Organizational culture: an important context for addressing and improving hospital to community patient discharge

Are physiotherapists and occupational therapists following the guidelines for discharge summary?-An analysis of the content of physiotherapists' and occupational therapists' discharge summaries and their adherence to stroke guideline recommendations

PURPOSE

Discharge summaries are important tools for communication between health care levels and can ensure continuity of rehabilitation. This study aims to gain insight into the content of discharge summaries written by hospital physiotherapists and occupational therapists regarding patients with stroke, and their adherence to recommended criteria for discharge summaries.

MATERIAL AND METHODS

31 physiotherapy and multidisciplinary discharge summaries, for stroke patients discharged home from hospital with need of follow-up, were included in the study. We employed qualitative content analysis and descriptive statistics to explore and describe the content.

RESULTS

The physiotherapists and occupational therapists adhered to the recommended criteria for content in varying degree. The main focus for physiotherapists and occupational therapists were description of ADL, sensorimotor and general cognitive functions, they rarely report tolerance to exercise, and the specific cognitive abilities to follow instruction and learn were often omitted. Less focus was put on patients' experiences and needs during acute stroke, and description of goals were omitted in the physiotherapy discharge summaries.

CONCLUSION

While the physiotherapists and occupational therapists complement each other in their assessment of patients and inform the reader about both sensorimotor and cognitive functions and abilities, they omit some of the specific criteria for rehabilitation. Despite the omissions, the information provided is specific to the patients' function and needs.

A Culturally Competent Approach to Discharge Planning and Transfer of Care

Culturally competent discharge planning and transfer of care play a leading role in communication and the effective provision of high-quality care to patients from diverse sociocultural backgrounds. However, no standardization has been established. Here, we present the case of a Spanish-speaking patient discharged with instructions in English on two separate occasions, which resulted in readmission and deleterious outcomes. We emphasize the need to provide a safe and culturally competent transition of care.

Transitional care for patients with acute stroke-A priority-setting project

Background

The scope of this priority‐setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority‐setting methods are time‐consuming and require extensive resources. They are therefore not feasible in small‐scale research. This article describes a pragmatic priority‐setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke.

Methods

A pragmatic priority‐setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list.

Results

The process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories ‘patients and caregivers’ needs and health literacy’, ‘health personnel's common understanding’, ‘information flow between health personnel and patients and caregivers’, ‘available interventions and follow‐up of patients and caregivers’, ‘interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare’ and ‘disabilities after stroke’.

Conclusion

This paper outlines a pragmatic approach to identifying and prioritizing users' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke.

Patient and Public Contribution

Members of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.

Toward Nurses' Transformative Agency in Transitional Care for Older Adults: A Change-Laboratory Intervention

Mobilization of nurses' agency across healthcare sectors is needed to counter challenges associated with older adults' transitions between hospital and primary care. Based on Cultural Historical Activity theory and the Change Laboratory method, we developed a learning intervention with 16 nurses. The aim was to foster the nurses' transformative agency to improve care. Video-recording of nine learning sessions were transcribed and analyzed. Results demonstrated that shared transformative agency exhibited as an emergent phenomenon crossing sectoral boundaries as a prerequisite for change in transitional care. The nurses progressed from acting as individuals criticizing the current conditions to collectively forming a vision around a transitional care model. This was nurtured through the nurses' negotiations which included a recognition of sharing similar challenges deriving from the healthcare organization and related financial restrictions, and conflicting healthcare and nursing ideals across healthcare sectors. The evolution of transformative agency was grounded in a professional nursing identity.

Hospital clinical research activity, rather than staff motivational engagement, significantly links effective staff communication and favourable patient feedback; a cross-sectional study

OBJECTIVES

Healthcare staff behaviour can impact on the performance of hospitals. Staff involvement in clinical research can have a wider positive effect on patients and hospital performance. The aim of this study was to further assess the putative positive effect of clinical research activity on patient feedback with a more recent dataset, and if staff's motivational engagement levels may impact on aspects of in-patient feedback.

METHODS

A retrospective cross-sectional study was conducted with (survey) data from 2019; the sample was 129 English National Health Service hospital Trusts. Sources were the national in-patient survey, national staff survey (for staff motivational engagement), and research activity (based on Trust size-corrected National Institute for Health Research records data). Spearman correlation analyses were conducted (minimum rho value 0.25, p-value<0.005), followed by principal component analysis (score cut-off 0.2).

RESULTS

Initial correlation analyses identified eleven in-patient survey questions where better in-patient feedback was associated with increased clinical research activity, and only three questions linked with higher degree of staff motivational engagement. Subsequent principal component analysis confirmed that increased staff engagement is mainly linked to overall Trust performance such as staff levels, whereas staff in research-active hospitals provided in-patients with sufficient information - including on medication - and did well answering patient questions.

CONCLUSIONS

Staff involvement in clinical research is associated with better patient feedback. Clear and thorough information provision to patients, may be a mechanism for improved patient outcomes including mortality.

Systemic contradictions as causes to challenges in nurses' transitional care: A change laboratory intervention

BACKGROUND

Transitional care involves coordination of care for patients transitioning between primary care and hospital care. This necessitates collaboration with patients, health professionals and organizations with different goals for patient care. This can result in fragmented patient care pathways. Education of health professionals is a means to improve transitional care. We therefore developed a learning intervention in order to enable nurses to develop transitional care.

OBJECTIVE

The objective was to understand how participants identified needs for development can improve transitional care.

DESIGN

The design was that of a formative intervention design based on Cultural Historical Activity Theory.

