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Unintended Consequences: the U.S. Postal Service Conundrum of Service, Business, Labor, and Politics

Philip f. rubio.

Department of History and Political Science, North Carolina Agricultural and Technical State University, Greensboro, NC 27411 USA

This paper examines the 2020 turmoil surrounding the U.S. Postal Service—a crisis not seen since roughly 209,000 employees struck its predecessor the U.S. Post Office Department in March 1970, which led to passage of the Postal Reorganization Act that summer and the inauguration of the USPS in July 1971. The 2020 conflict was not merely rooted in the economic disaster following the COVID-19 pandemic, but in fact stretches back to the 2009 postal financial crisis. I argue that these crises are an unintended consequence of the compromise formation of the USPS as a hybrid government agency/business. Debates over whether public or private postal service too often leave out conflict over the rights of postal labor. The origins of that debate lie in the former USPOD’s management of labor using “business methods” that included authoritarian discipline, contingent workers to cut costs, and creating racial divisions among employees.

COVID-19 2020: the USPS Conundrum Explodes

On April 9, 2020, the U.S. Postal Service (USPS) warned that it could run out of cash to run daily operations by September 2020 because of a huge loss of revenue as mail volume plummeted–especially from businesses–due to the COVID-19 pandemic. That was the announcement by Megan Brennan, a former letter carrier who was the seventy-fourth postmaster general, the thirteenth of the USPS, the first woman appointed to that position, and the fourth in a row to be a USPS career employee (Bogage, 2020g ; Johnson, 2020 ; Rushing, 2020 ). Brennan’s retirement officially came on June 15, 2020, with the appointment by the USPS Board of Governors (BOG) of Louis DeJoy, a major donor to President Donald Trump and the Republican Party, and whose postal experience is quite different: twenty-five years of USPS contracts for logistics support (Heckman, 2020 ; Piette, 2020 ). We can reasonably assume that Trump has seen DeJoy as an ally in the USPS. This is especially the case with DeJoy’s cost-cutting measures that have also curtailed mail service across the country, shaking confidence in the USPS and its ability to handle mail-in ballots in November—balloting that Trump has dismissed (without evidence) as fraudulent (Rein & Bogage, 2020 ; “Return to Sender”, 2020 ; “USPS Reaches Agreement”, 2020 ).

It is always risky to try and write history as events unfold. Nevertheless, tackling the ongoing debate over postal privatization without mentioning current events misses an opportunity to highlight in real time the contingency of historical action. All the pieces are in place to tell this story regardless of what political drama occurs next–and much more is expected after this writing. Indeed, the post office has never seen this much political conflict in its 245-year history–to the point where many wonder and worry over its future (Rein & Bogage, 2020 ). As well, there has never been this much turmoil surrounding the USPS since approximately 209,000 employees struck its predecessor the U.S. Post Office Department (USPOD) in March 1970, which led to passage of the Postal Reorganization Act that summer and the inauguration of the USPS in July 1971 (Rubio, 2020d ; United States Postal Service, 2020b ). The current conflict is not limited to the COVID-19 pandemic, but in fact stretches back to the 2009 postal financial crisis that seems unending. I argue that this is an unintended consequence of the compromise formation of the USPS itself as a hybrid government agency/business. In addition to debates over whether this service should be public or private, we too often leave out the other half of USPS debates over the rights of postal labor. The origins of that debate lie in the former USPOD’s management of labor, making use of “business methods” that included authoritarian discipline, hiring contingent workers to cut costs, and encouraging divisions among employees over race (President’s Commission on Postal Organization, 1968 ; Rubio, 2010 ).

It is easy to miss the labor component to this ongoing crisis owing to the preponderance of criticism aimed at the USPS service model by Trump and Senate Republicans. Trump dismissed Postmaster General Brennan’s 2020 request for bailout funds to help with the $13 billion in revenue losses due to the pandemic, along with projected losses of $22 billion over the next 18 months. In April, Trump even vowed to block a $10 billion loan earmarked for the USPS under the CARES Act unless the USPS increased parcel rates, and Treasury Secretary Steven Mnuchin asked for the power to demand labor concessions and oversee senior executive appointments (Rein & Bogage, 2020 ). The loan finally was approved July 29 without labor contract changes or parcel rate increases, and the appointment of Postmaster General DeJoy rendered the appointment condition moot. However, the loan agreement did obligate the USPS to provide proprietary information about their largest private-sector contracts to the Treasury Department (Bogage, 2020e ).

Trump’s reported personal animus toward Amazon CEO and Washington Post owner Jeff Bezos should not distract us from the collective forces that support USPS privatization, led by Trump’s own failed June 21, 2018 proposal to Congress that included the termination of collective bargaining for postal unions (Rubio, 2020d ). Those include the American Postal Workers Union, the National Postal Mail Handlers Union, the National Rural Letter Carriers Union, and the National Association of Letter Carriers (NALC). One wonders what happened to the intended “divorce” of politics from the daily operations of what would become the USPS, as another Republican president, Richard Nixon, called for in 1969 when he proclaimed, “There is no Democratic or Republican way of delivering the mail. There is only the right way” (Nixon, 1969 ).

The 1970 Postal Strike, the USPOD, and the USPS

In refuting Trump’s diatribes against the USPS and its alleged bad business practices, historian Richard John correctly characterized the founders’ intent that the post office should be a service, not a business. That fundamental service model has remained up to the present time, including the transformative 1970 Postal Reorganization Act (PRA, also known as Title 39 of the U.S. Code), and the 2006 Postal Accountability and Enhancement Act that amended it (John, 2020 ). However, even before the USPS, the USPOD also operated “like a business” in the sense of its management of labor and selling postage. Postage and taxpayer funds approved by Congress paid the USPOD bills and employees. However, that did not stop the USPOD from trying to increase worker productivity and cut labor costs. Ironically, labor rights that expanded considerably in 1971 with the operations of the new USPS have also paid the same price of vulnerability to political whims that the USPS itself faces today. Absent the automatic congressional financial support that existed for the USPOD, we have now witnessed the possibility of the USPS becoming insolvent and forced to shed jobs as well as services if future congressional support is not forthcoming (Bogage, 2020g ; Rubio, 2020c ).

The fact that the post office has always been a service, yet for years also functioned as a business even before it became the USPS, goes to the heart of its conundrum today, including the promise (or threat) of privatization by Trump. That conundrum is baked into the USPS’s very design and can only be managed successfully in a similar atmosphere to the one in which it was founded, namely that of bipartisan political agreement (Rubio, 2020d ).

Ten months before the March 18, 1970, nationwide illegal postal wildcat strike that began in New York City for decent, comparable wages and job dignity, Nixon had given Congress an inspired speech on May 27, 1969, which concluded with the words quoted earlier. In that speech, he lamented how the post office had fallen behind the times and failed taxpayers along with the “three quarters of a million dedicated men and women who today wear the uniform of the postal service” (Nixon, 1969 ). By way of remedy, Nixon proposed a “modernized” new hybrid government agency/corporation he called the “United States Postal Service.” Nixon evoked masculinist construction worker imagery to make the case that this was the best way to put “tools” in the hands of postal workers to do their jobs effectively. He peppered his speech with remarks that seem ironic today yet are also indicative of the fundamental service/business dilemma. Nowhere in the 1970 PRA is there mention of “business,” “business model,” or “corporation.” For that matter, any associated language like “customers,” “breaking even,” or even “self-supporting” is noticeably missing. Yet Nixon used some of those very terms in his May 1969 address to Congress that represented a revision of the USPOD original draft speech that their general counsel David A. Nelson had sent to the White House a couple of weeks earlier. It is possible that in that revised draft is where we first encounter the idea explicitly advanced that the future USPS should “operate like a business”—although Nixon did aver that Congress should still provide funds on occasion for public service groups (Nelson, 1969 ).

Nixon’s entire speech bears reading. In it we see him attempt to “sell” his proposed commercialized postal government agency to Congress based on two paradoxical tropes: 1) the “inefficient non-businesslike” government agency that had routinely run up deficits since 1838; and 2) the underpaid, disempowered postal workers who deserved better, as did their bosses and customers. For Nixon, mail processing and delivery would be better performed in the future with “business methods.” While making these grand promises, Nixon meanwhile kept wage raises low for postal workers, rejected their full collective bargaining rights within a reformed USPOD, and tried to hold postal raises hostage in early 1970 unless his postal corporation bill was passed (Rubio, 2010 , 2020d ).

