Ford James H, Nora Anna T, Crnich Christopher J
Social and Administrative Sciences Division, University of Wisconsin School of Pharmacy, Madison, WI, USA.
William S. Middleton VA Hospital, Madison, WI, USA.
Implement Sci Commun. 2023 Dec 12;4(1):156. doi: 10.1186/s43058-023-00535-y.
Implementation evaluations based on a hybrid deductive-inductive approach provide a detailed understanding of organizational choices to introduce and implement complex interventions and may help explain implementation success or failure. However, such evaluations may not be feasible due to resource constraints. Qualitative analyses of artifacts collected for other purposes during implementation may represent a cost-effective method to understand program implementation when robust evaluations are not feasible. This study used a work systems evaluation of how nursing homes (NHs) implemented a urinary tract infection (UTI) recognition and management improvement toolkit.
Thirty NHs participated in a randomized control trial in which intervention NHs (n = 12) were assigned a clinical coach who employed a standard template to structure coach calls with the NH champion. A hybrid inductive-deductive approach, using the Systems Engineering Initiative for Patient Safety (SEIPS) model, characterized three action domains related to (1) engagement of staff and providers, (2) distribution of toolkit elements, and (3) toolkit use.
A total of 369 coded segments from 148 coach notes generated by three coaches working with 18 NH champions were examined. Planned changes (n = 203) were more frequent compared to actual changes (n = 169). While most NHs quickly engaged staff and providers, which leadership appeared to support, engagement actions were hindered in some NHs due to champion instability or extended champion or medical director absences. Dissemination of materials to family and providers and distribution of tools to staff occurred quickly in 75% of NHs, although delays were encountered in some NHs, usually because of champion instability.
Implementing NH practice change is challenging, and studies examining actions to support planned versus actual change in this setting are limited. The application of the SEIPS model to coach notes collected during the implementation of a structured behavioral intervention to improve the recognition and management of UTI in NHs generated unique insights into the work system and how staff attempted to implement changes. This study identified several factors that interfered with progression from planning to actual change. Future studies are needed to better understand how to best support change interventions in NHs.
ClinicalTrials.gov, NCT03520010 , Registered May 9, 2018.
基于混合演绎-归纳法的实施评估能够详细了解引入和实施复杂干预措施时的组织选择，并有助于解释实施的成功或失败。然而，由于资源限制，此类评估可能不可行。在实施过程中对为其他目的收集的工件进行定性分析，可能是在无法进行有力评估时了解项目实施情况的一种经济有效的方法。本研究采用工作系统评估方法，研究养老院如何实施尿路感染（UTI）识别与管理改进工具包。
30家养老院参与了一项随机对照试验，其中干预组养老院（n = 12）被分配了一名临床教练，该教练使用标准模板与养老院负责人进行指导通话。采用混合归纳-演绎法，运用患者安全系统工程倡议（SEIPS）模型，对与以下三个方面相关的行动领域进行了特征描述：（1）工作人员和提供者的参与；（2）工具包要素的分发；（3）工具包的使用。
对三名教练与18名养老院负责人合作生成的148份指导记录中的369个编码片段进行了检查。计划中的变更（n = 203）比实际变更（n = 169）更为频繁。虽然大多数养老院迅速让工作人员和提供者参与进来，且似乎得到了领导层的支持，但在一些养老院，由于负责人不稳定或负责人或医疗主任长期缺席，参与行动受到了阻碍。75%的养老院迅速向家属和提供者分发了材料，并向工作人员分发了工具，不过一些养老院出现了延迟，通常是因为负责人不稳定。
实施养老院实践变革具有挑战性，在这种背景下，研究支持计划变革与实际变革的行动的研究有限。将SEIPS模型应用于在实施结构化行为干预以改善养老院尿路感染识别与管理过程中收集的指导记录，对工作系统以及工作人员如何尝试实施变革产生了独特的见解。本研究确定了几个妨碍从计划变革向实际变革推进的因素。未来需要开展更多研究，以更好地了解如何最好地支持养老院的变革干预措施。
ClinicalTrials.gov，NCT03520010，2018年5月9日注册。