SETTING

A regional hospital and a primary care department in a municipality in Denmark.

PARTICIPANTS

Nine health professionals from primary care services and seven health professionals from hospital services.

METHOD

The change laboratory method and the principle of double stimulation guided the facilitation of the learning intervention, which consisted of nine learning sessions (from May to October 2019). A quantitative and qualitative analytical framework was used for data analysis.

RESULTS

The participants identified needs for development, including a wish to involve patients and their next of kin more and to emphasise relational care. Participants developed an appreciation of challenges concerning collaboration between nurses and the formation of nursing practice. Furthermore, participants began to view challenges as caused by a systemic contradiction between nurses' preoccupation with bureaucratic and managerial demands and patients' expectations of coherent care in transitional care.

CONCLUSION

The process of understanding challenges enabled the participants to change their perception from a need to solve problems as they appear on the surface to a need to address underlying systemic contradictions. This possibly has far-reaching consequences for long-term processes underpinning the development of practice and may serve as an alternative to expedient problem solving.

'Patients come with two garbage bags full of problems and we have to sort them.' A qualitative study of the experiences of healthcare professionals on patients admitted to short-term residential care in the Netherlands

BACKGROUND

Short-term residential care (STRC) facilities were recently implemented in the Netherlands to provide temporary care to older adults with general health problems. The aim of STRC is to allow the individual to return home. However, 40% of patients are discharged to long-term care facilities. In-depth data about characteristics of patients admitted and challenges in providing STRC are missing.

OBJECTIVE

To obtain perspectives of STRC professionals on the patient journey from admission to discharge.

DESIGN

Qualitative study.

SETTING

Eight nursing homes and three hospitals.

SUBJECTS

A total of 28 healthcare professionals.

METHODS

A total of 13 group interviews with in-depth reviews of 39 pseudonymised patient cases from admission to discharge. Interviews were analysed thematically.

RESULTS

Many patients had complex problems that were underestimated at handover, making returning to home nearly impossible. The STRC eligibility criteria that patients have general health problems and can return home do not fit with current practice. This results in a mismatch between patient needs and the STRC that is provided. Therefore, planning care before and after discharge, such as advance care planning, social care and home adaptations, is important.

CONCLUSIONS

STRC is used by patients with complex health problems and pre-existing functional decline. Evidence-based guidelines, appropriate staffing and resources should be provided to STRC facilities. We need to consider the environmental context of the patient and healthcare system to enable older adults to live independently at home for longer.

Nurses' role in delivering discharge education to general surgical patients: A qualitative study

AIMS

To explore nurses' perceived role and experience in providing discharge education to general surgical patients.

DESIGN

Qualitative, using focus groups and face-to-face individual interviews.

METHODS

Purposive sampling with maximum variation was used to recruit nurses from the general surgical wards in a tertiary hospital in Queensland, Australia. Semi-structured interviews (three focus groups and four individual interviews) were conducted with 21 nurses involved in delivering postoperative discharge education from August 2018 - July 2019. Interview data were analysed using inductive content analysis.

RESULTS

Four themes emerged: assuming responsibility for patient education in the absence of discharge communication; supporting patients to participate in self-management after hospitalization; variability in the resources, content and delivery of discharge education; and meeting operational demands compromises the quality of patients' discharge education.

CONCLUSION

This study highlights the importance of nurses' role and the challenges encountered in delivering effective discharge education. These findings can be used to identify strategies to enhance discharge communication among health professionals and standardize the delivery of education to improve surgical patients' postoperative outcomes.

IMPACT

Ineffective discharge education contributes to patients' poor management of their postdischarge recovery. Developing an understanding of nurses' role in discharge education can inform policies and nursing practice to improve patients' well-being and reduce the potential for unplanned and emergency care.

Exploring the Organizational Culture in Adult Day Services (ADS) and Its Effect on Healthcare Delivery in Taiwan

Studies conducted in nursing homes/hospitals have shown that organizational culture plays an important role in care delivery and group culture leads to better quality of care. To explore the organizational culture and care delivery in adult day services (ADS) centers in Taiwan, we used both quantitative and qualitative research methods. Quantitative data from the Competing Values Framework (CVF) assessment showed that the group culture was dominant at all three centers. Qualitative data from observation and staff interviews uncovered both group and nongroup cultural elements. The group cultural elements, such as flexible management, teamwork environment, and sharing the same values, contributed to good care; however, the nongroup cultural elements, such as the staff-centered view, hierarchy, and conflicts within the leadership, led to negative staff-staff and staff-clients interactions. Further research is needed to untangle the complexity between quality care delivery and organizational culture.

Challenges of 21st-century health governance

Purpose

The purpose of this review is to provide an overview of the articles included within one issue of International Journal of Health Governance (IJHG) together with some commentary and reference to other published works.

Design/methodology/approach

The design is a literature review based on the articles in the current issue of IJHG. Other literature studies are referred to for expansion or clarification of the discussion.

Findings

Finding ways to provide efficient, equitable and compassionate care continues to occupy the minds of health managers and health professionals.

Originality/value

The originality value lies in the fact that IJHG is the only journal in the Emerald suite of health care–related publications that includes a regular review of this type.

Safe handovers for every patient: an interrupted time series analysis to test the effect of a structured discharge bundle in Dutch hospitals

OBJECTIVE

Patient handovers are often delayed, patients are hardly involved in their discharge process and hospital-wide standardised discharge procedures are lacking. The aim of this study was to implement a structured discharge bundle and to test the effect on timeliness of medical and nursing handovers, length of hospital stay (LOS) and unplanned readmissions.