Richard John has also noted that historically, Congress typically gave the USPOD whatever it asked for by way of annual appropriations. These were annual subsidies , not bailouts (John, 2020 ). What then, did Nixon mean when he said that the post office should “operate like a business?” Does self-funding make organizations inherently more efficient as opposed to those that rely on taxpayer money while simultaneously earning revenue by selling their products? That would include the USPOD, which was also mandated to provide universal service at reasonable rates. Until 1971, Congress also had the power of the purse over postal wages and benefits and was notorious for keeping both low. Some context is worth remembering here that includes the Progressive-era scientific management campaigns to cut postal wages and increase productivity with new time-management methods (Mikusko & Miller, 2014 ; Rubio, 2010 , ch.1, 2020d , ch.1).

The USPOD also found other means to save labor costs such as requiring “Part-Time Flexible” employees to wait until enough mail had accumulated before “clocking in” to work (Mikusko & Miller, 2014 ; Rubio, 2020d , ch.1). The USPS inherited and reproduced these methods with constant campaigns to cut labor costs. These included the notorious attempted “Kokomo Plan” of timing letter carrier work in the 1970s. For distribution clerks, there was constant management pressure to process mail quickly both manually and by machine according to management standards. And post offices frequently have been sites of daily shop floor clashes between supervisors and carriers over getting the maximum amount of mail out without using overtime or getting “auxiliary assistance.” Supervisors, who are often former carriers themselves, to this day are quick to remind letter carriers that they are leaning on their former co-workers because they have to “get their numbers up,” which is to say, leaving as little non-preferential mail behind as possible (“non-preferential” refers to mail that is not first class, priority, newspapers, or time-sensitive business mail).

The USPOD from 1775 to 1971 was the predecessor to the USPS. It began as America’s political and information network. It promoted newspapers, letter-writing, national development, innovation, and invention (Acemoglu et al., 2016 ; United States Postal Service, 2020b ). There is not enough room for a full discussion here, but the post office has not historically been a singularly progressive force, nor even a neutral institution. For example, during the first half of the nineteenth century it became the contentious center of political debates over the free circulation of abolitionist and other literature, as well as over patronage and power. It lost the telegraph to private industry then also. But it won the right from Congress to establish postal banking and parcel post in the early twentieth century because of private industry neglect and gouging of customers. Moreover, it has both enabled and suppressed black and female labor throughout its history (Rubio, 2010 , 2020d ).

The USPS as the successor to the USPOD was a product of contentious 1960s political debates over USPOD growing deficits, technological lags, repressive work culture, and finally a 1970 postal wildcat strike that forced the issue over wages, worker rights, and the future status of the post office. Sociologists Thomas Germano and Vern Baxter have both written on the problems with how service culture began to look more like business culture in the transition from the USPOD to the USPS—even as problematic and authoritarian as that USPOD overall work culture had once been (Baxter, 1994 ; Germano, 1983 ).

The post office in 1970 was a story of partisan wrangling and ultimately bipartisan compromise prodded by a massive labor action. There were political choices that postal unions preferred, such as collective bargaining rights within a reformed USPOD along with a living wage. However, the hybrid that was constructed ultimately made the USPS vulnerable to devastating congressional oversight in the PAEA in 2006 that hobbles it today. Separating politics from the nation’s mail was always an illusion. The PRA that poetically called for the USPS to “bind the nation together” never intended to make the USPS profit driven as a later partisan ideology came to frame it. Quite unintentionally, however, its founders set the stage for the popular de facto reframing of the post office as a “business” in speeches and position papers leading up to and immediately following the PRA’s enactment (Rubio, 2020d , chs.2–6). The political and financial vulnerability of the USPS was never inevitable but was in fact contingent on privatization forces who were able to directly access political power in both the executive branch and the USPS itself. These forces, as journalist Lisa Graves recently pointed out, revolved in part around “free market” conservatives associated with billionaire Charles Koch and think tanks like the Cato Institute and Citizens for a Sound Economy (later Americans for Prosperity). Unrequited postal privatization efforts during the 1980s administration of President Ronald Reagan finally found fruit during the George W. Bush administration of the early 2000s. Certainly helpful for those forces was the appointment of Koch protégé James C. Miller III to the USPS Board of Governors (BOG) in 2003, and later elected BOG chair in 2005. Miller was instrumental in the passing of the PAEA (Graves, 2020 ; Rubio, 2020d , ch.8). Besides limiting its ability to sell certain products and services, the PAEA imposed massive annually accruing debt on the USPS. That debt provided the appearance that the USPS was a poorly run business—a narrative privatizers promoted during the 2020 pandemic (Graves, 2020 ; Kosar, 2009 ; Rubio, 2020c , 2020d , ch.8; Sherman, 2020 ).

DeJoy’s 2020 Mail Slowdown and the Prior Postal Crisis

In early July 2020, after massive volume and revenue losses due to that pandemic, leaked USPS internal documents signaled Postmaster General DeJoy’s willingness to treat the service as a business, curtailing mail and rationalizing labor ostensibly to avoid insolvency. In early August, DeJoy conceded that those had been his policies. Major media outlets by then had already pointed out that this could have especially disastrous effects for mail-in voting in November, with the pandemic by now showing no letup (Bogage, 2020b , 2020f ; Lee & Bogage, 2020 ; Slisco, 2020 ; Waldman, 2020 ). DeJoy’s subsequent July 28 statement on “operational excellence and financial stability” seemed tone-deaf to the harm his policies were causing to service as he blamed a “broken business model” for the USPS crisis without even mentioning the pandemic or the PAEA continuing debt crisis (DeJoy, 2020 ).

The USPS has never been a business, earns no profits, has no shareholders, and has received no taxpayer funds since 1982. In addition to its universal service obligation, there are legislated product constraints in the PAEA designed to protect private carrier competition (Graves, 2020 ; Rubio, 2020d , ch.8). There is real irony in the “broken business model” trope invoked by DeJoy and others. In fact, the disastrous results of cutting transportation and overtime costs (with an expected annual savings of only $200 million), as well as dismantling mail-sorting machines, mothballing collection boxes, and cutting retail hours, damaged what the USPS is best known for—its dependable service (Hutkins, 2020c ; Ingraham & Guskin, 2020 ; Viebeck & Bogage, 2020 ).

Self-defeating business decisions like these could typically cost CEOs their positions in the private sector–unless they were managing a private equity firm whose mandate was to restructure a failing business to benefit the firm’s shareholders. DeJoy as postmaster general, ironically has been able to make these kinds of decisions based on the semi-autonomous public-sector status of the USPS, without accountability to anyone but the PRC, the USPS BOG, and Congress. Asserting oversight powers over the USPS, Democrats in early August asked the USPS OIG (Office of Inspector General) to investigate DeJoy’s policies and practices (Bogage, 2020c ). Democrats in Congress also called DeJoy to appear for an August 24, 2020 hearing before the House Oversight and Reform Committee on the impact of USPS slowdowns on mail-in balloting. In the week before that hearing, intense heat from consumers, postal unions, the media, and politicians elicited promises from DeJoy to suspend those policies until after the election, as well as dropping its carrier “test” plan to settle the NALC’s national grievance (Bogage, 2020a ; Broadwater et al., 2020 ; Edmondson et al., 2020 ; National Association of Letter Carriers, 2020b ).

That test plan began with a July 16 USPS letter to the NALC that, according to the union contravened the postal policy manual and the union contract in conducting a “test” for the next 30–60 days in 384 delivery units around the country starting July 25. It required carriers in those units to take their presorted mail directly to the street in the morning and not wait for any other late arriving first-class mail until they returned to the office in the afternoon (National Association of Letter Carriers, 2020d ). The NALC filed a national-level grievance in August (National Association of Letter Carriers, 2020a ), along with an NALC press release informing the public that letter carriers were “angry, frustrated and embarrassed” at the new service cutbacks (National Association of Letter Carriers, 2020c ). The NALC did not indicate the USPS’s rationale, but some possibilities include providing 1) cover for DeJoy’s national mail delay policies; 2) data for future collective bargaining negotiations, and 3) justification for making permanent these radical mail sortation changes. Whatever the case, postal workers in all crafts and units found themselves forced to violate their training to leave no mail behind and always work for “the good of the service” (National Association of Letter Carriers, 2020e ; Rubio, 2020a ).

