title: Barriers and Strategies for Effective Patient Rescue: A Qualitative Study of Outliers.
abstract: BACKGROUND
  Organizational factors influencing failure-to-rescue (FTR)-or death after postoperative complications-are poorly understood. Case studies were conducted to generate hypotheses that could inform future FTR research and improvement strategies.
  
  
  METHODS
  Publicly reported 2009-2011 data were used to identify 144 outlier hospitals with statistically better or worse FTR performance than the national average. Of these 144 hospitals, 7 were selected for case studies in a purposive sample. Outliers enabled a focus on the organizational factors and processes at the extremes of performance. Semi-structured interviews were conducted in 2013 with key informants at each hospital, and transcripts were analyzed using the constant comparative method to identify emergent organizational behavioral themes.
  
  
  RESULTS
  The 7 hospitals-4 high- and 3 low-performing-yielded 106 interviews. Critical barriers to effective rescue were ineffective communication, lack of psychological safety, staffing discontinuity, imbalance of shared ownership and individual responsibility, lack of appropriate training and education, and difficulty using current metrics. Participants also identified strategies to overcome these barriers-rapid response teams, flattening the hierarchy, escalation strategies, health information technology, structured communication tools, constant team structures, standardized care pathways, and organizational learning.
  
  
  CONCLUSIONS
  FTR is a complex process that is viewed, defined, and acted on differently across and within organizations. Early recognition of patients deviating from normal recovery was enhanced in high-performing hospitals through the use of standardized postoperative recovery pathways and automated escalation protocols. Current FTR measures may be less actionable for the purposes of quality improvement.
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, USA.
authors.forename: Elliot
authors.initials: E
authors.lastname: Wakeam
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Hyder
authors.forename: Stanley W
authors.initials: SW
authors.lastname: Ashley
authors.forename: Joel S
authors.initials: JS
authors.lastname: Weissman