RESUMEN
BACKGROUND: Understanding the role of relationships health care organizations (HCOs) offers opportunities for shaping health care delivery. When quality is treated as a property arising from the relationships within HCOs, then different contributors of quality can be investigated and more effective strategies for improvement can be developed. METHODS: Data were drawn from four large National Institutes of Health (NIH)-funded studies, and an iterative analytic strategy and a grounded theory approach were used to understand the characteristics of relationships within primary care practices. This multimethod approach amassed rich and comparable data sets in all four studies, which were all aimed at primary care practice improvement. The broad range of data included direct observation of practices during work activities and of patient-clinician interactions, in-depth interviews with physicians and other key staff members, surveys, structured checklists of office environments, and chart reviews. Analyses focused on characteristics of relationships in practices that exhibited a range of success in achieving practice improvement. Complex adaptive systems theory informed these analyses. FINDINGS: Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes. DISCUSSION: Although this model of practice relationships was developed from data collected in primary care practices, which differ from other HCOs in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties.
Asunto(s)
Atención a la Salud/métodos , Relaciones Interprofesionales , Innovación Organizacional , Atención Primaria de Salud/normas , Calidad de la Atención de Salud , Humanos , Modelos Organizacionales , Cultura Organizacional , Atención Primaria de Salud/organización & administración , Estados UnidosRESUMEN
BACKGROUND: Primary care practices would benefit from improved understanding of how to make and sustain fundamental changes in their delivery systems. An improvement collaborative project was conducted in 2005 to not only improve the quality of depression care but help participating practices adopt and adapt more effective change processes to implement improved depression care. In a follow-up to an article on the project's impact in terms of measurable, sustained improvements in depression care, an exploratory qualitative study was conducted to examine primary care practices' adoption of effective change processes. METHODS: Qualitative data were collected from 16 primary care practices participating in the National Depression Management Leadership Initiative's Improving Depression Care project. A multistep process of qualitative analysis was used to identify exemplar practices, and a constant comparative method was applied to identify salient features that influenced adoption of change processes associated with improvements in depression care during the course of the 18-month project. RESULTS: The participating practices showed considerable variability in terms of the improvements they made in depression care and corresponding adoption of change processes to help make these and other improvements. Nearly all practices that showed the greatest improvements in depression care also adopted more effective processes for change, with several features associated with exemplar practices able to improve depression care and change processes. DISCUSSION: These findings support the thesis that successful quality improvement efforts should address both clinical content and change processes. They also add to the literature on the impact of improvement collaborative projects, which to date have demonstrated mixed effects in a variety of chronic diseases, including depression.