DESIGN

Interrupted time series with six preintervention and six postintervention data collection points (September 2015 to June 2017).

SETTING

Internal medicine and surgical wards PARTICIPANTS: Patients (≥18 years) admitted for more than 48 hours to surgical or internal medicine wards.

INTERVENTION

The Transfer Intervention Procedure (TIP), containing four elements: planning the discharge date within 48 hours postadmission; arrangements for postdischarge care; preparing handovers and personalised patient discharge letter; and a discharge conversation 12-24 hours before discharge.

OUTCOME MEASURES

The number of medical and nursing handovers sent within 24 hours. Secondary outcomes were median time between discharge and medical handovers, LOS and unplanned readmissions.

RESULTS

Preintervention 1039 and postintervention 1052 patient records were reviewed. No significant change was observed in the number of medical and nursing handovers sent within 24 hours. The median (IQR) time between discharge and medical handovers decreased from 6.15 (0.96-15.96) to 4.08 (0.33-13.67) days, but no significant difference was found. No intervention effect was observed for LOS and readmission. In subgroup analyses, a reduction of 5.6 days in the median time between discharge and medical handovers was observed in hospitals with high protocol adherence and much attention for implementation.

CONCLUSION

Implementation of a structured discharge bundle did not lead to improved timeliness of patient handovers. However, large interhospital variation was observed and an intervention effect on the median time between discharge and medical handovers was seen in hospitals with high protocol adherence. Future interventions should continue to create awareness of the importance of timely handovers.

TRIAL REGISTRATION NUMBER

NTR5951; Results.

Transitional safety incidents as reported by patients and healthcare professionals in the Netherlands: A descriptive study

Background: Care transitions between general practice and hospital are hazardous regarding patient safety. For developing an improvement strategy adjusted to local settings, understanding of type and potential causes of transitional safety incidents (TSIs) is needed.

Objectives: To provide a broad overview of the nature of TSIs reported by patients and healthcare professionals.

Methods: We collected data (2011–2015) from three hospitals and 56 affiliated general practitioners (GPs) in two Dutch regions (one urban, one rural). We collected data from patients through a survey, interviews and incident reporting weeks, and from GPs and hospital specialists through incident reporting systems, surveys, interviews and focus group discussions. We classified reported TSIs according to type, cause and severity.

Results: In total, 548 TSIs were reported by 411 patients and 137 healthcare professionals; 368 of 548 TSI reports contained sufficient information for classification into aspects of the care transition process, 191 of 548 for cause, and 149 of 548 for severity. Most TSIs concerned handover correspondence from hospital to GP (26%), referral (14%) and communication/collaboration (14%). Concerning cause, reported TSIs could be attributed to organizational (48%) and human factors (43%). Twenty-four percent concerned unsafe situations, 45% near misses and 31% adverse events. Patients and healthcare professionals reported differently on referral (17% vs 9%), repeated diagnostic testing (20% vs 1%), and uncertainty about assigned responsible physician (10% vs 3%).

Conclusion: Reported TSIs typically concerned informational discontinuity. One third caused harm to the patient. Patients report different TSIs than healthcare professionals, suggesting a different view.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs

BACKGROUND

Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks.

OBJECTIVES

We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients.

METHODS/PARTICIPANTS

We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs).

MAIN MEASURES

We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews.

KEY RESULTS

The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed.

CONCLUSIONS

We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

Impact of Hospital Context on Transitioning Patients From Hospital to Skilled Nursing Facility: A Grounded Theory Study

Background

Twenty-five percentage of patients who are transferred from hospital settings to skilled nursing facilities (SNFs) are rehospitalized within 30 days. One significant factor in poorly executed transitions is the discharge process used by hospital providers.

Objective

The objective of this study was to examine how health care providers in hospitals transition care from hospital to SNF, what actions they took based on their understanding of transitioning care, and what conditions influence provider behavior.

Design

Qualitative study using grounded dimensional analysis.

Participants

Purposive sample of 64 hospital providers (15 physicians, 31 registered nurses, 8 health unit coordinators, 6 case managers, 4 hospital administrators) from 3 hospitals in Wisconsin.

Approach

Open, axial, and selective coding and constant comparative analysis was used to identify variability and complexity across transitional care practices and model construction to explain transitions from hospital to SNF.

Key Results

Participants described their health care systems as being Integrated or Fragmented. The goal of transition in Integrated Systems was to create a patient-centered approach by soliciting feedback from other disciplines, being accountable for care provided, and bridging care after discharge. In contrast, the goal in Fragmented Systems was to move patients out quickly, resulting in providers working within silos with little thought as to whether or not the next setting could provide for patient care needs. In Fragmented Systems, providers achieved their goal by rushing to complete the discharge plan, ending care at discharge, and limiting access to information postdischarge.

Conclusions

Whether a hospital system is Integrated or Fragmented impacts the transitional care process. Future research should address system level contextual factors when designing interventions to improve transitional care.