Strangely, a USPS memo from DeJoy and Executive Vice President Isaac Cronkhite from August 7, 2020, on organizational restructuring, concludes with a commitment to “involve employees in the process and communicate.” These words are belied by the unilateral service initiatives cited above, not to mention the reassignment of 23 senior executives and a senior-management hiring freeze widely referred to as the “Friday Night Massacre” (DeJoy & Cronkhite, 2020 ; Politi, 2020 ). These policies as noted above, negatively affect both service and labor rights. DeJoy’s repeated emphasis on “efficiency” found a new twist in his remarks to the BOG meeting on August 7, where he noted that the USPS had been marked by “ingrained inefficiency” (United States Postal Service, 2020a ). However, as Vern Baxter once pointed out, “Efficiency is a prevailing institutional myth of the modern post office, and it has usually been operationally defined as scientific management of labor to secure greater standardization and intensity of effort a reduced cost to the government” (Baxter, 1994 , 56).

It must be remembered that the USPS is a not a hapless public service victim of outside privatization forces. Under the helm of President Bush’s postmaster general appointee, John Potter, the USPS in 2002 displayed sympathy for partial privatization and rollback of labor rights in a discussion of three possible models. Those included: 1) return to government agency format, 2) privatization, and 3) (its preference), a “commercialized Postal Service” which the USPS concluded “would need to operate more like a business” (United States Postal Service, 2002 , 65–75, quote on 65; Graves, 2020 ). The USPS’s 2002 Transformation Plan was followed in 2003 by a Bush administration task force that shared those sentiments on making service and labor adjustments while framing the low employee “quit rate” of less than 1.5 percent as problematic (President's Commission on the United States Postal Service, 2003 ). The low-waged but dependable postal job with a 26 percent turnover in 1969 had now become a desirable career. Nixon hated unions but accepted them as the price to be paid for high productivity and labor peace, especially after the 1970 strike. For Nixon and others who supported his postal corporation idea (including Postmaster General Winton Blount), unions were a normative part of modern corporate life. Nixon recognized postal workers’ drive for wage “comparability” (not with auto or steel but rather shipping clerks and delivery drivers), good wages and benefits, and strong unions to enforce labor peace. This was a vision he shared with AFL-CIO President George Meany, who prior to the strike did not really exhibit much interest in government workers (Cowie, 2010 ; Halpern, 2003 , ch.5). “Comparability” in fact is written into the PRA (Postal Reorganization Act,  1970 , 101 (c)). In some ways, postal work would become a more secure job than the auto and steel industries that faced layoffs and “runaway shops” starting in the 1970s. Even without the right to strike, postal workers enjoyed not only mediation and arbitration of contract negotiation breakdowns with the PRA, but also a “no-layoff” clause after six years of service as of 1978 (Rubio, 2020d , chs.5–6).

The year 1981 was the last time postal unions threatened to call a formal (and still illegal) strike. Postal workers were relatively well-paid with good benefits, but they also enjoyed less sympathy when they threatened to strike than when they struck in 1970. In 1970, they had shocked America by striking the government, but they also revealed how shockingly low their wages were. Fortunately, postal unions in 1981 did not suffer the fate of the Professional Air Traffic Controllers Organization (PATCO)–crushed by President Reagan after its strike that year. Mediation and arbitration produced decent USPS contracts when talks broke down. The hostility to the USPS as a public service by conservatives now merged with their opposition to strong postal unions that had won some successes in collective bargaining (Rubio, 2020d , chs.5–7). Postal privatization gained no legislative traction in the 1980s–1990s for its advocates in the Cato Institute and Heritage Foundation. Yet as postal scholar and researcher Steve Hutkins has pointed out, “piecemeal privatization” in the form of work-sharing and outsourcing crept into USPS operations beginning in the mid-1970s with mailers providing presorted letters (Hutkins, 2018 ).

By the early 2000s, the USPS had become a political football where the USPOD had once been one of the coaches on the sidelines, so to speak. This happened with the discovery that the USPS had overfunded its CSRS payments to the Treasury by as much as $71 billion. To reduce, transfer, or return any of those payments back to the USPS would have created an unbalanced unified federal budget (which included USPS revenue and debt). Congress’s solution was to impose an annual financial burden on the USPS starting in 2007 for ten years at about $5.5 billion a year to prefund a Retiree Health Benefits Fund (RHBF). This is the major cause of the USPS suddenly finding itself in perpetual debt, not the Internet or the Great Recession, although both of those factors have provided major challenges. The USPS plight today also reflects the loss of USPOD political power since it was reorganized into the USPS effective 1971 (Hutkins, 2013 ). Since then, a kind of “digital determinism” has enabled privatization proponents to explain the USPS debt as proof of its obsolescence in the Cyber Age (Will, 2011 ). This has combined with what could be called “governance by gaslighting” with relentless conservative excoriation of alleged USPS financial mismanagement. This disingenuous narrative ignores the fact that the USPS typically earned annual operational revenue surpluses between 1995 and 2018 (Hutkins, 2013 ; Report from the Task Force on the United States Postal System, 2018 ; Rolando, 2020 ; Rubio, 2020b , 2020e ).

For its part, the USPS has also consistently frustrated sympathetic narratives in how it has enabled competitors and ideological opponents who wanted it to be “leaner and meaner” –meaning pursuing revenue surplus over service and with fewer worker benefits. Those who remember the postal financial crisis of 2009 and media headlines over the next three years warning of “default” and “collapse” of the USPS must feel a sense of déjà vu seeing headlines during the COVID-19 pandemic–but with an important change. There is more publicly expressed sympathy today for postal workers and the USPS itself. The former has been the beneficiaries of social media campaigns while the latter enjoyed a 91 percent favorability rating in a national survey by the Pew Research Center (American Postal Workers Union, 2020b ). Before DeJoy, the USPS seemed to be strangely surviving an existential battle with privatizing forces while providing crucial services. Advocates of universal postal service, consumer organizations, and postal unions helped push back over the last decade and continue to do so today against arguments for privatization that use the USPS’s shortage of cash as evidence of its inability to provide universal service in a financially “sustainable” fashion (Rubio, 2020c ; 2020d , ch.8; Sherman, 2020 ). But with DeJoy’s appointment, the rapid deterioration of services suggests a Trojan Horse effect and an existential threat from within the USPS (Jamison, 2020 ). Once again, we would do well to contrast two Republican administrations fifty years apart: Trump in 2020 trying to take the wheels off the USPS that Nixon imagined as the solution to the government-service-budget-deficit conundrum.

Nixon, the USPS, and the Last Days of the (Corporate) Liberal Consensus

At the PRA signing ceremony on August 12, 1970, Nixon praised everyone involved in constructing that compromise bill, including the postal unions that had shot down his idea of calling the USPS a corporation (Nixon, 1970 ; United States Postal Service Office of Inspector General, 2010 ). As he did in May 1969, Nixon was praising the nation’s postal workers, extolling the law that ensured full collective bargaining rights (except striking) and better pay. Nixon had good reason to praise the postal union leaders present, as the wildcat strike had almost killed his postal reform bill until union negotiations ironically helped bring it back to life. Nixon’s post-strike public relations salvage operation was known as the “White House Plan to Sell New Postal Reorganization Legislation.” It convened on April 18, 1970–two days after Nixon signed a mammoth pay raise bill for all federal employees that was a direct result of the strike. The April 18 meeting laid out a strategy that included Nixon holding a press conference to tout his bill as one that would “emancipate the postal employee from poor working conditions, poor career opportunities, and poor salaries” (Whitman, 1984 ).

