NR 449 Evidence Based Practice RUA Topic Search Strategy Essay

Hesselink et al. BMC Health Services Research 2014, 14:389 http://www.biomedcentral.com/1472-6963/14/389

RESEARCH ARTICLE Open Access

Improving patient discharge and reducing hospital readmissions by using Intervention Mapping Gijs Hesselink1*, Marieke Zegers1, Myrra Vernooij-Dassen1,2,3, Paul Barach4,5,6, Cor Kalkman4, Maria Flink7,8, Gunnar Öhlén9,10, Mariann Olsson7,8, Susanne Bergenbrant11, Carola Orrego12, Rosa Suñol12, Giulio Toccafondi13, Francesco Venneri13, Ewa Dudzik-Urbaniak14, Basia Kutryba14, Lisette Schoonhoven1, Hub Wollersheim1

and on behalf of the European HANDOVER Research Collaborative

Abstract

Background: There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.

Methods: The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance.

Results: Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well- coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.

Conclusions: This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

Keywords: Patient handoff, Patient discharge, Patient readmission, Intervention mapping, Adverse events

* Correspondence: gijs.hesselink@radboudumc.nl 1Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands Full list of author information is available at the end of the article

© 2014 Hesselink et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Background Patients still experience needless harm and often struggle to have their voices heard, processes are not as efficient as they could be, and costs continue to rise at alarming rates while quality issues remain. A shorter length of hos- pital stay, the decrease in work-hours of health care pro- viders, and the increasing number of patient transitions between departments and institutions requires effective patient handovers, especially those of frail patients with comorbidities [1]. Continuity of care at patient discharge from the hospital is a critical aspect of high quality patient care [2,3]. Highly reliable care requires close cooperation between care providers across organisational boundaries, thereby establishing an interdisciplinary network [4]. Unfortunately, incomplete or incorrect information and communication errors between hospital care providers and the multiple receiving parties often increase the chance of adverse events. These may ultimately lead to life threatening situations, avoidable treatments, un- planned re-hospitalisations [5,6], and extra costs [7-9]. Although studies have identified discharge problems

in the social, organisational, linguistic and technical context [10-12], there is insufficient, evidence driven insights into more effective solutions. The effectiveness of most interventions is highly variable and limited in daily practice. Explanations for these disappointing re- sults include the difficulty of changing providers behav- iour and existing practices, non-optimal intervention strategies, inadequate resources devoted to evaluating the impact of interventions, and inadequate methods to design and evaluate interventions [13-15]. A systematic approach for translating discharge problems into custo- mised solutions is lacking. Many clinical intervention developers select their strategies intuitively. Effective interventions need to be theory- and evidence based, and targeted at specific behavioural and environmental factors [16,17]. The aim of our study was to systematically develop a

guiding framework to more effective design of interven- tions that support care providers and policy-makers to improve patient handovers from the hospital to primary care.

Methods Intervention mapping (IM) is a systematic, iterative six- step process that helps to develop an intervention, based on theoretical, empirical and practical information [18]. The steps are summarised in Table 1. IM was originally used effectively in the health promotion domain to de- velop programs for smoking cessatation [19], stroke pre- vention [20], asthma management [21], HIV prevention [22], and leg ulcer management [23]. We modified the IM terminology in order to apply it to the quality im- provement domain.

Step 1: Problem analysis We structured the problem analysis by using the PRE- CEDE PROCEED model [24] (see Additional file 1), to analyse and describe the scale, causes, and conse- quences of the health problem and to identify the target population.

Procedure and participants A literature search on the frequency and consequences of ineffective hospital discharge problems was performed [25]. We performed a large qualitative study on patient handovers between acute care hospitals and primary care in five countries, i.e. The Netherlands, Spain, Poland, Sweden, and Italy, to identify the behavioural and envir- onmental determinants influencing ineffective hospital discharge [10-12]. The study adhered to the RATS (Rele- vance, Appropriateness, Transparency, Soundness) guide- lines for qualitative studies. Data collection and analysis consisted of multi-method qualitative research including individual and focus group interviews [26], process maps, artefact analyses [10-12], and Ishikawa diagrams [27] (Table 1). The discharged patients and their care pro- viders were recruited using general and country-specific inclusion criteria (see Additional file 2). The study was approved by the ethics committee of the University Med- ical Center Utrecht — Medical Ethics Committee. Pa- tients were asked for informed consent.

