Williams Mark V, Li Jing, Hansen Luke O, Forth Victoria, Budnitz Tina, Greenwald Jeffrey L, Howell Eric, Halasyamani Lakshmi, Vidyarthi Arpana, Coleman Eric A
From the Department of Internal Medicine, the Center for Health Services Research, University of Kentucky, Lexington, Division of Hospital Medicine, the Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, Society of Hospital Medicine, Philadelphia, Pennsylvania, Harvard University School of Medicine, Massachusetts General Hospital, Boston, Johns Hopkins University School of Medicine, Baltimore, Maryland, St Joseph Mercy Hospital, Ann Arbor, Michigan, Division of Hospital Medicine, Singapore Health Services, HealthcareLeadership College, Duke-National University of Singapore Graduate Medical School, Singapore, and Division of Health Care Policy and Research, University of Colorado, Denver.
South Med J. 2014 Jul;107(7):455-65. doi: 10.14423/SMJ.0000000000000140.
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.
加强护理协调和减少医院再入院率一直是多项质量改进（QI）举措的重点。BOOST项目（通过优化安全过渡实现更好结果）旨在加强从医院到家庭的出院过渡。先前的研究表明，外部发起的QI举措在医院往往难以获得动力或实现持久变革。我们通过考察六个试点地点所经历的成功与失败，对BOOST项目的实施进行了定性评估。我们还评估了该项目独特的医生指导部分。最后，我们考察了强化医生指导模式对伊利诺伊州后来的两个队列（27家医院）采用BOOST干预措施的影响。
对六家试点医院进行定性分析，采用方法三角测量法，并分析BOOST注册申请、邮件列表以及电话访谈内容。通过年中及年末调查对伊利诺伊州医院的BOOST项目实施情况进行评估。
确定的常见障碍包括对当前出院流程理解不足、行政支持不足、缺乏受保护时间或专用资源以及一线工作人员缺乏认同。实施的促进因素包括指导者、小规模起步、团队合作以及患者的积极参与。值得注意的是，医院将其指导者视为变革的关键促进因素。各试点一致表示，个性化指导非常有帮助，提供了重要的问责制并激发了创造力。在伊利诺伊州的队列中，改进后的指导模式显示BOOST干预措施得到了更全面的实施。
BOOST项目的实施受到了医院的欢迎，尽管各试点面临着与其他QI研究报告一致的重大障碍。BOOST项目独特的指导元素在帮助各试点克服独特挑战并确定成功的促进因素方面被证明极具价值。这项定性研究的结果应有助于未来BOOST项目实施的成功以及其他人优化医院出院过渡的努力。
