HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.
Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA.
Implement Sci. 2020 Mar 18;15(1):18. doi: 10.1186/s13012-020-0979-y.
Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants' fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity.
Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010-2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis.
Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity.
This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.
有效的实施策略可能通过针对变革的障碍来促进以患者为中心的医疗之家（PCMH）的采用和传播。基于临床研究人员合作的循证质量改进（EBQI）是一种多方面的实施策略。它通过促进创新和成功创新的传播来促进组织变革。先前的研究表明，与标准 PCMH 实施相比，EBQI 加速了退伍军人健康管理局初级保健实践中 PCMH 的采用。迄今为止，研究尚未记录对 EBQI 实施策略的保真度，限制了先前研究结果的有用性。本文为 PCMH 的三个核心 EBQI 要素（EBQI-PCMH）制定并评估临床参与者的保真度，探讨保真度与成功的 QI 项目完成和传播（EBQI-PCMH 的结果）之间的关系，并评估临床研究人员合作在实现 EBQI-PCMH 保真度方面的作用。
2010-2014 年，九家初级保健实践地点和七家跨地点、专题重点工作组参与了研究（n=9）。核心 EBQI 要素包括为 QI 设定领导层一线优先级、持续获得技术专长、通过 QI 合作提供 QI 方法的辅导和指导，以及使用数据/证据为 QI 提供信息。我们使用明确的标准来衡量和评估临床参与者的 EBQI-PCMH 保真度。我们将保真度映射到关于成功的 QI 项目/产品的实施和传播的评估数据上。为了评估临床研究人员合作在 EBQI-PCMH 中的作用，我们使用主题分析对 73 个关键利益相关者的访谈进行了分析。
9 个地点中有 7 个和 7 个工作组中的 3 个达到了领导力一线设定优先级的高或中保真度。持续的技术专长和数据/证据使用的保真度参差不齐。在 EBQI-PCMH 中持续时间较长且对优先级设定和持续技术专长的保真度较高与成功的 QI 项目完成和传播相关。根据关键利益相关者的说法，与研究人员的合作以及领导者与 QI 团队以及项目管理/数据支持之间的双向沟通对于实现 EBQI-PCMH 的保真度至关重要。
本研究通过开发针对核心 EBQI 要素的度量标准并评估其与 QI 创新项目或解决 PCMH 挑战的工具的完成和传播之间的关系，推进了实施理论和研究。这些结果有助于缩小 EBQI 要素与其预期结果之间的差距，并发现 EBQI-PCMH 加速了 PCMH 的采用。
