Implementation and adaptation of the Re-Engineered Discharge (RED) in five California hospitals: a qualitative research study

Abstract

BackgroundProject Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. To date, little is known about how adapting Project RED from its original protocol impacts RED implementation and/or sustainability. The goal of this study was to identify and characterize contextual factors influencing how five California hospitals adapted and implemented RED and the subsequent impact on RED program sustainability.MethodsParticipant observation and key informant and focus group interviews with 64 individuals at five California hospitals implementing RED in 2012 and 2013 were conducted. These involved hospital leadership, personnel responsible for Project RED implementation, hospital staff, and clinicians. Interview transcripts were coded and analyzed using a modified grounded theory approach and constant comparative analysis.ResultsBoth internal and external contextual factors were identified that influenced hospitals’ decisions on RED adaptation and implementation. These also impacted RED sustainability. External factors included: impending federal penalties for hospitals with high readmission rates targeting specific diagnoses, and access to external funding and technical support to help hospitals implement RED. Internal or organizational level contextual factors included: committed leadership prioritizing Project RED; RED adaptations; depth, accountability and influence of the implementation team; sustainability planning; and hospital culture. Only three of the five hospitals continued Project RED beyond the implementation period.ConclusionsThe sustainability of RED in participating hospitals was only possible when hospitals approached RED implementation as a transformational process rather than a patient safety project, maintained a high level of fidelity to the RED protocol, and had leadership and an implementation team who embraced change and failure in the pursuit of better patient care and outcomes. Hospitals who were unsuccessful in implementing a sustainable RED process lacked all or most of these components in their approach.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2242-z) contains supplementary material, which is available to authorized users.

Transition to home study

“…However, team-based discharges are difficult to implement in practice because the discharge process is not standardized, and providers often lack a shared understanding of the discharge process and patient needs (Ashbrook et al, 2013;Canary & Wilkins, 2017;Greysen et al, 2012;Mitchell, Weigel, Laurens, Martin, & Jack, 2017;Waring et al, 2016). Evaluating hospital discharge team-based interventions is difficult because there are few methods available to examine the discharge process from a team perspective (Greysen et al, 2012;McDonald et al, 2007;Mitchell et al, 2017).…”

“…Methods to examine interprofessional team SMMs are needed to evaluate teambased interventions. Team-based interventions to improve patient transition to home include rounds, huddles, checklists, interprofessional or patient-centered care plans, as well as standardization and role delineation of the discharge process (AHRQ, 2012;Kripalani et al, 2007;Mitchell et al, 2017;Nosbusch et al, 2011;Parry et al, 2008). A common goal among these team-based interventions is that they aim to increase the inpatient team's shared understanding of patient readiness for discharge and/or knowledge of the team member's roles and interaction during hospital discharge.…”

“…Transitional care includes a broad range of time-limited services and is designed to ensure continuity of care, avoid preventable poor outcomes, and promote the safe and timely transfer of patients from one setting to another (Naylor et al, 2011). These care models have been shown to reduce hospital readmission and improve patient-centered care; however, there is mixed evidence on the overall effectiveness as well as the generalizability of the interventions to other settings (Hansen et al, 2013;Mitchell et al, 2017;Naylor et al, 2011). In addition, many of these models of care are resource intensive, require extensive staff training, include additional staff members, and are not being widely implemented (Mitchell et al, 2017;Naylor et al, 2011).…”

“…These care models have been shown to reduce hospital readmission and improve patient-centered care; however, there is mixed evidence on the overall effectiveness as well as the generalizability of the interventions to other settings (Hansen et al, 2013;Mitchell et al, 2017;Naylor et al, 2011). In addition, many of these models of care are resource intensive, require extensive staff training, include additional staff members, and are not being widely implemented (Mitchell et al, 2017;Naylor et al, 2011). For example, initial studies implementing the BOOST bundle found a reduction in readmissions (Hansen et al, 2010); however, when expanded to multiple sites, only minimal reductions in 30-day, all-cause readmissions were measured (Hansen et al, 2014).…”

“…Methods to examine the discharge process from an interprofessional perspective are also needed to evaluate the effectiveness of transitional care model interventions (Greysen et al, 2012;McDonald et al, 2007;Salas & Frush, 2012). outcomes (Ashbrook et al, 2013;Canary & Wilkins, 2017;Greysen et al, 2012;Mitchell et al, 2017;Waring et al, 2016). The divergence in the perceptions of teamwork and taskwork is suggested to be an indication of poor performing teams as well as a barrier to implementing change in practice (McCaffrey et al, 2010;Mitchell et al, 2017;Tang et al, 2013;Thomas et al, 2003).…”