Now at the PRA signing, Nixon’s remarks fairly sang of bipartisanship and capital-labor peace: “This is the American system working in a way that we all like to see it work,” he exclaimed, “where we put the country above the party and where we put service to the people above any other interest” (Nixon, 1970 ). Nixon also made sure to introduce Postmaster General Winton Blount. The former Alabama construction contractor who was about to become the USPS’s first Postmaster General (and the last one for the USPOD) had helped get Nixon’s bill back on track. Indeed, Blount had insisted before his 1969 appointment that Nixon prioritize postal reform legislation based on the recommendations of the President’s Commission on Postal Organization (also known as the “Kappel Commission”) in its 1968 final report Toward Postal Excellence . At the PRA signing Nixon left those conclusions unspoken. He had said it all before, so there was no need to rub it in (Nixon, 1970 ; Rubio, 2020d , chs.2, 5–6). But it is worth remembering here that the report’s summary begins by emphasizing that the way out of the Post Office’s “crisis” of operating each year “at a huge financial loss” is to create a “self-supporting” government-owned “postal corporation.” That corporation would then resolve the contradiction between the Post Office’s inconsistent status as “one of the nation’s largest businesses” that they argued was “not run as a business (President’s Commission on Postal Organization, quotes from 1–2).” For its part, the PRA left subsequent generations to invent shorthand terminology (“hybrid,” “agency/corporation,” “quasi-government corporation,” “quasi-corporate government agency,” etc.…) with its own insistently neutral official description of the USPS as “an independent establishment of the executive branch” (Postal Reorganization Act, 1970 , 201). If anything, the USPS today has stretched that contradiction to its limits because it not only is fundamentally a public service; it is also a commercial and political institution.

Ominously, in 1968, the Kappel Commission report interjected how privatization was not an option at that time “largely for reasons of financing,” while allowing for privatization in the future “if such a transfer were considered feasible and in the public interest” (President’s Commission on Postal Organization, quotes on 1–2). The implication seems to be here that if the future USPS proved to be somehow not “corporate enough,” it would then need to become all -corporate. If it appeared that Nixon in August 1970 was stealing from the Democratic Party playbook, it was because there was still that much left of the “liberal consensus” then (Chafe, 2015 , 97–98), although in the end, liberal Democratic postal legislation supported by the unions that would have reformed the USPOD without corporatizing it lost out to Nixon’s bill. Under the bipartisan compromise approved by Nixon, postal services would expand, sound business principles and semi-autonomy would improve service and work culture, and postal workers’ would enjoy stronger union representation (private-sector style) for this sole group of federal government employees to enjoy full collective bargaining rights. This would also ensure labor peace and high productivity. In fact, Nixon was “stealing from Democrats’ playbook,” as the Kappel Commission had been convened by President Lyndon Johnson at the behest of his Postmaster General Lawrence O’Brien (President’s Commission on Postal Organization, quotes from 1–2). This was two years before Watergate and the 1972 election, when Nixon campaign operatives were arrested for breaking into the Democratic Party headquarters—so one could say that Nixon literally was stealing Democrats’ playbook as the operatives’ plan had been to steal Democratic campaign strategy documents (Chafe, 2015 , 402–409).

The shared political assumptions of the 1970s were quite different from today. One might even say that we have lived in a different time for some time. On the other hand, the same issues of universal service, business models, congressional oversight, government agency autonomy, and labor-management relations endure. The USPS will never be divorced from politics, and its financial health is a barometer of how effectively our democracy functions by ensuring that the nation’s mail network helps connect Americans with their elected officials and each other. Only outright repeal of Title 39 can eliminate or privatize the USPS, but lack of political will, can still cripple it into something barely recognizable from any of its previous statutory mandates. Looking ahead from this writing in mid-October 2020, there may indeed be a USPS insolvency crisis in March or October 2021 as has been suggested, or even at some future date. But the dynamic has also changed since June 15. First, as noted before, Trump now has a pliant postmaster general with whom he has a close political relationship (Heckman, 2020 ; Piette, 2020 ). Second, there are now only Trump appointees on the USPS BOG. The last non-Trump appointed governors besides Postmaster General Brennan were also the last ones with postal experience. David C. Williams, USPS OIG and BOG vice-chair, resigned in protest of Trump’s interference in USPS matters in April. Deputy Postmaster General Ronald Stroman, an expert in voting by mail, was reportedly forced out in May. Megan Brennan, who retired in June, had resisted Trump’s calls to raise parcel rates (Hart, 2020 ; Rubio, 2020c ). On the other hand, as polls in 2020 have continued to show popular sympathy for the USPS while Trump’s popularity simultaneously keeps slipping, a Democratic administration taking office in January would likely provide some relief for the USPS (Goodkind, 2020 ). However, this chronic crisis will not end until Congress alleviates the debt burden it imposed on the USPS in 2006, and crafts legislation that allows the USPS to move the U.S. mail without compulsion of profit or denial of labor rights to its employees.

Conclusion: Trump, the USPS, and the Death of the Neoliberal Consensus

For nearly two centuries, postal workers had two employers: the post office and Congress, and for a nearly a century they had national unions that mostly functioned as lobbyists. The 1970 strike was a culmination of postal worker collective anger and ultimately rejection of this status quo. It also coincided and clashed with some shared assumptions on Capitol Hill that postal reform must be based on a corporate structure. While the strikers succeeded in forcing Nixon to the bargaining table and winning a compromise that was not entirely his postal corporation model, it nevertheless produced a hybrid that made put postal workers in a special category of federal employees. In 2010, the USPS OIG blogged a brief history of the postal strike, and observed that the binding arbitration clause of Title 39 “meant that the Postal Service has never been able to exert control over its labor costs” (United States Postal Service Office of the Inspector General, 2010 ). Postal workers still lack the right to strike, in contrast with auto or steel workers who can use that weapon at their own risk and discretion. Those private sector industries can either pressure their unions to agree to contract terms or find ways to cut costs or increase production to maintain profits. The USPS, however, is in that liminal space between government agency and private corporation. Besides being obligated to negotiate and respect its unions, it must also be self-financing, and is subject to oversight by Congress and the Postal Regulatory Commission (PRC) that also limits its ability to compete, although the USPS still enjoys a first-class mail monopoly under the private express statutes (United States Postal Service, 2020b , 11).

The USPS in 2020 certainly seems stuck in a seemingly permanent service/business conundrum. Reform is clearly needed for the USPS, although I think historian Daniel Carpenter overshot the mark in describing the USPS as a neoliberal creation. Economist Milton Friedman, a founder of neoliberal theory, opposed the USPOD’s “monopoly” and supported postal privatization (Carpenter, 2020 ; Friedman, 2002 , 29–20). What we think of as the neoliberal capitalist ideology that espouses free market, free trade, privatization, social spending cuts, balanced budgets, and contingent labor (all of these also typically associated with conservatism) does not lend itself to the expansionism of the USPS, particularly with regard to labor rights. Neoliberalism became a bipartisan consensus by the 1990s during the administration of President Bill Clinton, notwithstanding the conservative Republican “Gingrich Revolution” of the 1990s (Chafe, 2015 , ch.17; Fletcher & Gapasin, 2008 ). Arguably, this “neoliberal consensus” persisted into the 2010s as Democrats watched opportunities slip away to repeal the PAEA. Was this because they lost majorities in the House in 2011 and the Senate in 2014, or accepted the conservative narrative of businesslike postal service, or both? Was the PRA as dead to them as it apparently was to Republicans (Rubio, 2020d , ch.8)? It is worth quoting the first subsection of the 1970 PRA here, as a reminder of what that law’s bipartisan authors declared it would do:

The United States Postal Service shall be operated as a basic and fundamental service provided to the people by the Government of the United States, authorized by the Constitution, created by Act of Congress, and supported by the people. The Postal Service shall have as its basic function the obligation to provide postal services to bind the Nation together through the personal, educational, literary, and business correspondence of the people. It shall provide prompt, reliable, and efficient services to patrons in all areas and shall render postal services to all communities. The costs of establishing and maintaining the Postal Service shall not be apportioned to impair the overall value of such service to the people (Postal Reorganization Act, 101 (a), Postal Policy ).