Step 2: Identify intervention outcomes, performance objectives and change objectives In step 2, we identified the desired outcomes of the intervention and formulated specific performance objec- tives for the target population, such as writing a complete, accurate and timely discharge letter by the hospital physician. This resulted in a step-by-step check- list of what needs to be accomplished in order to obtain the desired outcomes [28]. It is important to identify what steps need to be

tweaked in order to affect the performance objective, and ultimately the intervention outcome [28]. We identified the most important determinants (e.g., lack of knowledge and understanding between hospital and primary care providers) that need to be changed and combined these with performance objectives to formulate our change ob- jectives. These change objectives specified who and what will change as a result of the intervention.

Procedure and participants A literature search of the desired outcomes of the inter- vention was conducted [25]. The performance objec- tives and matrices of change objectives were discussed in a multidisciplinary study panel (n = 5) that included experts in health-, social- and organisational sciences. Members of the European HANDOVER Research

Table 1 Intervention mapping steps, objectives and methods*

Steps Objectives Methods

1. Problem analysis ▪ Gain insight into health problem, quality of care, underlying causes and target population

▪ Problem analysis using PRECEDE-PROCEED model;

▪ Analysis based on:

- Literature research

- Individual interviews (n = 321)

- Focus group interviews (n = 26)

- Process maps (n = 5)

- Artifact analyses (n = 5)

- Ishikawa (fishbone) diagrams (n = 5)

2. Identify intervention outcomes, performance objectives and change objectives

▪ State intervention outcomes ▪ Use evidence from literature and empirical data from problem analysis (step 1)

▪ Specify performance objectives

▪ Select important and changeable determinants ▪ Input from experts in the field of patient handover (healthcare providers, and organizational, social and health scientists)

▪ Develop matrices with change objectives based on performance objectives and determinants of suboptimal hospital discharge

3. Select theory-based methods and strategies

▪ Identify and select theoretical methods ▪ Literature search on theory-based methods

▪ Select evidence-based interventions and design of practical strategies

▪ Input from experts (n = 220)

▪ Ensure that interventions and strategies address change objectives

▪ Systematic literature review on evidence based discharge interventions

▪ Additional search for experience based practical strategies

▪ Matching methods and practical strategies with determinants and performance objectives (step 1 and 2)

4. Develop an intervention ▪ Provide suggestions for developing an intervention ▪ Input from literature search and experts

5. Implementation ▪ Provide suggestions for writing an implementation plan

▪ Literature search of implementation strategies and tools

6. Evaluation ▪ Provide suggestions for writing an evaluation plan ▪ Literature search on methods for effect and process evaluation on complex interventions

*Adapted from Bartholomew et al. [18].

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Collaborative (n = 15 experts in the field of handover and health care providers) prioritised using a survey the large number of determinants of importance on a 5-point Likert scale.

Step 3: Selection of theory-based methods and strategies We selected theory-based methods that relate to the change objectives in step 2. These methods were required to change the behavioural and environmental determi- nants of ineffective hospital discharge. Subsequently, these methods were translated into practical strategies.

Procedure and participants Theory-based methods were identified from our litera- ture search and mainly found in overviews provided by

Bartholemew et al. [18], Achterberg et al. [29], and Grol et al. [30]. A total of 220 international researchers, policy-makers and regulators in the field of quality and safety in healthcare, healthcare providers and patient representatives were consulted about their experiences with successful strategies or promising ideas during three expert meetings in 2010–2011 [31]. A systematic review of randomised controlled trials (RCTs) of the ef- fects of discharge interventions provided an overview of evidence-based strategies [32]. The systematic review was performed in accordance with the PRISMA guide- lines. An additional literature search was performed to identify promising strategies that were not included in the systematic review (e.g., evaluated with a weaker study design than RCTs) or not evaluated yet (e.g., local

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initiatives). The strategies were selected by the study panel after 11 iterative discussion sessions based on the findings from the systematic review, the experiences of the experts and the additional literature search.

