Background
Methods
Hospital selection
Hospital | Location | Hospital type & number of beds | RED implementation start and target pop: | Average # discharges annually (2009-2014) |
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A | Suburban/Urban | Military hospital. 205 beds. Fully implemented EMR. | Implemented in June 2012. 100% of patients in general medicine and surgery | 4356 |
B | Suburban | Safety net, community, tertiary care, non-profit. 160 general acute care beds, 14 ICU. Fully implemented EMR. | Implemented in Nov 2012. 100% of patients 18 + in general medicine and surgery | (Acute care only, medical and surgical) 7967 |
C | Urban | Teaching/academic, safety net, community, non-profit. 375 total beds (180 acute care). Partially implemented EMR. | Implemented in 2013. Target pop originally ≥ age 55 for AMI, PNA, COPD patients; then ≥ 18 for patients with CHF, now all adults | 16,905 |
D | Suburban | Safety net, community, non-profit. 217 beds. Fully implemented EMR. | Implemented in Nov 2012. Target patients at highest risk for readmissions. | (Inpatient only) 7856 |
E | Urban | Teaching/academic, community, non-profit. 313 beds. Fully implemented EMR. | Implemented in Sept 2013. All adults. | 12,564 |
Site visit data collection
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▪ To gain insight and impressions on the experience of implementing RED, decisions regarding adaptation of RED components and the impact of these on RED sustainability.
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▪ To directly observe the service delivery to see the discharge process in action and to learn from the staff involved in the implementation and delivery of RED.
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▪ To construct a conceptual model of how contextual factors and adaptation strategies influence/hinder/support sustainable implementation.Table 2Breakdown of interviewed participants across all five participating hospitalsParticipantsNumberSenior Leadership & Hospital Executives:11Clinical RED Implementation Team:22Ex: Doctors, Nurses, PharmacistsNon-Clinical RED Implementation Team:19Ex: Social Workers, Transitions Coordinators, Data Analysts, DieticiansNon-RED Staff:9Community Based Organization Partners:3TOTAL:64
Data analysis
Contextual factor | Strength | Concern |
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RED as a Priority to Leadership | Leadership demonstrated buy-in by making RED an institutional priority. They also showed involvement, and support of RED implementation, and encouraged employees to embrace change, adaptation and creative solutions. | Leadership showed lack of focus on addressing readmissions and failure to commit adequate resources. There was also an absence of leadership involvement in RED implementation, and lack of guidance and direction from management. |
Adaptation and Implementation strategy | Implementation strategy started with a purposeful planning period and careful deliberation on how to best implement RED. Adaptations maintained a high level of fidelity to the intention of the intervention. | Implementation strategy was unplanned, disorganized, and approached RED as a time-limited project. Focused on select elements of the RED toolkit, thereby failing to address critical aspects of the discharge process and inherently changing the possible impact of RED. |
Implementation Team | Leadership selected an implementation team that had depth, was accountable, was multidisciplinary and had a dynamic leader who was able to effect change. Components of the RED toolkit were divided amongst enough individuals to delegate and distribute the workload, and where each person had a distinct role to play. | Implementation team lacked multidisciplinary input and representation; team often lacked the social capital and ability to influence others to be enthusiastic about RED implementation. Components of the RED were assigned in a manner that was burdensome to staff and lacked accountability. |
Planning for Sustainability and Longevity | Forward-thinking planning to approach RED as a transformational process, rather than a project, with clear goals for integration into daily workflow. | Approached RED implementation as a grant-dependent project without consideration for sustainability of RED staff salary support or workflow integration of RED discharge process. |
Hospital Culture | Positive hospital culture that embraced failures, fostered a feeling of empowerment for both employees and patients, and remained patient-centered. Leadership was supportive of implementation team, which promoted the feeling that chance was possible, fostering a spirit of continuous improvement. | Negative hospital culture that lead to employees holding defeatist attitudes towards their patient populations, felt helpless in effecting positive change in their environment, and failed to see discharge as a necessary area for improvement. |
Results
External vs internal contextual factors
External factors
Internal factors
RED as a priority to leadership
“We would not apply…for a program that didn’t align with one of our priorities… we had to be committed to…do it, even if we weren’t funded … we would have to be committed to keep it going.”
