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Learning from implementation setbacks: Identifying and responding to contextual challenges

机译：从实施过程中的挫折中吸取教训：识别和应对环境挑战

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Introduction We address organizational learning about implementation context during setbacks to primary care redesign in an ambulatory system. The redesign expanded care teams and added a medical assistant assigned administrative and coordination tasks. The redesign was expected to improve care efficiency, prevention, and continuity. In response to setbacks, redesign and system leaders used understanding of context to plan system‐wide changes, as well as program adjustments. Doing so enhanced the redesign's prospects and contributed to system learning. Methods We conducted a 33‐month, mixed‐methods study. Qualitative data included quarterly calls with the redesign leaders and 63 activity log entries. There were three site visits; 73 interviews with practice leaders, providers, and medical assistants. Data analysis used categories from an implementation research framework; these were refined and then expanded inductively using log reports, debriefings with change leaders, and documents. Quantitative analysis used system operational data on chronic care, prevention, efficiency, productivity, and patient access. Results Redesigned teams were not implemented as widely or rapidly as anticipated and did not deliver hoped‐for gains in operational metrics. Interviews reported that team redesign was leading to improvements in chronic care and prevention and eased provider burden. Besides making small adjustments to cope with setbacks, redesign and system leaders engaged in more thorough organizational learning. They examined contextual challenges underlying setbacks and posing risks to the delivery system as a whole. Their responses to challenges helped strengthen the redesign's prospects, improved the delivery system's position in its labor market, and helped the system prepare to meet emerging requirements for value‐based care and population health. Conclusions This case points to benefits for both health care researchers and change practitioners of paying closer attention to how context affects implementation of organizational change, and to opportunities and conditions for learning from setbacks during change.
机译：简介我们介绍了在门诊系统对基础医疗重新设计的挫折过程中，组织对实施环境的了解。重新设计扩大了护理团队，并增加了分配管理和协调任务的医疗助理。重新设计有望提高护理效率，预防和连续性。为了应对挫折，重新设计和系统负责人使用对上下文的理解来计划系统范围的更改以及程序调整。这样做可以提高重新设计的前景，并有助于系统学习。方法我们进行了为期33个月的混合方法研究。定性数据包括与重新设计负责人进行的季度电话会议和63条活动日志条目。进行了三次现场访问;对业务负责人，提供者和医疗助手的73次采访。数据分析使用了实施研究框架中的类别;这些都经过了完善，然后使用日志报告，与变更负责人的汇报和文档进行归纳扩展。定量分析使用了有关慢性护理，预防，效率，生产力和患者就诊的系统操作数据。结果重新设计的团队没有像预期的那样广泛或快速地实施，也没有带来希望的运营指标收益。采访报道说，团队的重新设计正在改善慢性病的预防和预防并减轻提供者的负担。除了进行一些小的调整以应对挫折之外，重新设计和系统负责人还需要进行更彻底的组织学习。他们研究了挫折背后的背景挑战，并对整个交付系统构成了风险。他们对挑战的反应有助于加强重新设计的前景，改善了交付系统在劳动力市场中的地位，并帮助系统为满足基于价值的护理和人口健康的新要求做好了准备。结论该案例为医疗保健研究人员和变革从业人员带来了好处，他们可以更加关注环境如何影响组织变革的实施，以及变革期间从挫折中学习的机会和条件。

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