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【质量改善】剖析权威指南--教你怎样写出卓越的质量改善研究报告!(下)

 

编者按:在上一期,我们分享了质量改善报告 SQUIRE 指南中关于标题、摘要及前言的写作规范。今天将辅以实例,继续解读如何撰写质量改善报告的方法、结果、讨论及结论部分。

 

l  研究方法:表明研究中做了什么及怎样做

 

1.    研究环境

 

通过介绍研究环境,可以帮助读者理解此干预措施是否适用于本地。

 

2.    干预措施

 

a. 需要详细描述干预措施的细节以供他人参考;

 

b. 阐述参与研究团队的详细情况。

 

3.    对干预效果的评估

 

a. 阐明用于评估干预效果的方法; 

 

b. 提出验证「临床结局改变是由干预措施而引起「的评估方法。作者应表明该评估是由自己还是由外部团队来执行,以及作者与评估者之间的关系。

 

示范如下:

 

The nonparametric Wilcoxon-Mann-Whitney test was used to determine differences in OR use among Radboud UMC [University Medical Centre] and the six control UMCs together as a group. To measure the influence of the implementation of new regulations about cross functional teams in May 2012 in Radboud UMC, a [quasi-experimental] time-series design was applied and multiple time periods before and after this intervention were evaluated.

 

4.    评估指标

 

a. 为研究干预的过程和结局选择评估指标,包括选择此评估指标的基本原理,操作方法及其可靠性和有效性;

 

b. 评估环境因素对质量改善项目的影响;

 

c. 评估数据完整性及准确性的方法。

 

5.    统计方法

 

6.    道德伦理考量

 

l  研究结果:阐述研究中的具体发现

 

1.    干预的进展与评估指标的具体内容

 

a. 描述干预措施的初始步骤及随时间进展而调整的情况(如时间图表、流程图或表),包括项目中对干预措施的修改;

 

b. 评估指标的具体内容及结局。

 

示范如下:

 

Over the course of this initiative, 479 patient encounters that met criteria took place. TTA[Time to antibiotic] delivery was tracked, and the percentage of patients receiving antibiotics within 60 minutes of arrival increased from 63% to 99% after 8 months, exceeding our goal of 90% [figure1]…
Key improvement areas and specific interventions for the initiative are listed in [figure 2]. During phase I, the existing processes for identifying and managing febrile patients with central lines were mapped and analyzed. Key interventions that were tested …
In phase II, strategies focused on improving performance by providing data and other information for learning, using a monthly newsletter, public sharing of aggregate compliance data tracking…
In phase III, a management guideline with key decision elements was developed and implemented [figure 3]. A new patient identification and initial management
process was designed based on the steps, weaknesses, and challenges identified in the existing process map developed in phase I. This process benefited from feedback from frontline ED staff and the results of multiple PDSA cycles during phases I and II….
During the sustainability phase, data continued to be collected and reported to monitor ongoing performance and detect any performance declines should they…

 

 

 

2.    环境因素与非预期结果

 

3.    数据缺失

 

l  研究讨论:说明质量改善项目的意义

 

1.    总结

 

a. 此研究最关键的发现,包括相关的基本原理和指定的研究目标;

 

b. 此项目独特的优势。

 

示范如下:

 

In our 6-year experience with family-activated METs [Medical Emergency Teams], families uncommonly activated METs. In the most recent and highest-volume year, families called 2.3 times per month on average. As a way of comparison, the hospital hadan average of 8.7 accidental code team activations per month over this time. This required an urgent response from the larger team. Family activation less commonly resulted in ICU transfer than clinician activated METs, although 24% of calls did result in transfers. This represents a subset of deteriorating patients that the clinical team may have missed. In both family-activated and clinician-activated MET calls, clinical deterioration was a common cause of METcalls. Families more consistently identified their fear that the child’s safety was at risk, a lack of response from the clinical team, and that the interaction between team and family had become dismissive. To our knowledge, this study is the largest study of family-activated METs to date, both in terms of count of calls and length of time observed. It is also the first to compare reasons for MET calls from families with matched clinician-activated calls.

 

2.    解释

 

a. 表明干预措施与其结果的相关性;

 

b. 与其他已发表的类似研究结果的对比;

 

c. 此研究项目对人或者系统产生的影响;

 

d. 预期结果与实际结果存在差异的原因,包括环境所带来的影响;

 

e. 此研究的成本以及战略权衡,包括机会成本。

 

示范如下:

 

a. After QI interventions, the percentage of patients attending four or more clinic visits significantly improved, and in 2012 we met our goal of 90% of patients attending four or more times a year. A systematic approach to scheduling processes, timely rescheduling of patients who missed appointments and monitoring of attendance resulted in a significant increase in the number of patients who met the CFF national recommendation of four or more visits per year.
b. Although the increase in the percentage of patients with greater than 25th centile for BMI/W-L from 80% to 82% might seem small, it represents a positive impact on a few more patients and provides more opportunities for improvement. Our data are in agreement with Johnson et al. (2003), who reported that frequent monitoring among other interventions made possible due to patients being seen more in clinic was associated with improved outcomes in CF.
c. We learned that families are eager to have input and be involved…participation in the [learning and leadership collaborative] resulted in a positive culture change at the ACH CF Care Center regarding the use of QI methods.
d. We noticed our clinic attendance started to improve before the [intervention] processes were fully implemented. We speculate this was due to the heightened awareness of our efforts by patients, families and our CF team.
e. Replication of these processes could be hindered by lack of personnel, lack of buy-in by the hospital administration and lack of patient/family involvement….barriers to attendance included rising fuel costs, transportation limitations, child care issues, missed work-days by caregivers and average lowincome population.

 

3.    局限性

 

a. 表明此实验在适应性上的局限;

 

b. 说明此研究内部因素,包括设计的混杂因素、偏倚或误差、研究方法,测量方法及分析方法所导致的局限性;

 

c. 表明为将局限性最小化所做的努力及调整。

 

4.    结论

 

a. 此次研究的有效性;

 

b. 此研究的持续性;

 

c. 对其他研究存在的潜在影响;

 

d. 对相关领域的实践和进一步研究的启示;

 

e. 对下一步研究的建议。

 

在过去的 20 年间,质量改善领域迅速发展,通过对最新版 SQUIRE 2.0 的解读,希望能加深大家对质量改善研究的认识,掌握质量改善报告写作的要点;促使更多的质量改善方法被交流、分享,从而推进循证证据在临床的应用。

 

【参考文献】

 

Goodman D, Ogrinc G, Davies L, et al. BMJ Qual Saf 2016,25(12):e

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