Nelson E C, Splaine M E, Batalden P B, Plume S K
Lahey Hitchcock Clinic, Lebanon, New Hampshire 03756-0001, USA.
Ann Intern Med. 1998 Mar 15;128(6):460-6. doi: 10.7326/0003-4819-128-6-199803150-00007.
Clinicians can use data to improve daily clinical practice. This paper offers eight principles for using data to support improvement in busy clinical settings: 1) seek usefulness, not perfection, in the measurement; 2) use a balanced set of process, outcome, and cost measures; 3) keep measurement simple (think big, but start small); 4) use qualitative and quantitative data; 5) write down the operational definitions of measures; 6) measure small, representative samples; 7) build measurement into daily work; and 8) develop a measurement team. The following approaches to using data for improvement are recommended. First, begin with curiosity about outcomes or a need to improve results. Second, try to avoid knee-jerk, obstructive criticism of proposed measurements. Instead, propose solutions that are practical, goal-oriented, and good enough to start with. Third, gather baseline data on a small sample and check the findings. Fourth, try to change and improve the delivery process while gathering data. Fifth, plot results over time and analyze them by using a control chart or other graphical method. Sixth, refine your understanding of variation in processes and outcomes by dividing patients into clinically homogeneous subgroups (stratification) and analyzing the results separately for each subgroup. Finally, make further changes while measuring key outcomes over time. Measurement and improvement are intertwined; it is impossible to make improvements without measurement. Measuring and learning from each patient and using the information gleaned to test improvements can become part of daily medical practice in local settings.
临床医生可以利用数据来改进日常临床实践。本文提供了八项原则，用于在繁忙的临床环境中利用数据来支持改进：1）在测量中追求有用性，而非完美性；2）使用一套平衡的过程、结果和成本指标；3）保持测量简单（从大处着眼，但从小处着手）；4）使用定性和定量数据；5）写下指标的操作定义；6）测量小的、有代表性的样本；7）将测量纳入日常工作；8）组建一个测量团队。建议采用以下利用数据进行改进的方法。首先，从对结果的好奇或改进结果的需求开始。其次，尽量避免对提议的测量进行下意识的、阻碍性的批评。相反，提出切实可行、以目标为导向且足够好的起始解决方案。第三，收集小样本的基线数据并检查结果。第四，在收集数据的同时尝试改变和改进交付过程。第五，随时间绘制结果并使用控制图或其他图形方法进行分析。第六，通过将患者分为临床同质的亚组（分层）并分别分析每个亚组的结果，来完善你对过程和结果变异的理解。最后，在随时间测量关键结果的同时进行进一步的改变。测量和改进是相互交织的；没有测量就不可能进行改进。对每个患者进行测量并从中学习，利用收集到的信息来测试改进措施，可以成为当地日常医疗实践的一部分。
