Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems

Contextual Factors Influencing the Implementation of a Multifaceted Intervention to Improve Teamwork and Quality for Hospitalized Patients: A Multisite Qualitative Comparative Case Study

BACKGROUND

Many hospitals have begun to implement models that combine interventions to redesign care for medical patients. These models include localization of physicians to specific units, nurse-physician co-leadership, and interprofessional rounds. Understanding contextual factors, the circumstances surrounding an implementation effort that influence its success, is essential to provide guidance to leaders implementing similar models of care.

METHODS

A multisite qualitative comparative case study was conducted with four hospitals in the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Researchers conducted observations and semistructured interviews with 40 health care professionals and four implementation mentors. Researchers used inductive qualitative content analysis, reviewed fidelity of implementation trends, and performed cross-case analysis to identify contextual factors and their influence on implementation.

RESULTS

Four contextual factors were associated with implementation success: (1) senior hospital leader involvement and organizational support; (2) alignment of RESET with organizational, hospital, and professional group priorities; (3) site leaders' engagement in RESET and relationship with one another; and (4) perceptions of need and intervention benefits among professionals. Implementation was optimal when senior leadership was stable and tangibly involved; organizational, hospital, and group goals were aligned; site leaders were committed and collaborated well; and nurses and physicians perceived a need for and benefits from the interventions.

CONCLUSION

Four interrelated contextual factors are associated with the implementation of combined interventions to redesign care for hospitalized medical patients. Hospital leaders should consider these findings prior to implementing similar interventions and be prepared to address challenges related to these factors during implementation.

Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial

BACKGROUND

Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients.

OBJECTIVE

To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes.

DESIGN

Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677).

SETTING

Medical units at 4 U.S. hospitals.

PARTICIPANTS

Health care professionals and hospitalized medical patients.

INTERVENTION

Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities.

MEASUREMENTS

Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions.

RESULTS

Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (n = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; P = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; P = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience.

LIMITATION

Adverse events occurred less frequently than anticipated, limiting statistical power.

CONCLUSION

Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Effect of COVID-19 on the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a qualitative interview study

Background

Healthcare organizations made major adjustments to deliver care during the COVID pandemic, yet little is known about how these adjustments shaped ongoing quality and safety improvement efforts. We aimed to understand how COVID affected four U.S. hospitals’ prospective implementation efforts in an ongoing quality improvement initiative, the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) project, which implemented complementary interventions to redesign systems of care for medical patients.

Methods

We conducted individual semi-structured interviews with 40 healthcare professionals to determine how COVID influenced RESET implementation. We used conventional qualitative content analysis to inductively code transcripts and identify themes in MAXQDA 2020.

Results

We identified three overarching themes and nine sub-themes. The three themes were (1) COVID exacerbated existing problems and created new ones. (2) RESET and other quality improvement efforts were not the priority during the pandemic. (3) Fidelity of RESET implementation regressed.

Conclusion

COVID had a profound impact on the implementation of a multifaceted intervention to improve quality and teamwork in four hospitals. Notably, COVID led to a diversion of attention and effort away from quality improvement efforts, like RESET, and sites varied in their ability to renew efforts over time. Our findings help explain how COVID adversely affected hospitals’ quality improvement efforts throughout the pandemic and support the need for research to identify elements important for fostering hospital resilience.

A randomized non-inferiority study of low-dose and standard-dose ticagrelor after intervention for acute coronary syndrome: study protocol for the TIGER STUDY

Background

Current guidelines recommend that patients with acute coronary syndrome (ACS) who have successfully undergone percutaneous coronary intervention (PCI) should continue to use dual antiplatelet therapy (DAPT) for 12 months. The long-term use of standard-dose dual antiplatelet therapy will increase the risk of bleeding. An optimized antiplatelet strategy that can prevent ischemic events and reduce the risk of bleeding remains to be explored.

Methods

The study is a prospective, multicenter, randomized, open-label, controlled study involving 2090 patients from six clinical centers in China. Through the interactive web response system (IWRS), ACS patients undergoing successful PCI will be randomly divided into the low-dose ticagrelor group or the normal-dose ticagrelor group, after taking 100 mg aspirin and 90 mg ticagrelor bid for 1 week. The primary endpoint is a composite of cardiovascular death, non-fatal myocardial infarction, stent thrombosis, repeat revascularization, and stroke. The secondary endpoints are bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria, cardiovascular death, acute myocardium infarction, and coronary revascularization at 1 year.

Discussion

Recent studies have confirmed that 90 mg ticagrelor alone can safely and effectively reduce bleeding without increasing ischemic events of patients with ACS after PCI. Compared with standard-dose DAPT, whether low-dose ticagrelor combined with aspirin can ensure the anti-ischemic effect while reducing the bleeding risk remains unclear in Chinese patients.

The TIGER study will be the first large-scale, multicenter study to compare the efficacy and safety of low-dose and standard-dose ticagrelor combined with aspirin in ACS patients 1 week after successful PCI.

Trial registration

Clinicaltrials.gov NCT04255602. Registered on 5 February 2020.

