Background: Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of single interventions. We sought to implement a set of complementary interventions and evaluate the effect on interprofessional teamwork and patient safety.

Methods: The REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study used the Advanced and Integrated MicroSystems (AIMS) interventions, consisting of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive mentorship and resources as they implemented the AIMS interventions. A physician and nurse leadership dyad at each site led AIMS implementation, meeting monthly via webinar with a RESET physician and nurse mentor dyad for guidance. Site leaders selected 1 unit for initial implementation of interventions within their hospitals and 1-2 units for later implementation of interventions. Implementation of the AIMS interventions on the initial units was to occur in or around October 2018 and implementation on subsequent units to occur in or around October 2019. Herein, we report analyses for the initial units (intervention units) compared to units for which implementation was delayed (control units). Primary outcomes included teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events (AE) using the Medicare Patient Safety Monitoring System. We administered the teamwork climate survey to all physicians, nurses, nursing assistants, advanced practice providers, pharmacists, social workers, and case managers before and approximately 12 months after AIMS implementation on the intervention units. Research nurses at each site reviewed medical records to identify AEs for randomly selected study unit patients 12 months before and after AIMS implementation on the intervention units, with a target enrollment of 482 per site per year. We compared teamwork climate pre- and post-intervention using Wilcoxon Rank Sum tests and conducted difference-in-difference analyses of AEs experienced by patients on intervention and control units using Poisson regression with days on study units as the exposure variable and standard errors robust to the clustering of patients within each hospital.

Results: Across all 4 sites, 261 of 318 (82.1%) eligible professionals completed surveys pre- and 221 of 307 (72.0%) professionals completed surveys post-intervention. Teamwork climate was significantly greater post- compared to pre-intervention for all professionals in aggregate and nurses in subgroup analyses (Table 1). Difference-in-differences analyses showed a lower rate of AEs for patients on intervention units post-intervention, with the adjusted comparison achieving statistical significance (Table 2). The result was driven by higher rates of AEs on control units in the post-intervention period.

Conclusions: A multifaceted intervention to redesign systems for hospitalized medical patients was associated with greater teamwork climate and lower AEs, though the latter finding should be interpreted with caution because of an unexpected rise in AEs for control units. Hospital leaders should consider implementing the RESET AIMS interventions to improve interprofessional teamwork and patient safety.

IMAGE 1: Pre-Post Teamwork Climate Score Results

IMAGE 2: Difference-in-differences Analysis of Adverse Events by Study Period and Unit Type