Rapid evidence assessment of approaches to community neurological nursing care for people with neurological conditions post-discharge from acute care hospital

Neurological conditions represent leading causes of non-fatal burden of disease that will consume a large proportion of projected healthcare expenditure. Inconsistent access to integrated healthcare and other services for people with long-term neurological conditions stresses acute care services. The purpose of this rapid evidence assessment, conducted February-June 2016, was to review the evidence supporting community neurological nursing approaches for patients with neurological conditions post-discharge from acute care hospitals. CINAHL Plus with Full Text and MEDLINE were searched for English-language studies published January 2000 to June 2016. Data were extracted using a purpose-designed protocol. Studies describing community neurological nursing care services post-discharge for adults with stroke, dementia, Alzheimer's disease, Parkinson's disease, multiple sclerosis or motor neurone disease were included and their quality was assessed. Two qualitative and three quantitative studies were reviewed. Two themes were identified in the narrative summary of findings: (i) continuity of care and self-management and (ii) variable impact on clinical or impairment outcomes. There was low quality evidence of patient satisfaction, improved patient social activity, depression scores, stroke knowledge and lifestyle modification associated with post-discharge care by neurological nurses as an intervention. There were few studies and weak evidence supporting the use of neurology-generalist nurses to promote continuity of care for people with long-term or progressive, long-term neurological conditions post-discharge from acute care hospital. Further research is needed to provide role clarity to facilitate comparative studies and evaluations of the effectiveness of community neurological nursing models of care.

Identifying and Addressing Language Needs in Primary Care: a Pilot Implementation Study

BACKGROUND

Medical interpreters improve care for patients with Limited English Proficiency but are underused. Protocols to improve interpreter use in primary care are needed.

METHODS

Medical Assistants (MAs) screened patients for language needs and arranged for telephone interpreters during rooming in two pilot clinics (PCs). We interviewed MAs and providers and analyzed interviews using modified grounded theory, linking themes to the Promoting Action on Research Implementation in Health Services (PARiHS) framework categories of Context, Evidence, and Facilitation. Providers in PCs and four comparison clinics were surveyed.

RESULTS

Context themes included issues with the telephone interpreter vendor; having established teams, roles and workflows; and difficulty incorporating time-sensitive tasks. Evidence themes included engagement in language screening; preferring in-person interpreters; improving the patient experience; and having mixed responses to the protocol. Facilitation themes included MAs needing more support. PC providers were more satisfied with care (OR = 12.7) and communication (OR = 7.6) than comparison clinic providers.

CONCLUSIONS

The protocol may improve patient care and communication, but implementation was inconsistent. Language screening is a complex process and further research is needed to improve screening questions and procedures. Future interventions should capitalize on team members' drives to improve patient care and control costs but also need to consider the impacts of health system changes, and to consider the culture, training needs, roles, and relationships of team members.

Comorbidities and the referral pathway to access joint replacement surgery: an exploratory qualitative study

Background

Variation in access to joint replacement surgery has been widely reported but less attention has been given to the impact of comorbidities on the patient journey to joint replacement surgery. There is a lack of consensus amongst healthcare professionals and commissioners about how patients with comorbidities should be referred or selected for joint replacement surgery. It is therefore important to understand the views of healthcare professionals on the management, referral and selection of patients with comorbidities for joint replacement surgery.

Methods

An exploratory qualitative study involving semi-structured interviews with 20 healthcare professionals in England across the referral pathway to joint replacement surgery. They were asked to talk about their experiences of referring and selecting patients with comorbidities for joint replacement surgery. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a thematic analysis approach based on the principles of grounded theory.

Results

In general, the presence of comorbidities was not seen as a barrier to being referred or selected for joint replacement but was seen as a challenge to manage the patients’ journey across the referral pathway. Each professional group, concentrated on different aspects of the patients’ condition which appeared to affect how they managed patients with comorbidities. This implied there was a disagreement about roles and responsibilities in the management of patients with comorbidities. None of the professionals believed it was their responsibility to address comorbidities in preparation for surgery. This disagreement was identified as a reason why some patients seem to ‘get lost’ in the referral system when they were considered to be unprepared for surgery. Patients were then potentially left to manage their own comorbidities before being reconsidered for joint replacement.

Conclusions

At the clinician-level, comorbidities were not perceived as a barrier to accessing joint replacement surgery but at the pathway-level, it may create an implicit barrier such that patients with comorbidities may get ‘lost’ to the system. Further study is needed to explore the roles and responsibilities of professionals across the current orthopaedic referral pathway which may be less suitable for patients with comorbidities.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3565-0) contains supplementary material, which is available to authorized users.

Challenges in measuring interprofessional-interorganisational collaboration with a questionnaire

Background

Collaboration between medical professionals from separate organisations is necessary to deliver good patient care. This care is influenced by professionals’ perceptions about their collaboration. Until now, no instrument to measure such perceptions was available in the Netherlands. A questionnaire developed and validated in Spain was translated to assess perceptions about clinicians’ collaboration in primary and secondary care in the Dutch setting.

Aim

Validation in the Dutch setting of a Spanish questionnaire that aimed to assess perceptions of clinicians about interorganisational collaboration.

Design & setting

After translation, cultural adaptation, and pre-testing, the questionnaire was sent to GPs and secondary care clinicians (SCCs) in three regions in the Netherlands. The responses of 445 responders were used to assess the validity and reliability of the questionnaire.

Method

A confirmatory factor analysis (CFA) and an exploratory factor analysis (EFA) were performed to study the construct validity of the hypothesised factor model underlying the questionnaire. Test-retest reliability was evaluated using weighted Kappa statistics.

Results

Results of the CFA indicated poor fit of the hypothesised factor structure. EFA, executed separately for each region, showed a highly unstable factor structure. The test-retest reliability analysis demonstrated low re-test reliability.

Conclusion

The underlying factor structure of a Spanish questionnaire could not be reproduced. The construct validity and reliability of this questionnaire were insufficient to warrant use in the Dutch setting. This study demonstrates the need for evaluating validity and reliability of questionnaires in local settings.