Nixon’s faith that the USPS hybrid would work out due to a combination of business world “know-how,” a government imprimatur that would protect it from politics, and a future of ever-increasing mail volume—all aided by higher productivity and automation to lower labor costs–actually lasted almost four decades before it ran into trouble. It took a politically manufactured (but very real) financial crisis in 2009 to break something that all evidence shows was never broken in the first place, and an economic and health crisis in 2020 to push it even further to the brink. The policies of the previous three postmasters general (all USPS career employees) represented to varying degrees a rearguard action in trying to stave off insolvency under the crushing RHBF debt. There were unsuccessful attempts at curtailing services, such as ending Saturday delivery, or curbing worker benefits. But they were able to implement others, such as closing post offices and mail-sorting facilities, cutting hours, selling postal buildings, and relaxing service standards for first-class mail starting in 2012. The savings or proposed savings were always minimal, but the policies reflected the same neoliberal assumptions that kept Congress from rescuing the USPS from the legislated and therefore manufactured PAEA debt burden (Brown, 2012 ; Rein, 2015 ; Rubio, 2020d , ch.8). Put simply, the USPS, its employees, and postal consumers were supposed to learn to live with austerity in service and labor rights within a “reformed” mail corporation.

The USPS is an essential infrastructure institution that currently employs 633,108 government workers to move the mail (USPS, 2020 ). If it were solely a business, this would not be a political issue. Instead there would likely be frantic shareholder meetings and pleas for a “too big to fail” bailout from Congress. If on the other hand the USPS was solely a government agency as it was before the PRA, we would not even be discussing its possible imminent insolvency–with many Americans worrying that, in the 1966 lyrics of singer/songwriter Bob Dylan, “the post office has been stolen, and the mailbox is locked” (Dylan, 1966 ). Nor would we have a president able to suggest that he could issue executive orders to stop mail-in balloting based on his publicly displayed fear that most of those votes would go to his political opponent. Nor would President Trump be able to proclaim that he would refuse to sign legislation providing the USPS funds to operate in order to keep it from being able to handle those ballots (Gardner et al., 2020 ). We would also not have a postmaster general enabling Trump’s attempted voter suppression with policies cited above (Washington v. Trump, 2020 , 2).

Besides slowing the mail down by banning employee overtime plus extra and late truck trips from mail processing centers, USPS under DeJoy in July began removing mail collection boxes around the country in both urban and rural areas, cutting postal retail hours (Meet the New Boss, 2020 ). DeJoy also ordered the dismantling of 671 mail-sorting machines by August 1. Through his counsel Thomas Marshall, he warned 46 states and the District of Columbia that the USPS could not ensure that all ballots in the mail would be delivered to election boards on time during the November general election, reneging on past policies of treating all mail-in ballots as first-class (most are marketing mail). The brazenness of all of DeJoy’s chaotic and counter-productive policies even provoked a senior official in the nonpartisan League of Women Voters to denounce them as “voter suppression” (Bogage, 2020a ; Cox et al., 2020 ; Kumar, 2020 ; Murphy, 2020 ). Steve Hutkins made this point after uncovering internal documents revealing DeJoy’s goal of reducing work-hours: “Cutting 64 million work hours would save about $3 billion in labor costs. That equates to about 33,000 jobs. It may be the largest cost-cutting operation ever attempted by the Postal Service” (Hutkins, 2020b ). This amounts to pushing these frontline workers past the point of exhaustion, with 10,000 having tested positive for the coronavirus and 52,000 having used sick leave for illness or quarantine (as of mid-September), insufficient staffing, cutbacks in overtime, and speed-up (Hutkins, 2020c ).

The defense of a “more efficient business model” is curious here, although neoliberal ideology still provides cover for a gradual privatization by dismissing universal postal service. Even if the USPS were a business, that business would still be its service—the quick moving of time-sensitive mail. In addition, the investigation begun in September 2020 by the House Oversight and Reform Committee of DeJoy’s possible campaign law violations reminds us that corporate corruption at the expense of both stockholders and consumers becomes considerably magnified when combined with government service (Davis et al., 2020 ). Political corruption in government service, even if ignored by the USPS Board of Governors, is still accountable to the judicial system. While the House Oversight committee seemed helpless to block DeJoy’s mail curtailment policies, a federal district court judge in Washington state on September 17, 2020, issued a temporary injunction that did just that. Judge Stanley A. Bastian issued the first of what have become seven separate national injunctions (as of October 10) by four different federal district court judges around the country to stop mail delays, especially mail-in ballots. (An eighth case brought by the governor of Montana–out of twelve total lawsuits nationwide–was settled on October 14 in Bullock v. USPS that mandated a reversal of DeJoy’s mail delay policies.) Judge Bastian observed that the USPS changes reflected the Trump administration’s “intentional effort…to disrupt and challenge the legitimacy of upcoming local, state, and federal elections” (Hutkins, 2020c ; Ingraham & Guskin, 2020 ; Viebeck & Bogage, 2020 ; Washington v. Trump, 2020 , 2). In addition, lest we imagine that only lawyers and judges can save the post office, postal workers have been engaged in quiet acts of resistance during the DeJoy delays (Bogage, 2020d ), as well as noisy advocacy with labor-consumer coalitions like Stand By Your Mail (Stand By Your Mail, 2020 ).

As partisan a political actor as Nixon could be in his day (Cowie, 2010 ), the PRA that he signed into law was intended to take politics out of the post office, not convert it into a partisan instrument (Nixon, 1970 ). But the USPS was unintentionally created as a conundrum of service and business. While successful for a few decades, it was in fact a ticking time bomb. If anyone did anticipate that someday there would emerge forces using the USPS’s new design to run it into the ground, they failed in warning the public. The USPS’s hybrid format provided a measure of autonomy and freed it from political control. On the other hand, congressional oversight remained, but without the annual congressional subsidies to move the nation’s mail.

Now, in the autumn of a tumultuous year, the USPS—for the first time in its 245-year history–has become a partisan political weapon for reelection in the hands of an authoritarian president already committed to that agency’s privatization. Yet a poll taken in late August 2020 found Americans by more than a two to one margin preferring that the Postal Service operate as a service rather than as a business (Ingraham & Guskin, 2020 ). Ironically and unintentionally, DeJoy’s and Trump’s policies have provided a practical demonstration of the perils of postal privatization, partisan manipulation, and insolvency of a basic government service. Whether this society can muster the political will to prevent that kind of tragedy remains to be seen.

In fact, with 22.2 million Americans already having voted in record numbers by mail or in-person by October 16, 2020, there appears to be an insurgency that includes a desire to preserve the postal service as America’s post office (Riccardi & Kastanis, 2020 ). Democrats who captured the House and its committees after the 2018 midterm elections were able to introduce the USPS Fairness Act on April 29, 2019, and passed on February 5, 2020, that would repeal the PAEA’s prefunding requirement, forgiving its outstanding RHBF debt (H.R. 2382 ( 2019 –2020). The House followed up on May 15, 2020, with H.R. 6800, a huge stimulus package that included emergency funds for the USPS due to the coronavirus pandemic, hazard pay for “postal and other essential frontline workers,” and funds to enable mail-in voting (American Postal Workers Union, 2020a ). Both bills sit in the Senate awaiting action, but House advocacy of the protection of universal postal service and labor is finally a matter of twenty-first century record. Articulating similar sentiments is the popular website Save the Post Office.com, which recently proposed a unique thirteen-point postal reform agenda. Their plan aims to fix the conundrum that the PRA authors thought they were resolving in 1970 while unintentionally creating a new one (Hutkins, 2020a ). As a historian, I make no predictions about its chances. But I have hope for initiatives like this and look forward to writing their story after they happen.

Declarations

This article does not contain any studies with human participants or animals performed by either of the authors.

There were no individual participants in this study and, thus, informed consent does not apply to this study.

The authors declare that they have no conflicts of interest.