Step 4: Develop an intervention In this step, we provide suggestions for the design of the intervention by considering the target group and local setting [18]. The intervention studies identified in step 3 were classified independently by two researchers (GH and MZ) according to the Oxford Centre for Evidence-Based Medicine - Levels of Evidence from 2009 onward [33].

Steps 5 and 6: Implementation and Evaluation We made suggestions for developing an implementation plan for accomplishing program adoption, and for evalu- ating the effects and feasibility of the intervention pro- gram. The suggestions were based on literature regarding effective implementation strategies [17,30,34-36], existing implementation toolboxes [37,38], and a literature review on methods to evaluate complex interventions in health care [35,39,40].

Health care professional behavio

Poor information exchange betwee

care providers:

- delayed, incomplete, unclea information (e.g., discharge

- un- or misinformed health p specific needs)

Poor coordination of care:

- hospital and primary care pr actors

- delayed or poor discharge p follow-up

- lack of preparing patients fo

Many discharge problems remain

opportunities for improvement mis

Inadequate information exchange b

professional and patient:

- formal and swift discharge c - lack of discharge informatio

patient (and relative) or give

discharge;

- use of medical-technical lan providers

- overload of non-prioritized information received by pat

Determinants for health care professional behaviour INDIVIDUAL HEALTHCARE PROVIDER DETERMINANTS

- Lack of awareness of consequences of suboptimal hospital discharge

- Priority on providing medical or nursing care prevails over administrative handover tasks

- Lack of willingness, knowledge and skills to reflect, learn and improve discharge practice

- Relying too much on discharge routines ENVIRONMENTAL DETERMINANTS Interpersonal

- Inward attitude - Lack of collaborative attitude - Distant and negative attitudes/relationship between hospital

and primary care providers

- Lack of knowledge and understanding with organization, expectations and needs of primary care providers

- Lack of shared communication language - Lack of structural, problem-related feedback between

hospital and primary care providers

- Lack patient-centred attitude Organizational factors

- Hospital size and identity - Lack of priority and awareness on a managerial level - Lack of guidelines, standards of evidence-based practice - Work load/ time pressure - Work shift structures - Poor accessibility of hospital care providers - Pressure on available hospital beds and community care

Technical factors - Lack of (uniform) shared electronic information exchange

system between hospital and primary care

Determinants of patient behaviour

- Patient and relatives are unaware of option to take a (pro)active role to contribute to effective handover

- Patients are less skilled or don’t dare to speak up - Patients do not know what to ask - Neither patient nor family knows the medical

history/medication

- Low health literacy/care givers use too difficult language - Lack of family support - Lack of social resources

Patient behavioural causes - Patient does not ask for more - Patient does not protest again - Lack of knowledge of patient - Patient forgets to handover di - Patient does not signal specif

Figure 1 Model of suboptimal hospital discharge: overview of the he

Results Step 1: Problem analysis The health problem and the underlying causes are pre- sented in Figure 1. The published studies demonstrate that one in five patients experience an adverse event within 3 weeks after hospital discharge, of which one in three was considered preventable [41]. Three per cent of the adverse events led to permanent disability, in- cluding death. The one month unplanned readmission rates varied between 13% [42], and 20% [43]. Unneces- sary hospital readmissions lead to considerable suffer- ing, harm and extra costs. Friedman and Basu estimated hospital costs for preventable readmissions during 6 months at about $730 million [7]. Jencks estimated total hospital costs at $44 billion per year for rehospita- lisations among Medicare patients within 30 days of hospital discharge [44]. We found that ineffective handovers that lead to patient

readmissions are caused by poor information exchange, poor coordination of care and poor communication be- tween hospital and primary care providers, and between care providers and patients. The underlying causes in- clude attitudinal and behavioural factors (e.g., lack of un- derstanding of the needs of the counterpart, a distant relationship and a lack of collaborative attitude between

Health outcome

Preventable adverse

(drug) events

Preventable deaths

ural causes

n hospital and primary

r or inadequate

letters or medication lists)

rofessionals (e.g. patient-

oviders work as separate

lanning/organization of

r discharge

unspoken and possible

sed

etween healthcare

onsultations;

n and -instructions to

n just before actual

guage by healthcare

written and verbal

ients at discharge

Quality of care

Primary care providers

un- or misinformed after a

patient’s discharge

Delayed or inadequate

follow-up of care

Primary care providers

unable to provide optimal

care

Patients un- or

misinformed and

unprepared at discharge

specific information

st discharge decisions

s

scharge letter to GP

ic needs

Inefficiencies leading to cost constraints

Unplanned

readmissions

Unplanned outpatient

visits

Over- or underuse of

diagnostics, treatments,

medications

Quality of life

Patient anxiety

Misunderstandings

Dissatisfaction

alth problem, causes and their determinants.

