Implementation between text and work-a qualitative study of a readmission prevention program targeting elderly patients.

BACKGROUND: Numerous studies emphasize the importance of context in implementation. Successful implementation across the health care system depends on conditions and requirements that are often presented to health professionals through text-based materials and might present contradictory expectations to the work of health professionals. In this study, we operationalize institutional context as the text-based material, which from the perspective of health professionals, influence health care work. Via the case of a readmission prevention program for elderly patients, we examine the experiences of health professionals that work with implementation, concerning the contradictions that arise between the demands imposed by program implementation and their everyday work routines, and the role of text-based materials in these contradictions.

METHOD: We conducted five focus group interviews among health professionals working at different locations in a single administrative region of Denmark. The 24 health professionals in our study included hospital physicians, hospital nurses, medical secretaries, municipal care managers, registered municipal nurses, and general practitioners. All focus group interviews were transcribed verbatim. Inspired by institutional ethnography, we look into text-based materials, such as written guidelines, if health professionals indicate they are important.

RESULTS: The health professionals experience that specific demands of the readmission prevention program come into conflict with the existing demands and daily work routines. Professional resistance to control and the existing digital communication tools create tensions with a program requirement for standardized enrollment of patients to the program. In addition, the striving for autonomy among health professionals and the high level of mono-professional working routines create tension with the program requirements for an additional amount of interdisciplinary work. The different demands are widely mediated by text-based materials such as the existing digital communication tools and the instructions on how to use them, and the official agreement of the role and assignment for Danish GPs.

CONCLUSION: Successful implementation of the prevention program is affected by various tensions between the program demands and the existing health care work. Text-based materials mediate the different demands of the institutional context in to health care work and influence the process of implementation.