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Influences of Indian postal service quality factors on customer satisfaction amidst Covid-19 pandemic: an empirical study

• ORIGINAL ARTICLE
• Published: 21 June 2023
• Volume 15 , pages 758–773, ( 2024 )

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• Sengazhani Murugesan Vadivel   ORCID: orcid.org/0000-0002-5287-3693 1 &
• Kirubaharan Boobalan 2  

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This research intends to examine the Service Quality (SQ) factors in mail service operations conducted at NSH offices, Karnataka state, Southern India during the COVID-19 pandemic. Recently in the year 2020, India post has implemented lean service techniques in NSH (Speed Post) Mangalore in order to increase the delivery articles production, a part of initiation of service quality enhancement. Almost, they have increased 11.36% delivery of articles from 8620 to 9600 per day (Vadivel in Development and implementation of lean service tools and techniques in India post mail service—a case study, 2020). Measuring SQ performance in mail service operations is a major challenge in order to satisfy the customer. So, we have considered core service, human aspects of service delivery, systematization of service delivery, Tangibles of service and social responsibility factors from the suitable literature support. This study was proposed to examine the relationship between service qualities on postal customer satisfaction during COVID-19. The main objectives of the study are: (1) To analyse the India post service SQ on CS during COVID 19. (2) To study the relationship between SQ on CS in India post service during COVID-19. Data were collected from a sample of 296 respondents of the Indian postal customers. With the use of R programming, the findings are examined by structural equation modelling (SEM) analysis. The findings show that there is a significant impact of service quality factors on customer satisfaction during the COVID-19. Service quality factors such as, Human service delivery (Rank 1), Core service (Rank 2), and Social Response (Rank 3) having positive impact on customer satisfaction. The research results indicate that India post service has taking necessary steps to enhance the service quality factors in order to get good will from customers’ service which is exemplified in implications of this study.

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A Review on Quality of Service and SERVQUAL Model

Abbreviations.

Analytical Hierarchy Process

Average Variance Error

Book Now Pay Later

Centre for Excellence Postal technology

Core Service

Coronavirus disease

Consistency Ratio

Customer Satisfaction

Delivery Post Management System

Discriminant Validity

Fuzzy-set Qualitative Comparative Analysis

Human Aspects of Service Delivery

Inland Letter Card

Indian Rupee

Key Performance Indicator

Lean Service

Multi-Criteria Decision Making

Mail Network Optimization Project

National Sorting Hub

Operational Performance

Post Master General

Postal Training Centre

Quality Function Deployment

Railway Mail Service

Service Delivery

Structural Equation Modelling

Service Performance

Service Quality

Social Responsiveness

Systemization

Tangibles of Elements

Variance Inflation Factor

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Acknowledgements

The authors greatly acknowledge South Karnataka PMG’s and postal employees’ support and motivation for this survey. We greatly acknowledge Mr. Bharath for editing this manuscript in better form.

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library(lavaan)

library(haven)

library(qgraph)

library(semPlot)

library(semTools)

library(summarytools)

Postal=read_spss(file.choose()) # Data

model<-'

  Soc_respons=~SR1+SR2+SR4.

  Human_eff_of_SD=~HUM1+HUM2+HUM3+HUM4.

  Systemization=~SYSTZ 1+SYSTZ 2+SYSTZ 3+SYSTZ 4+SYSTZ5.

  Tangible_Ser=~TOSR 1+TOSR 2+TOSR 3+TOSR 4+TOSR 5.

  Core_services=~CORE1+CORE2+CORE3+CORE4+CORE5.

  Cust_satis=~CS1+CS2+CS3+CS4+CS5.

  Cust_satis~a*Systemization.

  Cust_satis~b*Human_eff_of_SD.

  Cust_satis~c*Soc_respons.

  Cust_satis~d*Tangible_Ser.

  Cust_satis~e*Core_services.

fit_cfa<-cfa(model, data=Postal)

semPaths(fit_cfa,"std", edge.label.cex=0.9, exoVar=FALSE, exoCov=FALSE)

summary(fit_cfa, fit.measures=TRUE, standardized=TRUE, rsquare=TRUE)

inspect( fit)

htmt(model, Postal, sample.cov=NULL, missing="listwise", ordered=NULL, absolute=TRUE)

summary(fit_cfa)

fitsem<-sem(model, data=Postal)

summary(fitsem, fit.measures=TRUE)

inspect(fitsem)

semPaths(fitsem, 'std','est',edge.label.cex=0.9, curveAdjacent=TRUE, style="lisrel")

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Vadivel, S.M., Boobalan, K. Influences of Indian postal service quality factors on customer satisfaction amidst Covid-19 pandemic: an empirical study. Int J Syst Assur Eng Manag 15 , 758–773 (2024). https://doi.org/10.1007/s13198-023-01949-6

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The U.S. Postal Service and financial sustainability: Research roundup

2013 collection of academic studies and research papers on the United States Postal Service, including its Constitutional mandate, legal constraints and financial situation.

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Since its founding in 1775, the United States Postal Service (USPS) has been an indispensable part of the country’s communication network. Unlike most other federal agencies, the Postal Service is explicitly authorized by the U.S. Constitution, and as the country grew and technology advanced, it has adapted and expanded. Horses were replaced by trains, and airmail service was added in 1918. First Class mail volume peaked at 104 billion pieces of mail in 2001, more than quadruple the figure 50 years earlier.

Despite that high-water mark, the Postal Service was already feeling the effects of competition and technological change. FedEx opened its doors in 1971, and UPS, founded in 1907, began to deliver packages to across the country in 1975. While the USPS still had a monopoly on First Class mail service, in the mid-1990s email was born, and within a decade, letter volumes started to drop. From 2002 to 2011, First Class stamped mail declined nearly 50% . In fiscal year 2012, the number of pieces of mail delivered fell by another 5% , from 168.3 to 159.9 billion; USPS lost $15.9 billion over that period. It is now losing an estimated $25 million a day.

Complicating the agency’s situation is the Postal Accountability and Enhancement Act, passed in 2006 during President Bush’s second term. The act helped in some ways — for example, it authorized the Postal Service to sell the highly popular “forever” stamp — but it hurt in others: The USPS was prohibited from engaging in nonpostal services and, more significantly, required to fully prefund employee retirement and retirement health care costs . Not only is this requirement a unique burden among U.S. public and private enterprises, it’s costly — approximately $5 billion a year until 2017 .

In a bid to stay solvent under such constraints, the USPS has responded by delivering more commercial mail and closing post offices , and has even considered ending Saturday deliveries. While some rural residents objected, a 2012 New York Times/CBS poll found general support for cutbacks that would help the Postal Service. Congress decided otherwise , however, and in April 2013 added a rider to a spending bill that mandated Saturday delivery. Free-market advocates have long suggested privatizing the Postal Service , a controversial step that the Conservative-led government of the United Kingdom recently took .

But is privitization — and the significant changes it would no doubt bring — really a viable option for the Postal Service? Beyond the agency’s Constitutional mandate, many constituencies depend on the USPS: Direct mail marketers and political operatives are nervous about potential delays in service. Post offices are often the centers of small-town life, and elderly and disabled populations could see reduced access. Christopher Huckle, the publisher of the Cadillac News , testified at a Senate hearing that the paper, like many smaller independent publications, relies on the Postal Service for delivery.

Below is a selection of reports, scholarly studies and research papers that address USPS operations are detailed below:

“The U.S. Postal Service’s Financial Condition: Overview and Issues for Congress” Kosar, Kevin R., Congressional Research Service, January 27, 2012.

Excerpt: “After running modest profits from FY2004 through FY2006, the USPS lost $25.4 billion between FY2007 and FY2011. Were it not for congressional action to reduce a statutorily required payment to the RHBF [Postal Service Retiree Health Benefits Fund], the USPS would have lost an additional $9.5 billion…. As the USPS’s finances have deteriorated, its ability to absorb operating losses has been diminished. Between FY2005 and FY2011, the USPS’s debt rose from $0 to $13 billion. (The agency’s statutory debt limit is $15 billion….) In July 2009, the GAO added the USPS’s financial condition “to the list of high-risk areas needing attention by the Congress and the executive branch. Many media headlines have characterized the USPS’s recent deficits as the result of a drop in mail volume and attendant postage purchase revenue. This is not entirely accurate. Mail volumes slid from a peak of 213.1 billion mail pieces in FY2006 to 212.2 billion in FY2007, and dropped to 202.7 billion in FY2008. Despite the drop in mail pieces, the USPS’s revenues actually held steady during those years — $72.7 billion, $74.8 billion, and $74.9 billion — largely due to postage increases. However, between FY2009 and FY2011 mail volume declined further. Since FY2008, mail volume has fallen 17.7%, from 202.7 billion to 167.9 billion mail pieces … and operating revenues have declined 12.3%, from $74.9 billion to $65.7 billion.”

