National Committee for Quality Assurance, Washington, DC.
From the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health.
J Patient Saf. 2022 Jan 1;18(1):e249-e256. doi: 10.1097/PTS.0000000000000752.
The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture.
This was a cross-case analysis study in 25 diverse U.S. PCMHs. Data sources included interviews of a clinician and an administrator in each PCMH, surveys of clinicians and staff, and existing data on the PCMHs' characteristics. We used coincidence analysis, a novel method based on set theory and Boolean logic, to evaluate relationships between factors and the implementation outcome of patient safety culture.
The coincidence analysis identified 5 equally parsimonious solutions (4 factors), accounting for all practices with higher safety culture. Three solutions contained the same core minimally sufficient condition: the implementation factor leadership priority for patient safety and the social network factor reciprocity in advice-seeking network ties (advice-seeking relationships). This minimally sufficient condition had the highest coverage (5/7 practices scoring higher on the outcome) and best performance across solutions; all included leadership priority for patient safety. Other key factors included self-efficacy and job satisfaction and quality improvement climate. The most common factor whose absence was associated with the outcome was a well-functioning process for behavioral health.
Our findings suggest that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists. Interventions to improve patient safety should consider measuring and addressing these key factors.
以患者为中心的医疗之家（PCMH）可能为门诊患者安全提供一个关键模型。我们的目的是探讨哪些 PCMH 和患者安全实施及社会网络因素对于提高患者安全文化是必要或充分的。
这是一项针对 25 个不同的美国 PCMH 的跨案例分析研究。数据来源包括每个 PCMH 中一名临床医生和一名管理人员的访谈、临床医生和员工的调查以及 PCMH 特征的现有数据。我们使用一致性分析，一种基于集合理论和布尔逻辑的新方法，评估因素与患者安全文化实施结果之间的关系。
一致性分析确定了 5 个同样简约的解决方案（4 个因素），涵盖了所有具有较高安全文化的实践。3 个解决方案包含相同的核心最小充分条件：领导对患者安全的重视和寻求建议网络关系中的互惠（寻求建议关系）。这个最小充分条件的覆盖率最高（5/7 个实践在结果上得分更高），并且在所有解决方案中表现最好；所有方案都包含对患者安全的领导重视。其他关键因素包括自我效能、工作满意度和质量改进氛围。最常见的缺失因素与结果相关的是行为健康的良好运作流程。
我们的发现表明，当临床医生和员工认为领导重视患者安全并且员工之间存在高度互惠时，PCMH 的安全文化水平更高。改善患者安全的干预措施应考虑衡量和解决这些关键因素。
