Background: The REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study sought to improve teamwork and quality for hospitalized patients by providing mentorship and resources to hospitals as they implemented: (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. Two mentors were assigned to the implementation team at each site. Acknowledging that context can influence implementation, we aimed to understand what contextual factors influenced the implementation of RESET interventions to provide guidance for future leaders and researchers.
Methods: We conducted non-participant observations at each of the 4 study sites and semi-structured interviews with participants from each site and their mentors. A team of researchers (IT, GJA, JSK, and KJO) conducted thematic analysis to inductively code the field notes and interview transcripts, and to identify themes in MAXQDA 2020.
Results: The research team (JKJ, MM, and KJO) conducted observations and took field notes during 2-day site visits (2 visits for 2 sites and 1 visit for 2 sites = 6 total site visits). One researcher (IT) conducted 1:1 semi-structured interviews with site mentors that lasted 60 minutes (8 total interviews). The research team identified two groups of factors: an overarching set of factors surrounding all the interventions and factors specific to each intervention. The four overarching factors that influenced implementation of RESET as whole were (1) system support and senior leader involvement; (2) alignment of RESET with system, hospital, and hospitalist group priorities; (3) site project team relationships, leadership, and turnover; and (4) frontline professionals’ buy-in as well as RESET’s perceived effect on workflow and workload. Intervention-specific factors for Unit-based Physician Teams include: (1) complex, poorly coordinated processes for assigning patients to beds and physicians; and (2) competing physician priorities. For Unit Co-leadership, factors include financial support and time for the physician unit leader to perform co-leader duties. For Enhanced Interprofessional Rounds, factors include (1) success of physician localization and (2) use of tools and training to ensure high quality discussions during rounds. For Unit-level Performance Reports, factors include: (1) the consistency and effectiveness of their use and (2) fidelity data collected as part of the RESET study, which helped confirm or refine site leaders’ perceptions of implementation success. For Patient Engagement Activities, factors include: (1) sites’ frequently missed opportunities to involve health system patient experience leaders and Patient and Family Advisory Councils and (2) assigning specific people for patient engagement related activities. The Table presents each contextual factor and an example.
Conclusions: This study yields valuable insights into contextual factors influencing the implementation of the RESET interventions. The findings provide a basis for practical strategies that health care leaders can employ to optimize the implementation of similar interventions to redesign systems to improve teamwork and quality for hospitalized patients.