Integrating new practices: a qualitative study of how hospital innovations become routine

Implementation Science

Elizabeth H. Bradley²  Leora I. Horwitz¹  Kristina Talbert-Slagle²  Emily J. Cherlin²  Leslie A. Curry²  Amanda L. Brewster² 

[1]Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, NY, USA

[2]Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA

关键词: Readmissions;    Management;    Integration of new practices;    Innovation;    Hospitals;   

Others  :  1235175
DOI  :  10.1186/s13012-015-0357-3

 received in 2015-06-17, accepted in 2015-11-30,  发布年份 2015

【 摘 要 】

Background

Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.

Methods

We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010–2011 to 2011–2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.

Results

When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.

Conclusions

Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations.

【 授权许可】

   
2015 Brewster et al.

【 图 表 】

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【 参考文献 】

• [1]Bailie RS, Robinson G, Kondalsamy-Chennakesavan SN, Halpin S, Wang Z. Investigating the sustainability of outcomes in a chronic disease treatment programme. Soc Sci Med. 2006; 63:1661-1670.
• [2]Brand C, Landgren F, Hutchinson A, Jones C, MacGregor L, Campbell D. Clinical practice guidelines: barriers to durability after effective early implementation. Intern Med J. 2005; 35:162-169.
• [3]Buchanan D, Fitzgerald L, Ketley D, Gollop R, Jones JL, Lamont SS et al.. No going back: a review of the literature on sustaining organizational change. Int. J. Manag. Rev. 2005; 7:189-205.
• [4]Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, Charns M. The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research. Implement. Sci. 2012; 7:17. BioMed Central Full Text
• [5]Goodson P, Murphy Smith M, Evans A, Meyer B, Gottlieb NH. Maintaining prevention in practice: survival of PPIP in primary care settings. Am J Prev Med. 2001; 20:184-189.
• [6]Higuchi KS, Davies BL, Edwards N, Ploeg J, Virani T. Implementation of clinical guidelines for adults with asthma and diabetes: a three-year follow-up evaluation of nursing care. J Clin Nurs. 2011; 20:1329-1338.
• [7]Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing. Implement. Sci. 2009; 4:50. BioMed Central Full Text
• [8]Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly. 2004; 82:581-629.
• [9]Bradley EH, Curry LA, Taylor LA, Pallas SW, Talbert-Slagle K, Yuan C et al.. A model for scale up of family health innovations in low-income and middle-income settings: a mixed methods study. BMJ Open. 2012; 2:e000987.
• [10]Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013; 8:117. BioMed Central Full Text
• [11]May C. Agency and implementation: understanding the embedding of healthcare innovations in practice. Soc Sci Med. 2013; 78:26-33.
• [12]Cohen WM, Levinthal DA. Absorptive capacity: a new perspective on learning and innovation. Adm Sci Q. 1990; 35:128-152.
• [13]Jansen JJP, Bosch FAJVD, Volberda HW. Managing potential and realized absorptive capacity: how do organizational antecedents matter? Acad Manage j. 2005; 48:999-1015.
• [14]Zahra SA, George G. Absorptive capacity: a review, reconceptualization, and extension. Acad. Manage. Rev. 2002; 27:185-203.
• [15]Rogers EM. Diffusion of innovations, 5th edition. 5th ed. Free Press, New York; 2003.
• [16]Blasinsky M, Goldman HH, Unützer J. Project IMPACT: a report on barriers and facilitators to sustainability. Adm Policy Ment Health. 2006; 33:718-729.
• [17]Silow-Carroll S, Alteras T, Meyer JA. Hospital quality improvement: strategies and lessons from U.S. hospitals. New York: The Commonwealth Fund; 2007.
• [18]Yin RK. Life histories of innovations: how new practices become routinized. Public Adm Rev. 1981; 41:21-28.
• [19]Stetler CB, Ritchie JA, Rycroft-Malone J, Schultz AA, Charns MP. Institutionalizing evidence-based practice: an organizational case study using a model of strategic change. Implementation Sci. 2009; 4:1-19. BioMed Central Full Text
• [20]Yin RK. Changing urban bureaucracies: how new practices become routinized. Rand Corporation, Santa Monica; 1978.
• [21]Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009; 119:1442-1452.
• [22]State action on avoidable rehospitalizations. http://www. ihi.org/offerings/Initiatives/PastStrategicInitiatives/STAAR/Pages/default.aspx webcite
• [23]Patton MQ. Qualitative research and evaluation methods. Sage Publications, Thousand Oaks; 2002.
• [24]Naylor, Brooten D, Campbell R, Jacobson BS, Mezey MD, Pauly MV, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613–20.
• [25]Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004; 52:675-684.
• [26]Phillips C, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA. 2004; 291:1358-1367.
• [27]Coleman E, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006; 166:1822-1828.
• [28]Parry C, Min S-J, Chugh A, Chalmers S, Coleman EA. Further application of the care transitions intervention: results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q. 2009; 28:84-99.
• [29]Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE et al.. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009; 150:178-187.
• [30]Brock J, Mitchell J, Irby K, Stevens B, Archibald T, Goroski A et al.. Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries. JAMA. 2013; 309:381-391.
• [31]Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN et al.. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013; 6:444-450.
• [32]Hernandez AF, Greiner MA, Fonarow GC, Hammill BG, Heidenreich PA, Yancy CW et al.. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010; 303:1716-1722.
• [33]Kociol RD, Peterson ED, Hammill BG, Flynn KE, Heidenreich PA, Piña IL et al.. National survey of hospital strategies to reduce heart failure readmissions findings from the Get With the Guidelines-Heart Failure registry. Circ Heart Fail. 2012; 5:680-687.
• [34]Bradley EH, Sipsma H, Horwitz LI, Ndumele CD, Brewster AL, Curry LA, et al. Hospital strategy uptake and reductions in unplanned readmission rates for patients with heart failure: a prospective study. J Gen Intern Med. 2015;30:605-11.
• [35]Hansen L, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011; 155:520–W–159.
• [36]Klein KJ, Sorra JS. The challenge of innovation implementation. Acad. Manage. Rev. 1996; 21:1055-1080.
• [37]Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: an organizational analysis. J. Appl. Psychol. 2001; 86:811-824.
• [38]Keenan PS, Normand S-LT, Lin Z, Drye EE, Bhat KR, Ross JS et al.. An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circ Cardiovasc Qual Outcomes. 2008; 1:29-37.
• [39]Krumholz HM, Lin Z, Drye EE, Desai MM, Han LF, Rapp MT et al.. An administrative claims measure suitable for profiling hospital performance based on 30-day all-cause readmission rates among patients with acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2011; 4:243-252.
• [40]Centers for Medicare & Medicaid Services. Medicare hospital quality chartbook. Baltimore: Centers for Medicare & Medicaid Services; 2013.
• [41]Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH et al.. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? Ann Intern Med. 2011; 154:384–w.130.
• [42]Morse JM. The significance of saturation. Qual Health Res. 1995; 5:147-149.
• [43]Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007; 42:1758-1772.
• [44]Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Aldine, Chicago; 1967.
• [45]Talbert-Slagle K, Berg D, Bradley EH. Innovation spread: lessons from HIV. Int J Qual Health Care 2013;25:352-6.
• [46]Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews, 2010. Issue 1. Art. No.: CD000313.
• [47]Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski RA. The efficacy of influenza vaccine in elderly persons. A meta-analysis and review of the literature. Ann Intern Med. 1995; 123:518-527.
• [48]Moberley SA, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2008;Issue 1. Art. No.: CD000422.