Mitchell S E, Weigel G M, Laurens V, Martin J, Jack B W
Department of Family Medicine, Boston Medical Center, 751 Albany St Dowling building 5th floor south, Boston, MA, 02118, USA.
BMC Health Serv Res. 2017 Apr 19;17(1):291. doi: 10.1186/s12913-017-2242-z.
Project 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.
Participant 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.
Both 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.
The 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.
“重新设计出院计划”（RED）项目是一项基于证据的策略，旨在减少再入院率，已在全国多个医疗系统中推广和应用。迄今为止，对于如何根据原始方案调整RED项目对其实施和/或可持续性的影响知之甚少。本研究的目的是识别并描述影响加利福尼亚州五家医院如何调整和实施RED项目的背景因素，以及这些因素对RED项目可持续性的后续影响。
2012年和2013年，对加利福尼亚州五家实施RED项目的医院中的64名人员进行了参与观察、关键信息提供者访谈和焦点小组访谈。这些人员包括医院领导、负责RED项目实施的人员、医院工作人员和临床医生。访谈记录采用改进的扎根理论方法和持续比较分析进行编码和分析。
识别出了影响医院对RED项目进行调整和实施决策的内部和外部背景因素。这些因素也影响了RED项目的可持续性。外部因素包括：针对特定诊断的高再入院率医院即将面临的联邦处罚，以及获得外部资金和技术支持以帮助医院实施RED项目。内部或组织层面的背景因素包括：致力于RED项目的领导；对RED项目的调整；实施团队的深度、问责制和影响力；可持续性规划；以及医院文化。五家医院中只有三家在实施期后继续开展RED项目。
只有当医院将RED项目的实施视为一个变革过程而非患者安全项目，对RED方案保持高度的忠诚度，并且有乐于接受变革和失败以追求更好的患者护理和结果的领导及实施团队时，参与医院的RED项目才有可能实现可持续性。在实施可持续RED项目过程中未取得成功的医院，其方法中缺乏所有或大部分这些要素。