How to improve healthcare? Identify, nurture and embed individuals and teams with "deep smarts"

Purpose Unlocking and transferring skills and capabilities in individuals to the teams they work within, and across, is the key to positive organisational development and improved patient care. Using the "deep smarts" model, the purpose of this paper is to examine these issues. Design/methodology/approach The "deep smarts" model is described, reviewed and proposed as a way of transferring knowledge and capabilities within healthcare organisations. Findings Effective healthcare delivery is achieved through, and continues to require, integrative care involving numerous, dispersed service providers. In the space of overlapping organisational boundaries, there is a need for "deep smarts" people who act as "boundary spanners". These are critical integrative, networking roles employing clinical, organisational and people skills across multiple settings. Research limitations/implications Studies evaluating the barriers and enablers to the application of the deep smarts model and 13 knowledge development strategies proposed are required. Such future research will empirically and contemporary ground our understanding of organisational development in modern complex healthcare settings. Practical implications An organisation with "deep smarts" people - in managerial, auxiliary and clinical positions - has a greater capacity for integration and achieving improved patient-centred care. Originality/value In total, 13 developmental strategies, to transfer individual capabilities into organisational capability, are proposed. These strategies are applicable to different contexts and challenges faced by individuals and teams in complex healthcare organisations.

Association between organisational and workplace cultures, and patient outcomes: systematic review

DESIGN AND OBJECTIVES

Every organisation has a unique culture. There is a widely held view that a positive organisational culture is related to positive patient outcomes. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses statement, we systematically reviewed and synthesised the evidence on the extent to which organisational and workplace cultures are associated with patient outcomes.

SETTING

A variety of healthcare facilities, including hospitals, general practices, pharmacies, military hospitals, aged care facilities, mental health and other healthcare contexts.

PARTICIPANTS

The articles included were heterogeneous in terms of participants. This was expected as we allowed scope for wide-ranging health contexts to be included in the review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient outcomes, inclusive of specific outcomes such as pain level, as well as broader outcomes such as patient experience.

RESULTS

The search strategy identified 2049 relevant articles. A review of abstracts using the inclusion criteria yielded 204 articles eligible for full-text review. Sixty-two articles were included in the final analysis. We assessed studies for risk of bias and quality of evidence. The majority of studies (84%) were from North America or Europe, and conducted in hospital settings (89%). They were largely quantitative (94%) and cross-sectional (81%). The review identified four interventional studies, and no randomised controlled trials, but many good quality social science studies. We found that overall, positive organisational and workplace cultures were consistently associated with a wide range of patient outcomes such as reduced mortality rates, falls, hospital acquired infections and increased patient satisfaction.

CONCLUSIONS

Synthesised, although there was no level 1 evidence, our review found a consistently positive association held between culture and outcomes across multiple studies, settings and countries. This supports the argument in favour of activities that promote positive cultures in order to enhance outcomes in healthcare organisations.

GPs' assessment of cooperation with other health care providers involved in cancer care-a cross-sectional study

Cancer is a complex disease requiring the involvement of several health care providers. A possible constant in the cancer care process is the general practitioner (GP). The aim of this project was to evaluate GPs' satisfaction with cooperation with other health care providers in the cancer care process of their patients and to explore which variables are associated with higher satisfaction with cooperation with other health care providers. We considered the following health care providers: outpatient oncology specialists, physicians in relatively small hospitals (≤400 beds), physicians in relatively large hospitals (>400 beds), home care services, outpatient psycho(onco)logists/psychotherapists, hospice/palliative care units and specialised palliative home care. The cross-sectional study was carried out as a postal survey all over Germany. Data were analysed descriptively and by means of logistic regression. Overall satisfaction with cooperation with other health care providers involved in cancer care was rather high. Only cooperation with outpatient psycho(onco)logists/psychotherapists was rated as not assessable/irrelevant by a majority of GPs. For all other health care providers under review, both communication and the transfer of sufficient information in good time were associated with overall satisfaction with cooperation. Little association was found between GP and practice variables and overall satisfaction with cooperation with the considered health care providers.

Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits

BACKGROUND

Care transitions between clinicians or settings are often fragmented and marked by adverse events. To increase patient safety and deliver more efficient and effective health care, new ways to optimize these transitions need to be identified. A study was conducted to delineate facilitators and barriers to implementation of transitional care services at health systems that may have been adopted or adapted from published evidence-based models.

METHODS

From March 2015 through December 2015, site visits were conducted across the United States at 22 health care organizations-community hospitals, academic medical centers, integrated health systems, and broader community partnerships. At each site, direct observation and document review were conducted, as were semistructured interviews with a total of 810 participants (5 to 57 participants per site) representing various stakeholder groups, including management and leadership, transitional care team members, internal stakeholders, community partners, patients, and family caregivers.

RESULTS

Facilitators of effective care transitions included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Commonly reported barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in.

CONCLUSION

True community partnership, high-quality communication, patient and family engagement, and ongoing evaluation and adaptation of transitional care strategies are ultimately needed to facilitate effective care transitions. Health care organizations can strategically prioritize transitional care service delivery through staffing decisions, by making transitional care part of the organization's formal board agenda, and by incentivizing excellence in providing transitional care services.