“The Postal Accountability and Enhancement Act: Overview and Issues for Congress” Kosar, Kevin R., Congressional Research Service, December 2009

Summary: “[In 2006] Congress enacted the PAEA, which made over 150 changes to postal law. Some of the more significant alterations are defining the term ‘postal service’; restricting the USPS’s authority to provide nonpostal services; altering the USPS’s budget submission process; requiring the USPS to prefund its future retiree health benefits by establishing the Postal Service Retiree Health Benefits Fund; and replacing the USPS’s regulator, the Postal Rate Commission, with the more powerful Postal Regulatory Commission. The inherent complexity of lawmaking and the execution thereof invites disagreement and confusion over what a law means and how it should be implemented. In the three years since the enactment of the PAEA, some issues and questions concerning the law’s provisions have arisen. These include, but are not limited to, possible executive branch concerns about the PAEA and the separation of powers; the cost of prefunding USPS future retiree health benefits; the role of the public in the closure of nonretail postal facilities; the USPS’s authority to provide nonpostal products and services, and the viability of the USPS’s business model.”

“U.S. Postal Service Workforce Size and Employment Categories, 1990-2010” Ginsberg, Wendy R. Congressional Research Service, April 4, 2011.

Excerpt: “USPS employed 671,687 persons as of September 30, 2010 (FY2010). USPS’s workforce size has dropped by 171,576 employees (20.3%) in the past 20 years, and USPS had 40,395 (6.0%) fewer employees at the end of FY2010 than it did at the end of FY2009. Since 1990, the career/non-career composition of the USPS’s workforce has also changed. The number of career employees has declined 23.2%, and the number of non-career employees has increased 6.3%. Facing financial problems, the USPS recently has instituted a hiring freeze, frozen the pay rate of managers, and offered some employees early retirement options. In FY2010, USPS operated with its smallest workforce in at least 20 years.”

“Projecting U.S. Mail Volumes to 2020” The Boston Research Group, March 2, 2010.

Executive Summary: “ The USPS will require significant structural changes to avoid staggering losses in the coming decade. The magnitude of these losses will require a combination of robust cost reduction actions, including changes in delivery model, including days of delivery and service standards; changes in network, including closing branches and integrating post activities into other retailers’ footprints; and changes in labor cost structure. Other countries facing similar declines are taking dramatic steps to preserve the viability of their national postal systems. Lesser solutions will fall short: price increases will drive volume away, and business diversification alone will not offset a $15B annual loss. If structural changes are unpalatable to the American people, then the Postal Service will require taxpayer support to offset its losses. Under the current volume trajectory, and with current policies, a financially viable Postal Service is not possible.”

“U.S. Postal Service: Ending Saturday Delivery Would Reduce Costs, but Comprehensive Restructuring Is Also Needed” United States Government Accountability Office, Report to the Ranking Member, Subcommittee on Federal Workforce, U.S. Postal Service and Labor Policy, Committee on Oversight and Government Reform, House of Representatives, March 2011, GAO-11-270. 40pp.

Findings: “USPS’s proposal to move to 5-day delivery by ending Saturday delivery would likely result in substantial savings; however, the extent to which it would achieve these savings depends on how effectively this proposal is implemented. USPS’s $3.1 billion net cost-savings estimate is primarily based on eliminating city- and rural-carrier work hours and costs through attrition, involuntary separations, or other strategies. USPS also estimated that 5-day delivery would result in minimal mail volume decline. However, stakeholders have raised a variety of concerns about USPS’s estimates, including, First, USPS’s cost-savings estimate assumed that most of the Saturday workload transferred to weekdays would be absorbed through more efficient delivery operations. If certain city-carrier workload would not be absorbed, USPS estimated that up to $500 million in annual savings would not be realized. Second, USPS may have understated the size of the potential mail volume loss due to questions about the methodology USPS used to develop.”

“Weighing the Universal Service Obligation: Introducing Rural Well-Being as a Consideration in the Viability Of the United States Postal Service” Community Development, 2012, 22pp. doi:10.1080/15575330.2012.705871.

Findings: “ On the topic of broadband, while broadband availability is increasing in rural America, many areas still lack access to the bandwidth necessary to be competitive in the global economy (USDA, 2009). In light of this situation, postal service cutbacks and changes in price or frequency of postal service may disproportionately affect rural areas because many residents and businesses continue to rely heavily on services provided by the USPS. Attenuating the USO potentially restricts access to weak ties – relationships that provide rural residents with access to information about jobs, alternative sources of news, and social networking opportunities. Without a comprehensive broadband infrastructure in place, rural residents and businesses will face significant challenges when conducting very basic business and personal transactions, such as paying bills, receiving coupons and information about sales, sending and receiving checks, contracts, and greeting cards, getting informational flyers and pamphlets, submitting applications, accessing education resources, receiving news media, collecting disability and social security benefits, accessing health care information, and numerous other transactions that are still normally carried out by mail… A sudden shift away from the reliance on postal service to conduct these transactions would either require that rural residents conduct these affairs less frequently, incur higher costs, or make a formidable and sudden jump into the information age. ”

“Can Services and Platform Thinking Help the U.S. Postal Service?” Communications of the ACM , April 2012, Vol. 55, No. 4, pages 21-23. doi: 10.1145/2133806.2133814.

Findings : “a more creative services and platform strategy could help reverse the USPS’s financial woes and provide a more positive way forward—generate new revenue rather than continue to reduce the scale and geographic scope, and thus the intrinsic value, of the network. While additional cuts in locations and headcount may still be necessary to get costs in balance with short-term revenues, the goal would be to halt the downward spiral of continually reducing the physical footprint of the USPS that ultimately could destroy its potential value as a service-delivery platform. How much would a bank pay for the privilege of locating ATM machines or customer service agents in every post office in the U.S.? Probably a lot, and maybe enough to solve the Postal Service deficit problem in one or two bold moves. At least, the services and platform alternative seems worth serious consideration.”

“Studies of Social and Commercial Benefits of Postal Services: Economic Effects of Post Offices” The Urban Institute, compiled for the Postal Regulatory Commission, August 2011.

Findings: “ Analysis of selected indicators reveals stark differences between ZIP codes where closures happened and where they did not… There is less variation by socioeconomic characteristics, although the closure ZIP codes tend to be substantially poorer. While the steps described above to reduce the pool of the closure ZIP codes resulted in lower average numbers of employees and establishments, no difference is apparent in socioeconomic characteristics. Because both minorities and the elderly represent potentially vulnerable populations that could be disproportionately affected by the loss of an easily accessible postal facility, it is encouraging that, in general, closures do not appear to be occurring in ZIP codes where these groups are concentrated.”

“One For All and All For One: Privatization and Universal Service Provision in the Postal Sector” Applied Economics , 2013, Vol. 45, No. 26, pp. 3667–3682. doi: http://dx.doi.org/10.1080/00036846.2012.727982.

Abstract: “Universal Service provision has a special role for the public utilities sector in many Organization for Economic Co-operation and Development (OECD) countries. These public utilities have largely been subject to privatization during the last 3 decades. Efficiency effects of privatization are widely documented while the impacts on the quality and accessibility of the Universal Service are not much examined. By using a unique dataset on privatization for 21 countries over the period 1980–2007 for the postal sector, we are able to show that privatization, in particular formal privatization, has led to a decrease in the quality of the Universal Service.”

“Providing Digital Public Services through Secure Digital Postal Systems” 2011 International Conference on Research and Innovation in Information Systems (ICRIIS), 23-24 November, 2011, Dublin, Ireland, pp. 1- 6.

Abstract: “As a result of the technological revolution, postal systems that were once viewed as efficient, trusted and inclusive have rapidly come to be seen as outdated, expensive and slow. Even though posts are still recognised as essential to citizens, they are showing evidence of decline. A direct effect of this decline is that the ability of posts to fulfill their universal service obligation (USO) is slowly being eroded. Ironically, research shows that, in order to protect their personal information online, citizens still seek trusted and efficient systems with which to interact, The aim of this paper is to present a privacy-enhanced Digital Postal Solution (DPS) designed to create public value through reducing citizens’ privacy concerns while providing secure government 2.0 services. Additionally, the DPS restores, in digital format, the full gamut of traditional universal services afforded by posts to citizens in earlier times. Additionally, it provides citizens with a platform where they can avail of web 2.0 technologies to interact with government, making way for a more transparent and collaborative relationship between government and the public. It also provides every citizen with a private digital space, where they can securely access, process and store (un)official and personal information such as bills, receipts, health and financial records. In summary, from this space, citizens can begin to fully and safely interact with digital society.”

