About 1 in 5 Medicare fee-for-service patients discharged from the hospital is rehospitalized within 30 days. Beginning in 2013, hospitals with high risk-standardized readmission rates will be ...subject to a Medicare reimbursement penalty.
To describe interventions evaluated in studies aimed at reducing rehospitalization within 30 days of discharge.
MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched for reports published between January 1975 and January 2011.
English-language randomized, controlled trials; cohort studies; or noncontrolled before-after studies of interventions to reduce rehospitalization that reported rehospitalization rates within 30 days.
2 reviewers independently identified candidate articles from the results of the initial search on the basis of title and abstract. Two 2-physician reviewer teams reviewed the full text of candidate articles to identify interventions and assess study quality.
43 articles were identified, and a taxonomy was developed to categorize interventions into 3 domains that encompassed 12 distinct activities. Predischarge interventions included patient education, medication reconciliation, discharge planning, and scheduling of a follow-up appointment before discharge. Postdischarge interventions included follow-up telephone calls, patient-activated hotlines, timely communication with ambulatory providers, timely ambulatory provider follow-up, and postdischarge home visits. Bridging interventions included transition coaches, physician continuity across the inpatient and outpatient setting, and patient-centered discharge instruction.
Inadequate description of individual studies' interventions precluded meta-analysis of effects. Many studies identified in the review were single-institution assessments of quality improvement activities rather than those with experimental designs. Several common interventions have not been studied outside of multicomponent "discharge bundles."
No single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalization.
None.
Objective. To define the relationship between hospital patient safety climate (a measure of hospitals' organizational culture as related to patient safety) and hospitals' rates of rehospitalization ...within 30 days of discharge.
Data Sources. A safety climate survey administered to a random sample of hospital employees (n=36,375) in 2006–2007 and risk‐standardized hospital readmission rates from 2008.
Study Design. Cross‐sectional study of 67 hospitals.
Data Collection. Robust multiple regressions used 30‐day risk‐standardized readmission rates as dependent variables in separate disease‐specific models (acute myocardial infarction AMI, heart failure HF, pneumonia), and measures of safety climate as independent variables. We estimated separate models for all hospital staff as well as physicians, nurses, hospital senior managers, and frontline staff.
Principal Findings. There was a significant positive association between lower safety climate and higher readmission rates for AMI and HF (p≤.05 for both models). Frontline staff perceptions of safety climate were associated with readmission rates (p≤.01), but senior management perceptions were not. Physician and nurse perceptions related to AMI and HF readmissions, respectively.
Conclusions. Our findings indicate that hospital patient safety climate is associated with readmission outcomes for AMI and HF and those associations were management level and discipline specific.
Quality improvement (QI) efforts hold great promise for improving care delivery. However, hospitals often struggle with QI implementation and fail to sustain improvement in either process changes or ...patient outcomes. Physician mentored implementation (PMI) is a novel approach that promotes the success and sustainability of QI initiatives at hospitals. It leverages the expertise of external physician mentors who coach QI teams to implement interventions at their local hospitals. The PMI model includes five core components(1) a hospital self-assessment tool, (2) a face-to-face training session including direct interaction with a physician mentor, (3) a guided continuous quality improvement and systems approach, (4) yearlong individual physician mentoring, and (5) a learning community supported by a resource center, listserv, and webinars. Mentors provide content and process expertise, rather than offering “one-size-fits-all” technical assistance that might not be sustained after the mentoring year ends. Mentors support and motivate QI teams throughout the planning and implementation phases of their interventions, help to engage hospital leadership, garner local physician buy-in, and address institutional barriers. Mentors also guide hospitals to identify opportunities for the adaptation and customization of original evidence-based models of care while ensuring the fidelity of those models. More than 350 hospitals have used the PMI model to implement successful national and statewide QI initiatives. Academic medical centers are charged with improving the health of patients and reengineering care delivery; thus, they serve as the ideal source for physician mentors and can act as leaders in implementing QI projects using the PMI model.