“We had [a] previous administration and then [the] new administration came in and their main focus was that the front doors of this hospital will shut down if we don’t fix the financial issues. So, the quickest and easiest way to do that? Lay off a bunch of people… there’s a big struggle between… staffing and finding the money to do [Project RED].”
“[We, the leadership] get into the workplace where the work’s being done … we go see what’s actually going on so that the decisions that we make at a higher level, from that 30,000 foot level, aren’t just these sweeping changes that people are like, ‘Woah, what are you doing?’ We don’t guess. We actually know.”
“When you have leadership at the very top that… is supporting, is rewarding, is acknowledging people… for taking risks. And saying, “A failure is not necessarily bad. It’s just an opportunity to learn.”…I think that creates an environment that people are willing to step outside of their comfort zone to serve a common good and to serve a common mission.”
“Without…direction from management saying, ‘It’s this way. Everybody will do it. This comes first, that comes second’… [Project RED] is not a key, central component of the system… the executive team needs to provide firm direction as to what’s the workflow, what are we trying to accomplish, what are the expectations, and then hold people accountable for whatever that is.”
Adaptation and implementation strategy
“This is your bible. Don’t deviate from it. You can add to it, but as long as you do these core things, you can have latitude to do whatever you want to do’… you can’t do Project RED and do element nine and five and four…You gotta do all twelve elements. You can’t pick and choose.”
“We tried to mirror Boston… but we realized… every hospital’s unique …. [after that] they came up with the transitional care nursing program. And the beauty of it is that we’ve evolved… and if it doesn’t work, we’re like, ‘Ok. Well, we gotta fix it. We gotta change it.’”
“The entire nursing application had to be…redesigned and rebuilt … but then we couldn’t implement [RED] because they had to retrain everybody on how to use the [new] clinical application. So we had a 2-3 month gap [due to] technology delays.”
Implementation team
“We make a very positive impact on the patients that we do see, but when we’re down-staffed to such degree, we see a very small number of patients… so we’re not actually impacting the overall readmission rate for the hospital.”
“makes [Project RED] nobody’s job, ‘cause when it’s everybody’s job, it’s nobody’s job… we did not inherit a hospital that has a culture of accountability…we get to pick and choose… We don’t even know if Project RED is or is not an effective intervention in our environment because we’ve never had all of the pieces in place for any period of time consistently.”
“It’s gotta be multidisciplinary to eliminate the perceived barriers… you have to have the right people at the table and it can’t just be nursing and it can’t just be medicine.”
“To get people to collaborate and for the good of the whole [is challenging] …Physicians are generally pretty autonomously functioning. They don’t like to be told what to do… Especially with regards to… readmission.”
“One of the things that… [we] do when we build the team, anything that touches Project RED, is… make sure we have the right fit for the right position… the element champions… they’re go-getters … they get stuff done.”
Planning for sustainability and longevity
“Don’t start this [RED] off as a project. Start this off as a process that you are going to adhere to forever. You’re going to continue to modify it and improve it, PDSA [plan-do-study-act] it… The standardization of the discharge process is more important than chasing that outcome [lower readmission rates].”
“My goal with Project RED is to have a focused team looking at this process – the twelve criteria … [so that] at the end of this two-year program … this becomes just standard work for all case managers, social workers, bedside nurses, and doctors. So that it’s enculturated.”
“The term Project RED is really kind of getting smaller here…the organization has changed… if you asked a nurse here that’s been here less than a year, ‘Tell me about Project RED, ’ they would not know what it is.”
Hospital culture
“[We] just are very fortune…to have a group of people that are really dedicated to giving really good patient care… and to doing the right thing…we’ve really started a culture of improvement and continuous improvement… Bring [an idea or issue] to this meeting and it gets done…I don’t think we’ve had a single thing yet where somebody’s like “No, we can’t do that” … they’re like “Oh, yeah, no problem. We can do that.” … so definitely hospital culture plays a role in feeling … like you have this professional agency. There’s a good chance that you can do something about it.”
“There’s chemical dependency, alcohol related stuff, there’s chronic abdominal pain, chronic pancreatitis… those people are probably gonna need something different than just Project RED. It ain’t gonna be enough.”
“Everybody has their thing that they identify as problems and a lot of us just live with it.”