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hospital and primary care providers), organisational fac- tors (e.g., lack of guidelines), technical factors (lack of a shared electronic information system) or patient factors (e.g., patients are less skilled or don’t dare to speak up). All the identified causes and their underlying factors are summarised in Figure 1.

Step 2: Matrices of change objectives Intervention outcomes and performance objectives Measurable and feasible endpoints to evaluate the dis- charge process are hospital readmission rates and ad- verse events rates after the hospital discharge. All performance objectives are listed in Table 2. It is

important for healthcare providers to transfer high- quality discharge information to primary care providers and patients. For example, using discharge letters that are complete (i.e., no redundant/irrelevant or missed in- formation), accurate and understandable (i.e., structured presentation of information, explanation of abbreviations jargon), and patients being informed at discharge in plain language. Regarding coordination of care, health- care providers are expected to have organised and accur- ate follow-up services at patient’s discharge in a timely manner and tailored to the patient’s preferences and

Table 2 Performance objectives for healthcare providers and patients

Healthcare providers

Discharge information 1a. Complete discharge information

1b. Clear discharge information

1c. Accurate discharge information

Coordination of care 2a. Ensure that follow-up services are being organized at actual discharge

2b. Tailor follow-up care to patient needs and preferences

2c. Organize timely and accurate follow-up

Discharge communication

3a. Seek direct/personal contact with primary care counterpart

3b. Discharge information easily accessible to counterpart care providers and patients (and relatives)

3c. Exchange discharge information on time to primary care counterparts

3d. Inform patient (and relatives) personally and in timely manner

Patients

Participation in discharge process

4. Contribute, if capable, to the continuity of care in the discharge process

Awareness of health status and treatment

5. Well aware about medical history and medication use, diagnosis/indication and (side) effects of the treatment, post discharge appointments, scheduled tests and (pending) test results

psychosocial needs (e.g., assessment of home setting, so- cial risks and support). Examples of performance objec- tives for discharge communication are hospital care providers being accessible for primary care providers or patients and exchanging discharge information in time to support primary care providers or patients. Patients are, if capable, expected to contribute to the

continuity of care by participating in the discharge process (e.g., by handing over a discharge letter to their GP after being discharged), and by being well aware of their health status (e.g., medical and medication history) and treatment plan.

Selected determinants and change objectives The most important determinants (as perceived by ex- perts in the field of patient handovers and described in step 2 of the methods) were classified according to the individual professional, interpersonal, organisational, technical and patient levels. Combining the performance objectives with the selected determinants resulted in two matrices with change objectives for healthcare providers and patients, which interventions need to target. The matrices are presented in Additional file 3.

Step 3: Selecting theory-based methods and strategies Our literature review identified a raft of change methods, such as knowledge transfer, active listening and guided practice from the Social Cognitive Theory (SCT) [45], consciousness raising from the Transtheoretical Model [46,47], shifting perspectives and interpersonal contact from the Intergroup Contact Theory [48] and standar- dised working processes from the SCT and Rational Decision-making theories [30] as influencers of the be- havioural and environmental determinants of ineffective hospital discharge. Goal-setting and implementation in- tentions were derived from theories of Goal Directed Behaviour [49,50], and multi-disciplinary collaboration and case management from theories of Integrated Care [51]. These theory-based methods were subsequently operationalised into practical strategies and correspond- ing activities and materials for the targeted population [52-76] as shown in Table 3.

