Discharge processes in US hospitals frequently lack key components that ensure and facilitate smooth transitions from the inpatient to the outpatient setting. As a result patients are more likely to experience poor outcomes such as further functional decline, readmission, emergency department visits, medications errors, higher cost. Project Re-Engineered Discharge (RED), an evidence-based intervention to improve the discharge process, demonstrates that many of the outcomes resulting from poor discharge processes are preventable. The goal of this study is to evaluate the implementation process of RED in five Veterans Administration Medical Centers (VAMCs).
This project has three specific aims: 1) examine the initial contextual factors that may affect the success of RED implementation; 2) assess the extent to which the actual implementation of RED adheres to the 11 components and 12 Toolkit implementation steps recommended by the developers of RED and, if modified, the ways in which these components and/or implementation steps were tailored; and 3) identify the factors facilitating successful implementation of RED, barriers to implementation, and approaches to overcoming the barriers.
Over sixteen months, 29 front-line staff and middle managers involved with RED at five large, geographically diverse VA teaching hospitals were interviewed at two time points. Analysts coded qualitative data gathered from these semi-structured interviews on implementation and contextual factors influencing implementation in NVivo10 software. Analysts then created single site-summaries and conducted cross-site analysis using a consensus process. Information on contextual influences was compared to 2012 All Employee Survey (AES) data. The VA Office of Systems Redesign moderated five Learning Groups for participating sites. Three Expert Panels were convened at VA Boston Healthcare System to guide research activities.
Aim 1: All sites selected RED to improve readmission rates and address problems with their prior discharge processes. Sites recognized that the following issues affected their previous processes: unstandardized medication reconciliation; coordination of follow-up appointments and home care services; inconsistent provider teaching; the absence of discharge instructions; and patients who lacked an understanding of who to call if a problem arose.
A number of positive contextual factors influencing implementation were identified, namely the ability to target the patient population, collect and analyze performance data, and obtain the resources necessary to hire staff. RED was considered evidence-based and patient-centered, required a dedicated RED team, coordination across many departments, and the need for shared goals.
Burden was one consistent negative influence in that executing RED required a time-intensive redesign of discharge processes and an allocation of resources to assist in the redesign. Staff at some sites felt RED could be viewed as burdensome to patients because they received multiple follow-up calls originating from different departments.
No meaningful statistically significant differences between sites on the AES workgroup functioning and organizational culture scales were found.
Aim 2: Implementation progress varied across sites; one being in the planning phase while the others had been active from eight months to two years. Sites differed in their adaptation of the 11 RED components, adopting only those aspects that fit their local environments. Four out of 11 components were fully or somewhat implemented by all sites including organizing post-discharge services, confirming the medication plan, expediting transmission of the discharge resume to physicians and other staff and providing telephone reinforcement. In addition, seven of 12 toolkit steps were fully or somewhat implemented.
In terms of Patient Aligned Care Team (PACT) involvement in RED, PACT provided telephone reinforcement of the discharge plan at four out of the five sites but their involvement in other aspects of the initiative varied across sites (e.g., involvement in team meetings).
Aim 3: There were several key findings regarding RE-AIM model outcomes. RED's reach fluctuated among the sites--from 170 to 1,000 patients enrolled in RED. Although each site had different inclusion criteria, patients with Congestive Heart Failure, Acute Myocardial Infarction, and Pneumonia were consistently recruited across sites. In terms of effectiveness, all sites collected data on readmission rates, while two sites also assessed emergency department visits. Two sites identified and measured process measures. At Time 2, overall implementation adherence to the RED components and Toolkits steps ranged from 14 to 43 points (out of 46 points). Sites were diverse in how they planned to further adopt RED within their organizations; two sites planned to expand throughout the medical service, two from medicine into surgery, and one had no expansion plans.
Based on RE-AIM performance, there were two high-performance sites, two middle-performance sites, and one low-performance site. Trends in contextual factors by performance were not evident. All sites encountered barriers during various points in the implementation process including obtaining leadership buy-in, engaging stakeholders, identifying realistic goals, and understanding work flow processes. At Time 2, some sites reported the need for the following: additional staff, role clarity, training, and updated patient education materials. The four sites currently utilizing RED expressed moderate to high levels of satisfaction with the intervention.
Respondents indicated they would focus on the following areas to overcome barriers: obtaining buy-in from appropriate staff members (e.g., nursing) and involving them from project inception, ensuring all tools were available to analyze work flow management, starting the contracting process early, setting realistic expectations about outcomes and timelines, conducting specialized RED training, instilling culture change, and dedicating attention to collecting the most relevant data.
Our results suggest that Project RED can be successfully tailored to the VA setting. Sites believed that the RED components were executable but differed in the way they applied the intervention. Sites furthest along in their implementation activities had a strong impetus to change (e.g., reducing high readmission rates), leadership and clinical staff support, and were ready to accept the amount of effort required to implement RED. Sites were able to adopt Project RED because of its adaptability; however, redesigning care processes to accommodate RED can be a large undertaking.
External Links for this Project
- Sullivan JL, Shin MH, Engle RL, Yaksic E, VanDeusen Lukas C, Paasche-Orlow MK, Starr LM, Restuccia JD, Holmes SK, Rosen AK. Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Administration (VHA) Hospitals. Joint Commission Journal on Quality and Patient Safety. 2018 Nov 1; 44(11):663-673. [view]