title: Integrating new practices: a qualitative study of how hospital innovations become routine.
abstract: 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.
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. amanda.brewster@yale.edu.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Brewster
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. leslie.curry@yale.edu.
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Curry
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. emily.cherlin@yale.edu.
authors.forename: Emily J
authors.initials: EJ
authors.lastname: Cherlin
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. kristina.talbert-slagle@yale.edu.
authors.forename: Kristina
authors.initials: K
authors.lastname: Talbert-Slagle
authors.affiliation: Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY, USA. leora.horwitz@nyumc.org.|Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center, New York, NY, USA. leora.horwitz@nyumc.org.|Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York, NY, USA. leora.horwitz@nyumc.org.
authors.forename: Leora I
authors.initials: LI
authors.lastname: Horwitz
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. elizabeth.bradley@yale.edu.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
mesh_terms: D003299:Cooperative Behavior; D006739:Hospital Administration; D006801:Humans; D009936:Organizational Innovation; D010359:Patient Readmission / Q000706:statistics & numerical data*; D015397:Program Evaluation; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*