Step 4: Develop an intervention We formulated a wide variety of change objectives at the individual clinician and patient levels, the interpersonal level, organisational and technical levels that need to be considered in order to tackle ineffective handovers at dis- charge more reliably (Additional file 3). Given these change objectives the intervention likely needs to be multi-faceted and needs to be tailored to the needs en- countered in the local setting. Table 3 shows a framework with examples of strategies and related materials and ac- tivities guiding healthcare providers and policy makers in

Table 3 Overview of change determinants, theory-based methods, strategies and practical applications, and evidence

Determinants and change objectives

Theory-based methods

Examples of strategies/ practical applications

Examples of activities and materials

References* Evidence†

Individual healthcare provider

Aware of the consequences of suboptimal hospital discharge

Knowledge transfer/Active learning

Education in the medical and nursing curriculum

Lectures on patient handover and exercises with workbook and online materials (e.g., communication skills and discharge letter requirements)

52 3a

Perceive handover administrative tasks as important part of patient discharge care and act accordingly

Stimulus control/ Reinforcement

Punishment by financial penalties; visual electronic reminders

Red, orange and green flags indicating status of discharge letter and planning; visualization of deadline for sending discharge letter

NF NA

Interpersonal

Outward focus by hospital-based care pro- viders to ensure continu- ity of care after discharge

Integrated care Post-discharge monitoring of follow-up

Standard post-discharge telephone call or home visit to the patient to evaluate follow-up, provide additional instructions and answer questions

53 1a

Hospital and primary care provider collaborative during the discharge process

Integrated care/ Intergroup contact/ Case management

Case conference Hospital or community-based face-to-face or telephone meetings between hospital and primary care providers

54-57 1b

Liaison person Designated care provider coordinating hospital discharge, follow-up care and the communication between hospital and primary care providers

58-60 1b

Knowledge and understanding of the primary care organization, expectations and needs

Team building/ Intergroup contact/ Shifting perspective

Meetings between hospital and primary care providers to increase mutual understanding and respect between both parties

Focus group sessions, regular meetings and site visits to get to know each other, to learn each other’s organization and needs and to identify improvement opportunities

61 1b

Structural, problem-related feedback between hos- pital and primary care providers

Stimulus control Means to facilitate and stimulate structural feedback

Standard feedback form and return envelop along with discharge letter send to primary care providers

NF NA

Patient-centered attitude Modeling/ Individualization

Use of plain, patient-friendly, nonmedical language

Discharge summary in language that is understandable for patients and relatives

62 1b

Active listening Teach back Care provider checks if patients received all discharge information needed and if they understood the received information

63 2b

Organizational

Guidelines and standards of evidence-based practice

Standardized working processes

Standardized discharge letter (e. g. templates, formats)

Templates, formats, required (web-based) fields, clinical decision-support, pick lists

64-66 1b

Standardized discharge planning

Guidelines, protocols, checklists for discharge planning, organizing follow-up

67-68 1b

Medication reconciliation Standardised medication reconciliation checklist/medication discrepancy tool/ reconciliation by (liaison) pharmacist

54,57,65-67, 69-71

1b

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Table 3 Overview of change determinants, theory-based methods, strategies and practical applications, and evidence (Continued)

Technical

Shared electronic information exchange system

Multi-disciplinary collaboration

Shared electronic patient information system

Electronic notifications to primary care providers to inform them about patient hospital visits and to provide them (web-based) access to available discharge information

65,66,71-73 1b

Patient and relative

Participation in the discharge process

Self- management/ Guided practice

Encouraging and facilitating patients in self-management skills

Provide patient with discharge record (e. g., active problem list, medication, allergies, patient concerns) owned and maintained by the patient to facilitate cross-site information transfer

62,74,75 1b

Skills and dare to speak up

Coaching/ Guided practice

Encouragement to assert a more active role during discharge

Question form for patients 74 1b

Understanding of medical history and/or medication

Guided practice/ Knowledge transfer

Medication counseling at the hospital at discharge or at the patient’s home

Visits by a pharmacist counselor 76 1b

NF = not found; NA = not available. *The majority of the references relate to interventions or a component of a studied intervention program with an aim to improve hospital discharge. Other types of interventions (e.g., improving clinical handovers within the hospital) were also used as references in case they were considered to be relevant and appropriate for improving hospital discharge. †Grading of evidence, adapted and adjusted from the Oxford Centre for Evidence-based Medicine Levels of Evidence33: 1b = systematic review or meta-analysis of randomized controlled trials (RCTs); 1a = RCT of good-moderate quality or sufficient size and consistency; 3-4 = comparative trials (non-randomized, cohort studies, patient-control studies); 4 = non-comparative studies; 5 = Expert committee reports, opinions and/or clinical experience of respected authorities.

