Zazove P, Klinkman M S
University of Michigan Health Systems, Ann Arbor 48103, USA.
Jt Comm J Qual Improv. 1998 Aug;24(8):391-406. doi: 10.1016/s1070-3241(16)30390-x.
Efforts to implement continuous quality improvement (CQI) principles in ambulatory or primary care settings still lag behind efforts in the hospital setting. Many physicians view the concept of CQI with unconcealed skepticism; the process of ambulatory care is very different from that of hospital-based care; and the data necessary to guide CQI efforts are often either missing or inaccurate in the outpatient setting. Since fall 1995, the Department of Family Medicine (DFM) at the University of Michigan (Ann Arbor), including approximately 35 faculty members at seven family practice sites, has been engaged in CQI projects.
The CQI committee had a six-month deadline to lay out a plan for educating all faculty and staff in the importance of the CQI approach to problems; design methods for all faculty and staff to buy in to the concepts; and develop a plan to address basic clinical CQI activities, administrative systems change and work environment improvement, and larger ad hoc projects in clinical care, educational programs, and research programs.
CQI activities were incorporated into the routine monthly business agendas at each clinical site, each of which had a functioning local committee and had begun development of at least one CQI project.
Cost cutting has further moved CQI from the sideline to center stage in the DFM's activities. An effective CQI program can be a major asset in the current competitive health care market, but designing and implementing an outpatient CQI program is a difficult and complex process. Three major problems--the ongoing resistance to change, the slow pace of adding CQI projects to already overburdened work schedules, and the need to conduct the program with ever-decreasing resources available-persist.
在门诊或初级保健机构中实施持续质量改进（CQI）原则的工作仍落后于医院环境中的努力。许多医生对CQI的概念持毫不掩饰的怀疑态度；门诊护理过程与医院护理过程有很大不同；而且在门诊环境中，指导CQI工作所需的数据往往缺失或不准确。自1995年秋季以来，密歇根大学（安娜堡）家庭医学系（DFM），包括七个家庭医疗点的约35名教员，一直参与CQI项目。
CQI委员会有六个月的期限来制定一项计划，以教育所有教职员工认识CQI方法对解决问题的重要性；设计让所有教职员工接受这些概念的方法；并制定一项计划，以解决基本的临床CQI活动、行政系统变革和工作环境改善，以及临床护理、教育项目和研究项目中的大型特别项目。
CQI活动被纳入每个临床点的每月常规业务议程，每个临床点都有一个运作的当地委员会，并已开始开展至少一个CQI项目。
成本削减进一步将CQI从边缘推向了DFM活动的中心舞台。一个有效的CQI项目在当前竞争激烈的医疗保健市场中可能是一项重要资产，但设计和实施门诊CQI项目是一个困难而复杂的过程。三个主要问题仍然存在——对变革的持续抵制、在已经负担过重的工作时间表中增加CQI项目的速度缓慢，以及需要在可用资源不断减少的情况下开展该项目。
