes of stakeholder management, navigating the system, and perceptions of the problem. Health services researchers reflected on the benefits of bridging professional divides and facilitating collective learning and problem solving, but noted frustrations around clinicians' time constraints that led to sparse interactions with the team, and lack of authority to effect change themselves.
Mixed success of adoption as an outcome was attributed to the complexity and highly nuanced nature of the setting. This made identifying the target behaviour, a key step in the TDFI approach, challenging. Introduced changes in the screening process led to new, unexpected issues yet to be addressed. Strategies to address challenges are presented, including using an internal facilitator with a focus on applying a theory-based implementation approach.
本回顾性过程评估报告了一项为期一年的实施计划的应用情况，该计划旨在加强对遗传性癌症综合征高危患者的识别和管理。该项目采用了理论领域框架实施（TDFI）方法，这是一种很有前景的实施方法，已在英国成功用于解决患者安全问题。这个澳大利亚项目在两家大型公立医院开展，旨在将基于筛查测试被标记为林奇综合征风险患者的转诊率提高至遗传服务部门。项目结束时，病理学家的流程发生了变化，但转诊率仍然不稳定且较低。
半结构化访谈探讨了参与者对TDFI方法的看法，卫生服务研究人员撰写了结构化反思。访谈记录和反思最初根据TDFI方法各项活动的实施结果进行编码：可接受性、适当性、可行性、时间成本价值和采用情况。在第二轮编码中，围绕该方法面临的挑战确定了主题。
对九名关键项目参与者进行了访谈，包括病理学家、肿瘤学家、外科医生、遗传咨询师和一名行政官员。两名卫生服务研究人员撰写了结构化反思。两个主要主题中的第一个是“与理论相关的挑战”，其分主题包括支撑TDFI的理论的可及性、对该基于理论的方法的承诺以及复杂性问题。第二个主题是“实际挑战”，其分主题包括利益相关者管理、在系统中运作以及对问题的认知。卫生服务研究人员反思了弥合专业分歧以及促进集体学习和解决问题的益处，但也指出了临床医生时间限制带来的挫折感，这导致与团队的互动稀少，以及他们自身缺乏进行变革的权力。
作为一种结果，采用情况喜忧参半，这归因于环境的复杂性和高度细微差别。这使得识别目标行为（TDFI方法的关键步骤）具有挑战性。筛查过程中引入的变化导致了新的、意想不到的问题有待解决。提出了应对挑战的策略，包括使用一名内部促进者，重点是应用基于理论的实施方法。