Use of Intervention Mapping to Enhance Health Care Professional Practice: A Systematic Review

Background. Intervention Mapping is a planning protocol for developing behavior change interventions, the first three steps of which are intended to establish the foundations and rationales of such interventions. Aim. This systematic review aimed to identify programs that used Intervention Mapping to plan changes in health care professional practice. Specifically, it provides an analysis of the information provided by the programs in the first three steps of the protocol to determine their foundations and rationales of change. Method. A literature search was undertaken in PubMed, Scopus, SciELO, and DOAJ using “Intervention Mapping” as keyword. Key information was gathered, including theories used, determinants of practice, research methodologies, theory-based methods, and practical applications. Results. Seventeen programs aimed at changing a range of health care practices were included. The social cognitive theory and the theory of planned behavior were the most frequently used frameworks in driving change within health care practices. Programs used a large variety of research methodologies to identify determinants of practice. Specific theory-based methods (e.g., modelling and active learning) and practical applications (e.g., health care professional training and facilitation) were reported to inform the development of practice change interventions and programs. Discussion. In practice, Intervention Mapping delineates a three-step systematic, theory- and evidence-driven process for establishing the theoretical foundations and rationales underpinning change in health care professional practice. Conclusion. The use of Intervention Mapping can provide health care planners with useful guidelines for the theoretical development of practice change interventions and programs.

Development of an interface-focused educational complex intervention

BACKGROUND

In many countries, the medical primary-secondary care interface is central to the delivery of quality patient care. There is prevailing interest in developing initiatives to improve interface working for the benefit of health care professionals and their patients.

AIM

To describe the development of an educational intervention designed to improve working at the primary-secondary care interface in NHS Scotland (United Kingdom) within the context of the Medical Research Council framework for the development and evaluation of complex interventions.

METHODS

A primary-secondary care interface focused Practice-based Small Group Learning (PBSGL) module was developed building upon qualitative synthesis and original research. A 'meeting of experts' shaped the module, which was subsequently piloted with a group of interface clinicians. Reflections on the module were sought from clinicians across NHS Scotland to provide contextual information from other areas.

FINDINGS

The PBSGL approach can be usefully applied to the development of a primary-secondary care interface-focused medical educational intervention.

Barriers and facilitators to improve safety and efficiency of the ICU discharge process: a mixed methods study

Background

Evidence indicates that suboptimal clinical handover from the intensive care unit (ICU) to general wards leads to unnecessary ICU readmissions and increased mortality. We aimed to gain insight into barriers and facilitators to implement and use ICU discharge practices.

Methods

A mixed methods approach was conducted, using 1) 23 individual and four focus group interviews, with post-ICU patients, ICU managers, and nurses and physicians working in the ICU or general ward of ten Dutch hospitals, and 2) a questionnaire survey, which contained 27 statements derived from the interviews, and was completed by 166 ICU physicians (21.8%) from 64 Dutch hospitals (71.1% of the total of 90 Dutch hospitals).

Results

The interviews resulted in 66 barriers and facilitators related to: the intervention (e.g., feasibility); the professional (e.g., attitude towards checklists); social factors (e.g., presence or absence of a culture of feedback); and the organisation (e.g., financial resources). A facilitator considered important by ICU physicians was a checklist to structure discharge communication (92.2%). Barriers deemed important were lack of a culture of feedback (55.4%), an absence of discharge criteria (23.5%), and an overestimation of the capabilities of general wards to care for complex patients by ICU physicians (74.7%).

Conclusions

Based on the barriers and facilitators found in this study, improving handover communication, formulating specific discharge criteria, stimulating a culture of feedback, and preventing overestimation of the general ward are important to effectively improve the ICU discharge process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2139-x) contains supplementary material, which is available to authorized users.

A systematic review on the effect of the organisation of hospital discharge on patient health outcomes

OBJECTIVE

The transition from hospital to home represents a key step in the management of patients and several problems related to this transition may arise, with potential adverse effects on patient health after discharge. The purpose of our study was to explore the association between components of the hospital discharge process including subsequent continuity of care and patient outcomes in the post-discharge period.

DESIGN

Systematic review of observational and interventional studies.

SETTING

We conducted a combined search in the Medline and Web of Science databases. Additional studies were identified by screening the bibliographies of the included studies. The data collection process was conducted using a standardised predefined grid that included quality criteria.

PARTICIPANTS

A standard patient population returning home after hospitalisation.

PRIMARY AND SECONDARY OUTCOMES

Adverse health outcomes occurring after hospital discharge.

RESULTS

In the 20 studies fulfilling our eligibility criteria, the main discharge-process components explored were: discharge summary (n=2), discharge instructions (n=2), drug-related problems at discharge (n=4), transition from hospital to home (n=5) and continuity of care after hospital discharge (n=7). The major subsequent patient health outcomes measured were: rehospitalisations (n=18), emergency department visits (n=8) and mortality (n=5). Eight of the 18 studies exploring rehospitalisations and two of the eight studies examining emergency department visits reported at least one significant association between the discharge process and these outcomes. None of the studies investigating patient mortality reported any significant such associations between the discharge process and these outcomes.

CONCLUSIONS

Irrespective of the component of the discharge process explored, the outcome considered (composite or not), the sample size and the study design, no consistent statistical association between hospital discharge and patient health outcome was identified. This systematic review highlights a wide heterogeneity between studies, especially in terms of the component(s) of the hospital discharge process investigated, study designs, outcomes and follow-up durations.

Association between organisational and workplace cultures, and patient outcomes: systematic review protocol

INTRODUCTION

Despite widespread interest in the topic, no current synthesis of research is available analysing the linkages between organisational or workplace cultures on the one hand, and patient outcomes on the other. This protocol proposes a systematic review to analyse and synthesise the literature to date on this topic. The resulting review will discuss characteristics of included studies in terms of the type of healthcare settings researched, the measurements of organisational and workplace culture, patient outcomes measured and the influence of these cultures on patient outcomes.

