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.
Highlights
Project Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country
External factors Two prominent external contextual factors were: 1) the focus of federal penalties on specific patient diagnostic populations and 2) the increased availability of grant funding and technical assistance resources to incentivize US hospitals to improve care transitions. Both factors were largely attributable to peaked national interest in readmissions as a patient safety issue, public reporting of hospital readmission rates and the commencement of federal penalty policies
The foundation grant funds were earmarked for nursing care initiatives, but did not set parameters for awardees about how much nursing to use in the implementation of RED
Summary
Project Re-Engineered Discharge (RED) is an evidence-based strategy to reduce readmissions disseminated and adapted by various health systems across the country. Medicare’s Quality Improvement Organizations program (QIO) and the Community-Based Care Transitions Program (CCTP), made the recommendation to implement care transition programs to improve the discharge process and reduce readmissions. This convergence of federal policy, financial penalties, QIO and CCTP recommendations and publication of encouraging research prompted the swift and often not well thought out adoption of the newly developed care transition interventions, with little understanding of the contextual factors that influence the success or failure of such interventions in a new environment. All hospitals encountered myriad challenges to the implementation of RED, stemming from various contextual factors (e.g. policy, external funding, organizational structure and culture among others) [8,9,10]
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