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the development of their intervention. The list of all identified strategies and related materials, level of evi- dence and references are available upon request. Many interventions were evaluated in well-designed

studies. For example, the use of standardised discharge practices such as the use of discharge letter templates, dis- charge planning guidelines and medication reconciliation checklists are effective strategies [65-67,70]. The use of a shared electronic patient information platform facilitates discharge communication between hospital and primary care providers [66,71-73]. There is evidence demonstrat- ing that the patient’s role in the discharge process is en- hanced by the provision of written and verbal discharge information and by assistance and guidance in self- management (e.g., discharge counselling, follow-up calls or home-based visits and a patient discharge record or question form) [74,76]. However, many promising inter- ventions have not been evaluated properly or were tested using weak study designs. For example, the effects of lec- tures and exercises on discharge practice in the medical curriculum, and regular group discussions involving hos- pital and primary care providers are largely unknown [52]. Moreover, there is limited evidence on the effects of

reinforcement by using discharge planning reminders, mandatory administrative tasks or financial incentives and penalties [77]. Insight also lacks into the effects of strategies to in-

crease care provider reflections on discharge practices (e.g., use of a standardised feedback form, video

reflection, role play or simulation of discharge consulta- tions) [52] and regarding the use of teach-back to check the patient’s understanding of their medical and medica- tion history [63,78].

Steps 5 and 6: Implementation and evaluation Commitment from and ownership by the target group is essential to successful implementation [79,80]. The aware- ness among end users is enhanced when they are directly involved in the development or modification of the innovation, in mounting the implementation plan, and in selecting the implementation strategies to be used [35]. Moreover, uptake of policies and protocols, reimburse-

ment and the consideration of patients’ preferences are necessary for a sustainable implementation [81]. Strategies that address the barriers to change are re-

quired to implement interventions in daily practice [36]. Most theories on implementing interventions in health care emphasise that an analysis of the barriers to change practice is a prerequisite to selecting or developing an effective implementation strategy [17]. An implementa- tion plan should be developed specifically after selecting the implementation strategies to tackle the barriers. This plan should be compatible with the target group and set- tings in which the implementation will take place. Good management and planning of implementation activities (i.e., what, when, where, how and by whom) also appears to be a requisite for successful implementation of inno- vations in patient care [35].

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Formative and summative effect evaluation should be carried out using hospital readmission and adverse events as defined patient outcome effects to evaluate whether the intervention led to the desired degree of change. The formulated performance objectives in step 2 can be oper- ationalised in measurable process indicators, for example by assessing the proportion of patients discharged with a complete discharge letter and assessing the proportion of patients discharged after medication reconciliation. A process evaluation should be performed to under-

stand the effect, success or failure of the intervention and to get an impression of its feasibility, generalizability and its acceptability in the target population. The process evaluation gives insight into the black box of the implementation process and can explain the variation in results in evaluating interventions. The activities carried out as part of the intervention, the actual exposure of participants to these activities, and their experience of these activities should be studied [40].

Discussion Effective hospital discharge and reducing patient re- admission rates are influenced by the behaviours of care providers and patients and their environmental context. Our findings demonstrate the existence of a large num- ber of determinants for (in)effective discharge that underscore the complexity of the discharge process. Therefore, improving hospital discharge requires a multi- component, multi-level intervention (“bundle”) instead of trying to find a “magic bullet” single intervention. An extensive overview of theory-based methods and

practical strategies suitable for improving patient hand- over skills and healthcare provider and patient behaviour in the discharge process was systematically created based on the scale, causes, and consequences of ineffective hos- pital discharge presented in our study. Most interven- tions were aimed at improving the organisational and technical aspects of the discharge process. There is a lack of evidence-based interventions on improving healthcare provider skills by means of handover training and evidence-based guidance. Moreover, effective interven- tions for changing the individual healthcare provider’s and patient’s competencies, awareness and attitudes (e.g., via education, reminders or teach-back), and the relation- ship between providers (e.g., via frequent informal meet- ing between hospital and primary care providers and reflexive feedback) are lacking. All this despite our over- whelming data demonstrating that awareness, attitudes and skills are key factors for improving hospital dis- charge. We found a gap between the discharge improve- ment needs and the evidence-based interventions that are suitable to address these needs. The lack of evidence about the effectiveness of interventions may be attributed