METHODS AND ANALYSIS

A systematic review will be conducted aiming to examine the associations between organisational and workplace cultures, and patient outcomes, guided by the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement. An English language search of abstracts will be executed using the following academic databases: CINAHL, EMBASE, Ovid MEDLINE, Web of Science and PsycINFO. The review will include relevant peer-reviewed articles from randomised controlled trials (RCTs), non-RCTs, controlled before and after studies, interrupted time series studies, cross-sectional analyses, qualitative studies and mixed-method studies. Multiple researchers will be involved in assessing the quality of articles for inclusion in the review. This protocol documents a detailed search strategy, including terms and inclusion criteria, which will form the basis of the subsequent systematic review.

ETHICS AND DISSEMINATION

Ethics approval is not required as no primary data will be collected. Results will be disseminated through a peer-reviewed publication and conference presentations.

Implementation of a Transfer Intervention Procedure (TIP) to improve handovers from hospital to home: interrupted time series analysis

Background

Accurate and timely patient handovers from hospital to other health care settings are essential in order to provide high quality of care and to ensure patient safety. We aim to investigate the effect of a comprehensive discharge bundle, the Transfer Intervention Procedure (TIP), on the time between discharge and the time when the medical, medication and nursing handovers are sent to the next health care provider. Our goal is to reduce this time to 24 h after hospital discharge. Secondary outcomes are length of hospital stay and unplanned readmission within 30 days rates.

Methods

The current study is set to implement the TIP, a structured discharge process for all patients admitted to the hospital, with the purpose to provide a safe, reliable and accurate discharge process. Eight hospitals in the Netherlands will implement the TIP on one internal medicine and one surgical ward. An interrupted time series (ITS) analysis, with pre-defined pre and post intervention periods, will be conducted. Patients over the age of 18 admitted for more than 48 h to the participating wards are eligible for inclusion. At least 1000 patients will be included in both the pre-implementation and post-implementation group. The primary outcome is the number of medical, medication and nursing handovers being sent within 24 h after discharge. Secondary outcomes are length of hospital stay and unplanned readmission within 30 days. With regard to potential confounders, data will be collected on patient’s characteristics and information regarding the hospitalization. We will use segmented regression methods for analyzing the data, which allows assessing how much TIP changed the outcomes of interest immediately and over time.

Discussion

This study protocol describes the implementation of TIP, which provides the foundation for a safe, reliable and accurate discharge process. If effective, nationwide implementation of the discharge bundle may result from this study protocol.

Trial Registration

Dutch Trial Registry: NTR5951

The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study

BACKGROUND

Improving the quality of care of at the medical primary-secondary care interface is both a national and a wider concern. In a qualitative exploration of clinicians' relationship at the interface, we want to study how both GPs and hospital specialists regard and behave towards each other and how this may influence patient care.

METHOD

A qualitative interview study was carried out in primary and secondary care centres in NHS Highland health board area, Scotland. Eligible clinicians (general practitioners and hospital specialists) were invited to take part in a semi-structured interview to explore the implications of interface relationships upon patient care. A standard thematic analysis was used, involving an iterative process based on grounded theory.

RESULTS

Key themes that emerged for clinicians included communication (the importance of accessing and listening to one another, and the transfer of soft intelligence), conduct (referring to perceived inappropriate transfer of workload at the interface, and resistance to this transfer), relationships (between interface clinicians and between clinicians and their patients), and unrealistic expectations (clinicians expressing idealistic hopes of what their colleagues at the other interface could achieve).

CONCLUSION

The relationship between primary and secondary care clinicians, and, in particular, difficulties and misunderstandings can have an influence upon patient care. Addressing key areas identified in the study may help to improve interface relationships and benefit patient care.

Role of context in care transition interventions for medically complex older adults: a realist synthesis protocol

INTRODUCTION

Approximately 30-50% of older adults have two or more conditions and are referred to as multimorbid or complex patients. These patients often require visits to various healthcare providers in a number of settings and are therefore susceptible to fragmented healthcare delivery while transitioning to receive care. Care transition interventions have been implemented to improve continuity of care, however, current evidence suggests that some interventions or components of interventions are only effective within certain contexts. There is therefore a need to unpack the mechanisms of how and within which contexts care transition interventions and their components are effective. Realist review is a synthesis method that explains how complex programmes work within various contexts. The purpose of this study is to explain the effect of context on the activities and mechanisms of care transition interventions in medically complex older adults using a realist review approach.

METHODS AND ANALYSIS

This synthesis will be guided by Pawson and colleagues' 2004 and 2005 protocols for conducting realist reviews. The underlying theories of care transition interventions were determined based on an initial literature search using relevant databases. English language peer-reviewed studies published after 1993 will be included. Several relevant databases will be searched using medical subject headings and text terms. A screening form will be piloted and titles, abstracts and full text of potentially relevant articles will be screened in duplicate. Abstracted data will include study characteristics, intervention type, contextual factors, intervention activities and underlying mechanisms. Patterns in Context-Activity-Mechanism-Outcome (CAMO) configurations will be reported.

ETHICS AND DISSEMINATION

Internal knowledge translation activities will occur throughout the review and existing partnerships will be leveraged to disseminate findings to frontline staff, hospital administrators and policymakers. Finalised results will be presented at local, national and international conferences, and disseminated via peer-reviewed publications in relevant journals.

Patients' perspectives on the medical primary-secondary care interface: systematic review and synthesis of qualitative research

OBJECTIVES

To synthesise the published literature on the patient experience of the medical primary-secondary care interface and to determine priorities for future work in this field aimed at improving clinical outcomes.

DESIGN

Systematic review and metaethnographic synthesis of primary studies that used qualitative methods to explore patients' perspectives of the medical primary-secondary care interface.