Using Accountable Care Teams to Improve Timely Discharge: A Pilot Study

BACKGROUND AND OBJECTIVE

Hospitals worldwide are faced with the problem of discharging patients on time. Delayed discharge creates domino effects with significant implications for hospitals. The accountable care team (ACT) is a multidisciplinary, unit-based approach to identifying opportunities to improve patient care and address inefficiencies in care delivery and throughput, including assuring timely discharges. In response to concerns about emergency department boarding times and delays in timely discharge, the ACT recommended a set of strategies to improve communication across team members and to reduce wait times for transportation within and outside the hospital. Collectively these strategies were thought to increase the proportion of patients discharged on time. In this article, we describe and assess changes in timely discharge resulting from the implementation of strategies recommended by the ACT.

METHODS

This study uses a retrospective, quasi-experimental design to compare the percentage of discharges by 1 pm of hospital units implementing the ACT intervention to those units not implementing the intervention. Median discharge time was compared pre- and post-implementation using the Wilcoxon rank sum test. Difference-in-differences modeling was employed to assess whether changes in the percentage of discharges by 1 pm differed between units implementing the intervention and units not implementing the intervention.

RESULTS

One month post-implementation, the percentage discharged by 1 pm was statistically significantly higher for units implementing the intervention (53.6%) compared with comparison units (22.5%, t = -4.48, P < .01). Statistically significant differences in the percentage discharged by 1 pm were also seen at 3 and 6 months post-implementation. The median discharge time showed a statistically significant decrease by 77 minutes from the baseline to intervention period ( P < .01).

CONCLUSION

The result from the study suggests that ACTs can be used to develop approaches aimed at improving patient care in general, and discharge efficiencies in particular. Health care organizations are encouraged to utilize and then evaluate the specific activities of multidisciplinary teams aimed at developing recommendations for practice improvement.

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study

BACKGROUND

Despite available evidence-based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness.

OBJECTIVE

This study assessed barriers and facilitators to HKTP implementation preparation.

METHODS

Interviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis.

RESULTS

Forty-four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health-care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders' focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients' transplant education needs. Implementation barriers included: stakeholders' perceptions that Hispanics' health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion.

DISCUSSION AND CONCLUSIONS

Our study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations' implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

A Multisite Study of Interprofessional Teamwork and Collaboration on General Medical Services

BACKGROUND

Teamwork and collaboration are essential to providing high-quality care. Prior research has found discrepancies between nurses' and physicians' perceptions in operating rooms, ICUs, and labor and delivery units. Less is known about health care professionals' perceptions of teamwork and collaboration on general medical services.

METHODS

This cross-sectional study included nurses, nurse assistants, and physicians working on general medical services in four mid-sized hospitals. Researchers assessed teamwork climate using the Safety Attitudes Questionnaire and asked respondents to rate the quality of collaboration experienced with their own and other professional categories.

RESULTS

Data for 380 participants (80 hospitalists, 13 resident physicians, 193 nurses, and 94 nurse assistants) were analyzed. Hospitalists had the highest median teamwork climate score (83.3, interquartile range [IQR] = 72.3-91.1), and nurses had the lowest (78.6, IQR = 69.6-87.5), but the difference was not statistically significant (p = 0.42). Median teamwork climate scores were significantly different across the four sites (highest = 83.3, IQR = 75.0-91.1; lowest = 76.8, IQR = 66.7-88.4; p = 0.003). Ratings of the quality of collaboration differed significantly based on professional category. Specifically, 63.3% (50/79) of hospitalists rated the quality of collaboration with nurses as high or very high, while 48.7% (94/193) of nurses rated the quality of collaboration with hospitalists as high or very high.

CONCLUSION

This study found significant differences in perceptions of teamwork climate across sites and in collaboration across professional categories on general medical services. Given the importance in providing high-quality care, leaders should consider conducting similar assessments to characterize teamwork and collaboration on general medical services within their own hospitals.

Patient safety in Work Environments: Perceptions of Pediatric Healthcare Providers in Taiwan

BACKGROUND

Extensive research on the link between the organizational characteristics of the work environment and patient safety in a healthcare organization has been conducted; yet, only a few studies have concentrated on care providers in a pediatric unit.

OBJECTIVES

To determine the correlation between different work environment factors impacting patient safety in a pediatric care unit from the perspective of registered nurses working in these units.

DESIGN

Cross-sectional design.

DATA SOURCES AND METHODS

The study was conducted with 155 registered nurses from a pediatric unit in a medical center in Taiwan with the Chinese version of the Safety Attitudes Questionnaire (SAQ) 2014-2017.

RESULTS

Teamwork climate, higher job satisfaction, and better working conditions are linked to positive perceptions of patient safety culture. Emotional exhaustion is negatively related to most dimensions of patient safety.

CONCLUSION

Teamwork climate, job satisfaction, working conditions, and emotional exhaustion were identified as critical factors impacting the patient safety climate.

IMPLICATIONS FOR NURSING OR HEALTH POLICY

Investments to improve teamwork climate, job satisfaction, and working conditions and reduce emotional exhaustion may have a positive effect on patient safety in pediatric care units.