ImportanceThough interprofessional bedside rounds have been promoted to enhance patient-centred care for hospitalised patients, few studies have been conducted in adult hospital settings and evidence ...of impact is lacking.ObjectiveTo evaluate the effect of patient-centred bedside rounds (PCBRs) on measures of patient-centred care.Design and settingCluster randomised controlled trial involving four similar non-teaching hospitalist service units in a large urban hospital.ParticipantsHospitalised general medical patients.InterventionWe assembled working groups on two intervention units, consisting of professionals and patient/family members, to determine the optimal timing, duration and format for PCBR. Nurses and hospitalists rounded together in PCBR using a communication tool to provide a framework for discussion and unit leaders joined PCBR to provide coaching during initial weeks of implementation.Main outcomesUsing patient interviews, we assessed preferred and experienced roles in medical decision-making using the Control Preferences Scale, activation using the Short Form of the Patient Activation Measure, and satisfaction. We also compared postdischarge patient satisfaction survey items related to teamwork, involvement in decisions and overall care. We assessed nurses’, physicians’ and advanced practice providers’ (APP) perceptions of PCBR using a survey developed for this study.ResultsOverall, 650 patients were approached for structured interview during hospitalisation: 284 were excluded because of disorientation, 54 were excluded because of non-English language, 72 declined to participate and 4 withdrew from the study after enrolment. Interview data were available for 236 (122 control and 114 intervention unit) patients, and postdischarge satisfaction survey data were available for 493 (274 control and 219 intervention unit) patients. We found no significant differences in patients’ perceptions of shared decision-making, activation or satisfaction with care. Results were similar in analyses based on whether PCBR had been performed (ie, per protocol). We also found no difference in postdischarge patient satisfaction items. Results were similar in multivariate analyses controlling for patient characteristics and clustering of patients within study units. A majority of nurses (78.6%), but only about half of hospitalist physicians and APPs felt that PCBR improved communication with patients (47.4%). A minority of nurses (46.4%) and physicians and APPs (36.8%) agreed that PCBR had improved the efficiency of their workday.ConclusionsPCBR had no impact on patients’ perceptions of shared decision-making, activation or satisfaction with care. Additional research is needed to identify optimal approaches that can be reliably implemented in hospital settings to improve patient-centred care.
To identify factors underlying heart failure hospitalization.
Between January 1, 2012, and May 31, 2012, we combined medical record reviews and cross-sectional qualitative interviews of multiple ...patients with heart failure, their clinicians, and their caregivers from a large academic medical center in the Midwestern United States. The interview data were analyzed using a 3-step grounded theory-informed process and constant comparative methods. Qualitative data were compared and contrasted with results from the medical record review.
Patient nonadherence to the care plan was the most important contributor to hospital admission; however, reasons for nonadherence were complex and multifactorial. The data highlight the importance of patient education for the purposes of condition management, timeliness of care, and effective communication between providers and patients.
To improve the consistency and quality of care for patients with heart failure, more effective relationships among patients, providers, and caregivers are needed. Providers must be pragmatic when educating patients and their caregivers about heart failure, its treatment, and its prognosis.
Project BOOST implementation: lessons learned Williams, Mark V; Li, Jing; Hansen, Luke O ...
Southern medical journal (Birmingham, Ala.),
2014-July, Letnik:
107, Številka:
7
Journal Article
Recenzirano
Enhancing care coordination and reducing hospital readmissions have been a focus of multiple quality improvement (QI) initiatives. Project BOOST (Better Outcomes by Optimizing Safe Transitions) aims ...to enhance the discharge transition from hospital to home. Previous research indicates that QI initiatives originating externally often face difficulties gaining momentum or effecting lasting change in a hospital. We performed a qualitative evaluation of Project BOOST implementation by examining the successes and failures experienced by six pilot sites. We also evaluated the unique physician mentoring component of this program. Finally, we examined the impact of intensification of the physician mentoring model on adoption of BOOST interventions in two later Illinois cohorts (27 hospitals).
Qualitative analysis of six pilot hospitals used a process of methodological triangulation and analysis of the BOOST enrollment applications, the listserv, and content from telephone interviews. Evaluation of BOOST implementation at Illinois hospitals occurred via mid-year and year-end surveys.
The identified common barriers included inadequate understanding of the current discharge process, insufficient administrative support, lack of protected time or dedicated resources, and lack of frontline staff buy-in. Facilitators of implementation included the mentor, a small beginning, teamwork, and proactive engagement of the patient. Notably, hospitals viewed their mentors as essential facilitators of change. Sites consistently commented that the individualized mentoring was extremely helpful and provided significant accountability and stimulated creativity. In the Illinois cohorts, the improved mentoring model showed more complete implementation of BOOST interventions.
The implementation of Project BOOST was well received by hospitals, although sites faced substantial barriers consistent with other QI research reports. The unique mentorship element of Project BOOST proved extremely valuable in helping sites overcome their distinctive challenges and identify facilitators for success. The findings from this qualitative study should contribute to future BOOST implementation success and others' efforts to optimize hospital discharge transitions.
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