In general, literature and research studies focus on developing, implementing or evaluating interventions to improve quality and safety, and less attention is paid in the literature to developing effective methods for their dissemination or diffusion and sustainability. In fact, little research has been conducted that addresses hospital health care managers' information behaviors, their decisionmaking processes, or their use of information to support decisionmaking.250
Much of the diffusion literature on hospitals focuses on dissemination of quality improvement strategies within a hospital, rather than strategies to disseminate to hospitals. Berwick251 notes that dissemination of innovations studies generally focus on three categories of information:
- Perceptions of the innovation.
- Characteristics of those who adopt or fail to adopt the innovation.
- Contextual factors that influence diffusion.
Conducting this environmental scan is the first step in understanding these clusters of information that affect dissemination.
AHRQ's Development of a Planning Tool to Guide Research Disseminationh is intended to help researchers disseminate research findings and products to potential users in the health care system. Our project builds on the best practices identified in this tool through:
- Seeking input from end users of the Guide during development via our Steering Group members: conducting testing of materials with patients, family members, providers, and hospital leadership; and responding and talking with those who request information about the Guide.
- Building on facilitators identified for patients, family members, and providers, as well as internal and external organizational motivators related to engaging patients and families in safety and quality.
- Using our respected partners to disseminate this information to hospitals (e.g., Joint Commission, Institute for Family Centered Care).
- Using appropriate strategies to communicate messages about the Guide (e.g., verbal presentations at conferences or email distribution).
- Developing a dissemination plan.
Strategies for reaching audiences are changing rapidly because of new technology and advances in social and digital media. We will track these trends during the project to inform and develop dissemination strategies. For example, we will ensure that key search terms are "built into" the Guide so that potential users can easily find the Guide during a Google search.
Information from our key informant interviews emphasized best practices. Participants noted that the Guide should be "validated" through publication in a peer-reviewed journal article and should be presented at conferences. Several noted that endorsement and promotion by the Joint Commission, the Institute for Family-Centered Care, or AHRQ would be important. In addition, when deciding how to implement change at their hospital, one key informant noted that they spent 6 months researching available strategies; this research included conducting Google searches to identify hospitals in similar situations, interviewing administrators at those hospitals, and selecting four hospitals at which to conduct site visits.
Recommendations from Key Informant Interviews
During the key informant interviews, we asked about recommendations for the content and format of the Guide. Below, we present topline findings from these interviews on priority topics, the format of the Guide, and ways to gain buy-in from hospitals.
Priority Topics, Content Areas, and Points of Communication
Almost all key informants recommended that the Guide focus on ways to encourage patients to speak up or ask questions. One noted that the focus should be "a lot lower than where smart people would like to go." Strategies to speak up include tips on how to communicate most effectively, not only with providers but also through the "chain of command." Participants noted that patients and family members would need an invitation to ask questions of providers and the hospital system as well as a positive response from providers—both nurses and physicians—when they do speak up.
Interview participants suggested that nurses should be the priority target audience with regard to providers; however, several noted that nurses could not effect much change without support from physicians and senior leadership. Participants noted that the focus of health professional materials should be related to communication with patients and family members and should give specifics on how to include patients and family members as part of the health care team. Also, several participants noted the importance of demonstrating to providers the benefits of patient-centered care.
Other interviewees noted specific topics that should be addressed, such as hand washing, medication safety, bedside change of shift, and risks and benefits of specific procedures. In terms of points of communication, reactions were mixed about focusing on admission or discharge. Although getting patients and families information at admission was perceived as important, patients receive so much information (particularly in written format) that some participants thought it would be difficult to include more. Likewise, the discharge process was perceived as important; and at least one participant related the importance of discharge to the poor performance of hospitals on HCAHPS discharge scores. However, another participant noted that discharge often is rushed for the patient and that it may be difficult to convey information during this time.
In terms of overall organization, one participant suggested organizing the Guide into individual toolkits by topic (e.g., including all components for medication safety or bedside rounds), so that hospital leadership could prioritize where to focus their efforts.
Most participants noted that the format of the Guide should be a combination of print and online materials. Participants assumed that health care organizations would access the Guide electronically. This Web site would include materials that could be used as is, such as downloadable materials or videos for patients and family members or assessment tools for hospital leadership. At least one participant noted that hospitals would want to brand patient and family materials with their logo.
Also, participants recommended that the Guide include materials that could be tailored, such as examples of letters sent to patients and family members asking them to participate in Patient and Family Advisory Councils or PowerPoint presentations for employee orientations or for convincing senior leadership of the importance of engaging patients and family members in safety and quality issues. One participant suggested that training for providers should include continuing education credits.
Gaining Acceptance from Hospitals
Almost every participant noted that engaging patients and family members in safety and quality issues is an organizational culture change that requires effective leadership and buy-in from the board, senior leadership, and front-line caregivers. In particular, participants noted that hospital leadership will need a compelling reason to institute changes, not only for changes in organizational policies and procedures, but also for individual-level changes in behavior in terms of improving patient-provider communication. Several participants discussed motivators tied to patient satisfaction (e.g., HCAHPS) because these scores have an impact on reimbursement by the Centers for Medicare & Medicaid Services (CMS), as well as market factors important to the bottom line for hospitals. One participant noted that those hospital leaders who focus only on the bottom line will be the most difficult to convince:
But one of the lessons that I learned early on was that so much follows. I didn't set out to fix the financial bottom line; I set out to fix the hospital. We did, and it was not an "I" it was a "we." And when we began fixing all the component parts and pieces of the hospital, the bottom line started following in place.
Also, participants noted the importance of "storytelling" for all levels of the organization. Stories about experiences from patients and family members have a large impact at all levels—from the board to senior leadership to providers.