The Sustainability of Innovations in Hospitals: A Look at Rapid Response Teams

This study sought to broaden our understanding of the factors, contexts and processes that bring about the sustainability of innovations in hospitals. Rapid response teams (RRTs)--an innovation that brings critical care expertise to patients in crisis with the goal of improving quality of care--was examined. Guided by an adapted version of Shediac-Rizkallah and Bone's (1998) Planning Model of Sustainability, a two phased approach that incorporated both quantitative and qualitative methods, was used. In Phase One, to determine the level of RRT sustainability, an online survey was administered to a convenience sample of 56 North Carolina (NC) hospitals that had participated in the NC Hospital Association's RRT Collaborative. The RRT-Institutionalization Scale, based on Goodman, McLeroy, Steckler, and Hoyle's (1993) Level of Institutionalization Scale, was developed and used to measure sustainability. Thirty-three hospitals (58%) participated in the survey. Descriptive statistics were used to obtain information about organizational and RRT characteristics, and to calculate and then rank hospitals into quartiles based on their sustainability scores. The mean sustainability score for participating hospitals was 3.71 (range, 1.0 to 5.19). In Phase Two, a multiple case study approach was used to examine four cases (two hospitals in the highest and two in the lowest quartiles of sustainability scores) and gather in-depth data about the sustainability of RRTs in hospitals. Data were gathered using a brief hospital questionnaire, interviews with key stakeholder groups (leadership, RRT members, and RRT end-users), and documentation review. Cross-case analyses were conducted by comparing (a) the two high-sustainability hospitals, (b) the two low-sustainability hospitals, and (c) the two groups of high- and low-sustainability hospitals. The results indicated that the presence of PMOS and other factors, as well as certain contexts, and processes facilitated sustainability in hospitals. Several differences were found between hospitals that reported high levels of RRT sustainability and those that reported low levels of RRT sustainability. Based on these findings, a model of RRT sustainability was proposed. Further research is needed to test the applicability of this model to hospitals in other states in the U.S., other types of hospitals, and other types of innovations.Doctor of Philosoph

A Survey of Hospitals That Participated in a Statewide Collaborative to Implement and Sustain Rapid Response Teams

To determine the level of sustainability of Rapid Response Teams (RRTs) among a group of hospitals that participated in a statewide collaborative to implement and sustain RRTs

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BackgroundThe first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.MethodsMARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.DiscussionA mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation

Implementation strategies in the context of medication reconciliation: a qualitative study

Abstract Background Medication reconciliation (MedRec) is an important patient safety initiative that aims to prevent patient harm from medication errors. Yet, the implementation and sustainability of MedRec interventions have been challenging due to contextual barriers like the lack of interprofessional communication (among pharmacists, nurses, and providers) and limited organizational capacity. How to best implement MedRec interventions remains unclear. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy, we report the differing strategies hospital implementation teams used to implement an evidence-based MedRec Toolkit (the MARQUIS Toolkit). Methods A qualitative study was conducted with implementation teams and executive leaders of hospitals participating in the federally funded “Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety” (known as MARQUIS2) research study. Data consisted of transcripts from web-based focus groups and individual interviews, as well as meeting minutes. Interview data were transcribed and analyzed using content analysis and the constant comparison technique. Results Data were collected from 16 hospitals using 2 focus groups, 3 group interviews, and 11 individual interviews, 10 sites’ meeting minutes, and an email interview of an executive. Major categories of implementation strategies predominantly mirrored the ERIC strategies of “Plan,” “Educate,” “Restructure,” and “Quality Management.” Participants rarely used the ERIC strategies of finance and attending to policy context. Two new non-ERIC categories of strategies emerged—“Integration” and “Professional roles and responsibilities.” Of the 73 specific strategies in the ERIC taxonomy, 32 were used to implement the MARQUIS Toolkit and 11 new, and non-ERIC strategies were identified (e.g., aligning with existing initiatives and professional roles and responsibilities). Conclusions Complex interventions like the MARQUIS MedRec Toolkit can benefit from the ERIC taxonomy, but adaptations and new strategies (and even categories) are necessary to fully capture the range of approaches to implementation

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BackgroundThe first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.MethodsMARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.DiscussionA mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation