The “hard, relentless, never-ending” work of focusing on discharge: a qualitative study of managers' perspectives
Bibliographic record
Abstract
PURPOSE: Interventions to hasten patient discharge continue to proliferate despite evidence that they may be achieving diminishing returns. To better understand what such interventions can be expected to accomplish, the authors aim to critically examine their underlying program theory. DESIGN/METHODOLOGY/APPROACH: Within a broader study on patient flow, spanning 10 jurisdictions across Western Canada, the authors conducted in-depth interviews with 300 senior, middle and frontline managers; 174 discussed discharge initiatives. Using thematic analysis informed by a Realistic Evaluation lens, the authors identified the mechanisms by which discharge activities were believed to produce their impacts and the strategies and context factors necessary to trigger the intended mechanisms. FINDINGS: Managers' accounts suggested a common program theory that applied to a wide variety of discharge initiatives. The chief mechanism was inculcation of a sharp focus on discharge; reinforcing mechanisms included development of shared understanding and a sense of accountability. Participants reported that these mechanisms were difficult to produce and sustain, requiring continual active management and repeated (re)introduction of interventions. This reflected a context in which providers, already overwhelmed with competing demands, were unlikely to be able (or perhaps even willing) to sustain a focus on this particular aspect of care. ORIGINALITY/VALUE: The finding that "discharge focus" emerged as the core mechanism of discharge interventions helps to explain why such initiatives may be achieving limited benefit. There is a need for interventions that promote timely discharge without relying on this highly problematic mechanism.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".