Lockwood Alistair Martin, Proulx Joshua, Hill Matthew, Pendray Joanna
St Austell Healthcare, St Austell, Cornwall, UK
Safe and Reliable Healthcare, Evergreen, Colorado, USA.
BMJ Open Qual. 2020 Mar;9(1). doi: 10.1136/bmjoq-2019-000860.
The rapid merger in a crisis of three GP practices to incorporate the patients from a neighbouring closing surgery, led to the redesign of primary care provision. A deliberate focus on patient safety and staff engagement was maintained throughout this challenging transition to working at scale in an innovative, integrated and collaborative GP model.
3 cycles of a staff culture tool (Safety, Communication, Organizational Reliability, Physician & Employee burn-out and Engagement) were performed at intervals of 9-12 months with structured feedback and engagement with staff after each round. The impact of different styles of feedback, the effect of specific interventions, and overall changes in safety climate and culture domains were observed in detail throughout this time period.
Strong themes demonstrated were that: there was a general improvement in all culture domains; specific focus on teams that expressed they were struggling created the most effective outcomes; an initial lack of trust of the management structure improved; adapting and tailoring the styles of feedback was most efficacious; and burn-out scores dropped progressively. A unique observation of the rate at which different modalities of safety climate and culture change with time is demonstrated.
With limited time, resources and energy, especially at times of crisis or change, the rapid and accurate identification of which domains of 'culture' and which teams required the most input at each stage of the journey is invaluable. Using this tool and prioritising patient safety, enables rapid and effective positive change to the culture and shape of expanding practices. It affirms that new models of working at scale in GP can be positively embraced with improvements in safety culture, if this is deliberately focused on and included in the transition process.
在一场危机中，三家全科医生诊所迅速合并，接纳了邻近一家即将关闭诊所的患者，这导致了初级医疗服务的重新设计。在向创新、整合与协作的大规模全科医生模式转变的这一具有挑战性的过程中，始终刻意关注患者安全和员工参与度。
每隔9至12个月进行三轮员工文化工具（安全、沟通、组织可靠性、医生与员工倦怠及参与度）评估，并在每轮之后进行结构化反馈并与员工互动。在此期间，详细观察了不同反馈方式的影响、特定干预措施的效果以及安全氛围和文化领域的总体变化。
展现出的强烈主题包括：所有文化领域普遍有所改善；对表示存在困难的团队给予特别关注产生了最有效的结果；对管理结构最初的不信任有所改善；调整和定制反馈方式最为有效；倦怠得分逐渐下降。展示了安全氛围和文化的不同模式随时间变化的独特速率。
在时间、资源和精力有限的情况下，尤其是在危机或变革时期，快速准确地确定在每个阶段“文化”的哪些领域以及哪些团队需要最多投入非常宝贵。使用此工具并将患者安全置于优先地位，能够迅速有效地对不断扩大的诊所的文化和形态产生积极改变。这证实了，如果在转型过程中刻意关注并纳入安全文化的改进，全科医生大规模工作的新模式能够得到积极接受。
