Primary Care and Public Health, Imperial College London, London, UK.
NIHR ARC Northwest London, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK.
BMJ Qual Saf. 2022 Jan;31(1):31-44. doi: 10.1136/bmjqs-2020-012367. Epub 2021 May 14.
Advancing the description and conceptualisation of interventions in complex systems is necessary to support spread, evaluation, attribution and reproducibility. Improvement teams can provide unique insight into how interventions are operationalised in practice. Capturing this 'insider knowledge' has the potential to enhance intervention descriptions.
This exploratory study investigated the spread of a comprehensive medication review (CMR) intervention to (1) describe the work required from the improvement team perspective, (2) identify what stays the same and what changes between the different sites and why, and (3) critically appraise the 'hard core' and 'soft periphery' (HC/SP) construct as a way of conceptualising interventions.
A prospective case study of a CMR initiative across five sites. Data collection included: observations, document analysis and semistructured interviews. A facilitated workshop triangulated findings and measured perceived effort invested in activities. A qualitative database was developed to conduct thematic analysis.
Sites identified 16 intervention components. All were considered essential due to their interdependency. The function of components remained the same, but adaptations were made between and within sites. Components were categorised under four 'spheres of operation': Accessibility of evidence base; Process of enactment; Dependent processes and Dependent sociocultural issues. Participants reported most effort was invested on 'dependent sociocultural issues'. None of the existing HC/SP definitions fit well with the empirical data, with inconsistent classifications of components as HC or SP.
This study advances the conceptualisation of interventions by explicitly considering how evidence-based practices are operationalised in complex systems. We propose a new conceptualisation of 'interventions-in-systems' which describes intervention components in relation to their: proximity to the evidence base; component interdependence; component function; component adaptation and effort.
为了支持传播、评估、归因和再现，有必要推进对复杂系统中干预措施的描述和概念化。改进团队可以提供干预措施在实践中如何运作的独特见解。捕捉这种“内幕知识”有可能增强干预措施的描述。
这项探索性研究调查了一项全面药物审查（CMR）干预措施的传播情况：（1）从改进团队的角度描述所需的工作，（2）确定不同地点之间相同和不同的内容以及原因，（3）批判性地评估“核心要素”和“软周边”（HC/SP）构建作为概念化干预措施的一种方式。
对五个地点的 CMR 计划进行前瞻性案例研究。数据收集包括：观察、文件分析和半结构化访谈。一个促进研讨会对调查结果进行了三角测量，并衡量了在活动中投入的感知努力。开发了一个定性数据库来进行主题分析。
各站点确定了 16 个干预组件。由于它们的相互依存关系，所有这些组件都被认为是必不可少的。组件的功能保持不变，但在站点之间和内部进行了调整。组件被归类为四个“操作领域”：证据基础的可及性；实施过程；依赖过程和依赖社会文化问题。参与者报告说，大部分投入都用于“依赖社会文化问题”。现有的 HC/SP 定义都没有很好地适应实证数据，对组件的 HC 或 SP 分类不一致。
这项研究通过明确考虑如何在复杂系统中实施基于证据的实践，推进了干预措施的概念化。我们提出了一种新的“系统中的干预措施”概念化，该概念化描述了干预措施组件与以下方面的关系：与证据基础的接近程度；组件的相互依存关系；组件的功能；组件的适应性和投入的努力。
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