SETTING

International primary-secondary care interface.

DATA SOURCES

EMBASE, MEDLINE, CINAHL Plus with Full text, PsycINFO, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts, eBook Collection, Web of Science Core Collection: Citation Indexes and Social Sciences Citation Index, and grey literature.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were eligible for inclusion if they were full research papers employing qualitative methodology to explore patients' perspectives of the medical primary-secondary care interface.

REVIEW METHODS

The 7-step metaethnographic approach described by Noblit and Hare, which involves cross-interpretation between studies while preserving the context of the primary data.

RESULTS

The search identified 690 articles, of which 39 were selected for full-text review. 20 articles were included in the systematic review that encompassed a total of 689 patients from 10 countries. 4 important areas specific to the primary-secondary care interface from the patients' perspective emerged: barriers to care, communication, coordination, and 'relationships and personal value'.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Patients should be the focus of any transfer of care between primary and secondary systems. From their perspective, areas for improvement may be classified into four domains that should usefully guide future work aimed at improving quality at this important interface.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42014009486.

Impact of patients' healthcare payment methods on hospital discharge process: evidence from India

This study investigates the impact of patients' payment methods on hospitals' discharge process. Patients' payment methods, particularly the use of third-party payers, are documented to impact hospitals' behavior. However, evidence is still missing on how differences across payment categories affect hospital discharge, a complicated and poorly standardized process. Data are derived from a single case study carried out in 2014 at the Mazumdar Shaw Medical Center at the Narayana Health City Campus in Bangalore, India. A mixed-method approach has been adopted. First, process mapping for different payment categories was conducted using unstructured interviews with staff and on-the-floor observations. Second, linear regression analysis was applied on a sample of 1000 discharges that occurred in January 2014 to investigate the impact of patients' payment categories on discharge turnaround time. The qualitative evidence highlights substantial variation in the discharge process across payment categories. Regression analyses reveal that the sequential process used to discharge community health insurance patients results in a significantly shorter discharge turnaround time and that cash-paying patients do not experience any significantly shorter discharge duration. For hospital managers, this study provides important evidence that patient utilization of a third-party payer does not hamper hospital efficiency. This finding should also encourage policy makers and third-party payers to work towards expanding the medical insurance system, particularly in India and particularly community-based schemes. At the same time, our findings document a strong fragmentation of discharge processes, which should spur hospitals and third-party payers to cooperate in order to set standards and minimize disruptions to patient flows. Copyright © 2015 John Wiley & Sons, Ltd.

Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge

Purpose

To systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge.

Methods

PubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies.

Results

From the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points.

Conclusions

This review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-015-3666-8) contains supplementary material, which is available to authorized users.

Improving patient discharge and reducing hospital readmissions by using Intervention Mapping

BACKGROUND

There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.

METHODS

The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance.

RESULTS

Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.

CONCLUSIONS

This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

The Trauma Center Organizational Culture Survey: development and conduction

BACKGROUND

The Trauma Center Organizational Culture Survey (TRACCS) instrument was developed to assess organizational culture of trauma centers enrolled in the American College of Surgeons Trauma Quality Program (ACS TQIP). The objective is to provide evidence on the psychometric properties of the factors of TRACCS and describe the current organizational culture of TQIP-enrolled trauma centers.

METHODS

A cross-sectional study was conducted by surveying a sampling of employees at 174 TQIP-enrolled trauma centers. Data collection was preceded by multistep survey development. Psychometric properties were assessed by an exploratory factor analysis (construct validity) and the item-total correlations and Cronbach alpha were calculated (internal reliability). Statistical outcomes of the survey responses were measured by descriptive statistics and mixed effect models.

RESULTS

The response rate for trauma center participation in the study was 78.7% (n = 137). The factor analysis resulted in 16 items clustered into three factors as described: opportunity, pride, and diversity, trauma center leadership, and employee respect and recognition. TRACCS was found to be highly reliable with a Cronbach alpha of 0.90 in addition to the three factors (0.91, 0.90, and 0.85). Considerable variability of TRACCS overall and factor score among hospitals was measured, with the largest interhospital deviations among trauma center leadership. More than 80% of the variability in the responses occurred within rather than between hospitals.

CONCLUSIONS

TRACCS was developed as a reliable tool for measuring trauma center organizational culture. Relationships between TQIP outcomes and measured organizational culture are under investigation. Trauma centers could apply TRACCS to better understand current organizational culture and how change tools can impact culture and subsequent patient and process outcomes.

Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study

Background

Accurate information transfer is an important element of continuity of care and patient safety. Despite the demonstrated urge for improvement of communication in acute care, there is a lack of data on improvements of communication. This study aims to describe the barriers to implementation of a redesign of the existing model for information transfer and feedback.

Methods

A case study with six cases (i.e. acute care chains), using mixed methods was carried out in the Netherlands. The redesign was implemented in one acute care chain while the five other acute care chains served as control groups. Focus group interviews were held with members of the acute care chains and questionnaires were sent to care providers working in the acute care chains.

Results

Respondents reported three sets of barriers for implementation of the model: (a) existing routines for information transfer and feedback in organizations within the acute care chain; (b) barriers related to the implementation method and time period; and (c) the absence of a high ‘sense of urgency’ amongst providers in the acute care chain which would aid in improving the communication process.

Conclusions

This study shows that organizational factors play an important role in the success or failure of redesigning a communication process. Organizational routines can hamper implementation of a redesign if it differs too much from the routines of care providers involved. Besides focussing on provider characteristics in the implementation of a redesigned process, specific attention should be paid to unlearning existing organizational routines.