to the difficulty of measuring attitudes and their effects on healthcare performance [82-84]. This study is supported by earlier research and discharge

programs in the United States: i.e., the RED (“ReEngineerd Discharge”) project [69,85], the Care Transitions Program [86] and BOOST (Better Outcomes for Older adults through Safe Transitions) [87]. An important strength of our study is the deliberate assessment of determinants and interventions that affect the discharge process. Qualitative input provides comprehensive insights into a variety of de- terminants. Our empirical data, results of a systematic litera- ture review, theories of social behaviour and multiple consultation rounds of a broad group of 324 experts (re- searchers, policy-makers, inspectors) in the field of quality and safety in healthcare, healthcare providers and patient representatives [31], provided useful input for the selection of change methods, practical strategies and related evidence. A limitation of the study is our focus on the micro-

level excluding other key factors for change. The possible barriers and facilitators at a macro- and meso-levels, i.e., financial and legal obligations or constrains were not in- cluded. Moreover, the relationships between the identi- fied determinants and theoretical-based methods and strategies were hypothetical. However, the determinants were systematically and

theory-driven and linked to practical strategies using the IM method and were not intuitively chosen.

Conclusions This study provides a comprehensive overview of patient discharge problems and underlying causes. It provides a guiding framework including theory-based strategies and practical tools to support care providers and policy- makers in their efforts to select and implement interven- tions on a more rational basis. Intervention mapping is a powerful method for care providers and policy makers to assess and prioritise intervention strategies and tailor them to the needs of individual facilities and healthcare systems. The next step for care providers and policy- makers is to look carefully into the discharge problems in their own local settings and to select appropriate solu- tions for improving hospital discharge effectively.

Additional files

Additional file 1: Modified model based on PRECEDE-PROCEED concept and the theory of planned behavior

Additional file 2: Study Population Inclusion and Exclusion Criteria.

Additional file 3: Matrix of change objectives.

Competing interests The authors declare that they have no competing interests.

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Authors’ contributions GH and MZ designed and managed the study. GH, MF, ED-U, CO and GT col- lected the data. All authors (GH, MZ, MVD, PB, CK, MF, GÖ, MO, SB, CO, RS, GT, FV, EDU, LS, HW) were involved in the analysis and interpretation of the data. GH and MZ drafted the manuscript. All authors read the manuscript for important intellectual content and approved the final version.

Acknowledgements We thank the patients, relatives, physicians and nurses who participated in this study. We also thank the 220 expert meeting participants for their contributions to this study.

Financial support This work was supported by a grant from the European Union, the Framework Programme of the European Commission (FP7-HEALTH-F2-2008- 223409).

Author details 1Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. 2Radboud University Medical Center, Kalorama Foundation, Nijmegen, The Netherlands. 3Radboud University Medical Center, Department of Primary Care, Nijmegen, The Netherlands. 4Patient Safety Center, University Medical Center Utrecht, Utrecht, The Netherlands. 5Department of Health Studies, University of Stavanger, Stavanger, Norway. 6University College Cork, Cork, Ireland. 7Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden. 8Department of Social Work, Karolinska University Hospital, Stockholm, Sweden. 9Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden. 10Quality and Patient Safety, Karolinska University Hospital, Stockholm, Sweden. 11Department of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden. 12Avedis Donabedian Institute, Universidad Autónoma de Barcelona, Barcelona, Spain. 13Clinical Risk Management and Patient Safety Centre, Tuscany region, Italy. 14National Center for Quality Assessment in Health Care, Krakow, Poland.

Received: 19 March 2014 Accepted: 10 September 2014 Published: 13 September 2014

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doi:10.1186/1472-6963-14-389 Cite this article as: Hesselink et al.: Improving patient discharge and reducing hospital readmissions by using Intervention Mapping. BMC Health Services Research 2014 14:389.

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