Background: The AHRQ-funded REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study was designed to improve teamwork and quality for hospitalized patients by providing mentorship and resources to hospitals as they implemented 5 interventions, which included (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 years into the project, the COVID pandemic impacted health systems in a variety of ways, often prompting rapid, major changes to staffing and space for patient care. The effect of the COVID pandemic on implementation of complex quality improvement interventions like RESET is unclear. We aimed to leverage this natural experiment to understand how COVID affected 4 geographically distinct hospitals and as a result, how this influenced implementation of RESET.

Methods: One researcher (IT) conducted 1:1 semi-structured interviews within the context of the larger RESET study. Leaders, physicians, nurses, and staff were recruited from the 4 diverse hospitals that participated in RESET. The interview protocol was structured to ask participants (1) how their work changed during COVID, (2) how COVID affected implementation of RESET, and (3) how RESET affected their response to COVID. Interviews were digitally recorded and transcribed verbatim. A team of researchers (IT, MM, JKJ, and KJO) conducted thematic analysis to inductively code interview transcripts and to identify themes in MAXQDA 2020.

Results: 40 participants (21 leaders, 8 physicians, 6 nurses, and 5 staff) agreed to be interviewed. We identified 5 overarching themes from the analysis. (1) COVID created unique problems that led to changes in workflow, communication, and emotional states. Changes related to census, patient acuity, finances, throughput, and staffing occurred. Further, communication, workflow, and workload changed due to COVID precautions. As a result, morale was low, and anxiety and stress were high. (2) There were disruptions in addition to COVID that impacted some hospitals. The hospitalist employment model changed at 2 sites and natural disasters occurred at the other 2 sites. These events added stress and challenged the sites to make adaptations during the pandemic. (3) RESET was not the priority. COVID was used by some as an excuse to abandon RESET, and site leaders focused on supporting staff and COVID changes. (4) The fidelity of implementing interventions regressed. Sites varied in their ability to renew their implementation efforts as the surges subsided. (5) RESET improved relationships and trust among disciplines, which helped sites manage COVID. RESET improved communication among staff and with patients and professionals perceived loss from not doing RESET. The Table presents each theme and an example.

Conclusions: Themes identified from our qualitative data describe the profound impact of COVID and its effect on the implementation of a complex quality improvement intervention in 4 geographically distinct hospitals. Leaders and researchers can incorporate our findings to design strategies to mitigate the effect of future external disruptions on complex quality improvement interventions.

IMAGE 1: Themes and Illustrative Examples (part 1)

IMAGE 2: Themes and Illustrative Examples (part 2)