Integrating new practices: a qualitative study of how hospital innovations become routine

Implementation Science, Dec 2015

Background Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs. Methods We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010–2011 to 2011–2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes. Results When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks. Conclusions Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations.

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Integrating new practices: a qualitative study of how hospital innovations become routine

Brewster et al. Implementation Science Integrating new practices: a qualitative study of how hospital innovations become routine Amanda L. Brewster 0 Leslie A. Curry 0 Emily J. Cherlin 0 Kristina Talbert-Slagle 0 Leora I. Horwitz 1 2 3 Elizabeth H. Bradley 0 0 Department of Health Policy and Management, Yale School of Public Health , New Haven, CT , USA 1 Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center , New York, NY , USA 2 Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine , New York, NY , USA 3 Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine , New York, NY , USA Background: Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs. Methods: We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010-2011 to 2011-2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes. Results: When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks. Conclusions: Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations. Hospitals; Innovation; Integration of new practices; Management; Readmissions Background Health care policy-makers, clinicians, and managers invest substantial time and resources in hospital quality improvement efforts, but many organizations fail to integrate new practices into organizational routines [ 1–4 ]. We use integrate to mean embedding a new practice into the standard workflow of the organization. Lack of integration undermines the potential to sustain the new practices [ 5, 6 ]. Within the field of health services research, several well-developed models have identified factors affecting implementation of new practices [ 7, 8 ], and recent theoretical work [ 4, 9–11 ] has highlighted the need to understand integration as a distinct and important feature of the implementation process. This stream of work in health services research supplements theory on absorptive capacity from the general management literature, which identifies an organization’s capacity to integrate new knowledge as a distinct ability [ 12–14 ] and posits a “routinizing” phase [ 15 ] during which integration takes place. Despite the presence of this theoretical literature, we have limited knowledge about the mechanisms by which integration occurs, as a paucity of empirical studies has focused on the integration of new practices into organizational routines. We use organizational routines to refer to procedures and staff behaviors that occur regularly as part of normal hospital operations, as distinct from extraordinary implementation efforts that often accompany the introduction of a new practice. The influential review by Greenhalgh and colleagues [ 8 ] cited a gap in research on “the process leading to longterm routinization” of innovations, but little evidence on this topic has emerged in the intervening years. The few existing studies have described factors that appear to facilitate integration, including visible improvements in outcomes [ 16–18 ], (...truncated)


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Amanda Brewster, Leslie Curry, Emily Cherlin, Kristina Talbert-Slagle, Leora Horwitz, Elizabeth Bradley. Integrating new practices: a qualitative study of how hospital innovations become routine, Implementation Science, 2015, pp. 168, 10, DOI: 10.1186/s13012-015-0357-3