Tags: infrastructure, research roundup, rural

About The Author

Leighton Walter Kille

White Papers

The Postal Service’s Role as Infrastructure

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Throughout its history, the U.S. Postal Service has been part of the nation’s vital infrastructure, facilitating economic activity, improving quality of life, and benefiting wider society in a variety of ways. But the Postal Service is also mandated to operate like a business, which can pose challenges to its public service mission. The resulting tension between the two was easier to manage when postal revenues were sufficient to fully cover the agency’s costs and obligations. But today, the Digital Age is cutting into the volume of the product that contributes more than half of the funds to support the network: First-Class Mail. And this strain has led to more tension between the Postal Service as a public service provider and as a business.

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Our white paper, The Postal Service’s Role as Infrastructure , presents three broad options the Postal Service and its stakeholders could consider when deciding how to adapt the Postal Service’s role for the future. These options are not mutually exclusive. But they should be evaluated together so all potential uses are recognized and accounted for as part of major changes to the size and scope of the Postal Service’s infrastructure. 

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Customer Satisfaction and Loyalty on Customer Delivered Value of Postal and Shipping Service

2018, https://www.ijrrjournal.com/IJRR_Vol.5_Issue.11_Nov2018/Abstract_IJRR004.html

Postal and package services must be able to provide value that customers want in gaining competitive advantage. Where, the company provides benefits compared to the costs incurred for satisfaction, so that customers can be loyal to the service. This study aims to analyze the characteristics of respondents, analyze customer delivered value affect customer satisfaction, analyze customer delivered value affect customer loyalty, analyze customer satisfaction as an intervening variable affect loyalty, analyze customer delivered value affect customer satisfaction, analyze customer delivered value affect customer loyalty on service letters and packages to Indonesia. This type of research is causal research. The population is customers who have used mail and package services. The number of samples is 180 respondents. The characteristics of customers are people who have purchased postal services and goods packages and respondents are more than 17 years old. The analysis technique used is Structural Equation Modeling (SEM) with the help of AMOS 21.

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USPS has a new organization

The infrastructure and operations support unit is part of the effort to transform the network.

The Postal Service has a new organization to support USPS network transformation initiatives.

Under the Delivering for America plan, the Postal Service is building a network that consists of regional processing and distribution centers, local processing centers, sorting and delivery centers, and integrated logistics infrastructure.

The new organization, called Infrastructure and Operations Support, is led by Senior Vice President Ronnie Jarriel.

The teams that comprise the organization, and their leaders, are:

• Facilities: Vice President Ben Kuo;

• Fleet Management: Director Justin Glass;

• Next Generation Delivery Vehicle Program: Director Victoria Stephen;

• Facilities and Fleet Acquisition portfolio: Senior Director Martin Petrey;

• Service Quality Assurance: Executive Director Greg White; and

• Product Acceptance and Support: Senior Director Randy Workman.

Postmaster General Louis DeJoy announced the new organization last week.

Post-story highlights

More to read.

Product solutions VP to retire

Thomas Foti oversees pricing, classification and other areas

Reshaping the Postal Service

The PMG discussed the organization’s future during a recent speech

USPS unveils first charging stations and electric delivery vehicles

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Is United States Postal Service (USPS) a Monopoly? Research Paper

The available facts need to be examined. First, the USPS is a government agency that is authorized by the US Constitution under “Article I, Section 8, Clause 7” (US Constitution). Spooner states:

“By the old articles of Confederation, it was declared “the United States, in Congress assembled, shall have the sole and exclusive right and power of establishing and regulating post-offices from one State to another throughout all the United States.” (Spooner, 1844, p. 15).

When the constitution came to be adopted, this phraseology was altered, and the words “sole and exclusive” were omitted. This alteration… must certainly have been intentional” (p.11).

The legal status as a monopoly, under the Constitution is open to challenge. During the 1970’s, USPS was made into a Corporation that still retained its government agency status. USPS has allowed contractors to move mails between post offices. Today, Federal Express and United Parcel Service deliver high value parcels and will utilize USPS to expedite non-profitable overnight deliveries.

USPS is running significant losses. Why?

According to the US Government Accountability Office (GAO), for the following reasons:

“Since 2006, the U.S. Postal Service (USPS) has closed redundant facilities and consolidated mail processing operations and transportation to reduce excess capacity in its network, resulting in reported cost savings of about $2.4 billion. Excess capacity remains, however, because of continuing and accelerating declines in First-Class Mail volume, automation improvements that sort mail faster and more efficiently, and increasing mail preparation and transportation by business mailers, much of whose mail now bypasses most of USPS’s processing network” (GAO 2012, p.1).

What then, are the conclusions reached by the GAO?

“In February 2012, USPS projected that its net losses would reach $21 billion by 2016” (GAO 2012, p.4). The GAO have in 2009 made the following recommendations: “(1) rightsizing its retail and mail processing networks by consolidating operations and closing unnecessary facilities and (2) reducing the size of its workforce” (GAO 2009, p.2). In 2012, the GAO stand behind their 2009 recommendations:

“GAO is not making new recommendations in this report, as it has previously reported to Congress on the urgent need for a comprehensive package of actions to improve USPS’s financial viability and has provided Congress with strategies and options to consider” (GAO 2012, p.6).

What needs to be done? Economic theory provides the answer. The price system allows economic calculation, which is expressed in accounting terms as profits and losses. Profits accrue when the good or service demanded by consumers is urgent enough to provide a monetary profit after all costs and expenses. If losses accrue, it is clear that the consumer demand is insufficient, and the resources should be reallocated.

Clearly in today’s technological environment there simply isn’t the demand for postal services, as they currently exist. Should a consumer demand remain, and clearly there would remain demand, the private providers already in this business segment can charge a price that reflects the economic realities, which, undoubtedly would be significantly higher. Therefore the rational decision is to close USPS and liquidate the business as a bankrupt.

Politically, this will never happen. As the second largest civilian employer in the US, in the current economic climate of recession, in a Presidential election year, the losses will be allowed to continue to accumulate.

Spooner, L. (1844). The Unconstitutionality of the Laws Of Congress, Prohibiting Private Mails. Web.

The United States Constitution: Article I, Section 8, Clause 7 (n.d.) Web.

U.S. Government Accountability Office. (2009) Network Rightsizing Needed to Help Keep U.S.P.S. Financially Viable (GAO-09-674T) Washington D.C., United States: Author. Web.

U.S. Government Accountability Office. (2012) Mail Processing Network Exceeds What is Needed for Declining Mail Volume (GAO-12-470) Washington D.C. United States: Web.

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IvyPanda. (2022, January 23). Is United States Postal Service (USPS) a Monopoly? https://ivypanda.com/essays/is-united-states-postal-service-usps-a-monopoly/

"Is United States Postal Service (USPS) a Monopoly?" IvyPanda , 23 Jan. 2022, ivypanda.com/essays/is-united-states-postal-service-usps-a-monopoly/.

IvyPanda . (2022) 'Is United States Postal Service (USPS) a Monopoly'. 23 January.

IvyPanda . 2022. "Is United States Postal Service (USPS) a Monopoly?" January 23, 2022. https://ivypanda.com/essays/is-united-states-postal-service-usps-a-monopoly/.

1. IvyPanda . "Is United States Postal Service (USPS) a Monopoly?" January 23, 2022. https://ivypanda.com/essays/is-united-states-postal-service-usps-a-monopoly/.

Bibliography

IvyPanda . "Is United States Postal Service (USPS) a Monopoly?" January 23, 2022. https://ivypanda.com/essays/is-united-states-postal-service-usps-a-monopoly/.

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March 12, 2024

USPS And USPIS Continue Nationwide Campaign to Combat Postal Crime and Protect Postal Employees

%subheading%

Arrests for Robbery of Letter Carriers Up 73% Year Over Year

High-Security Blue Collection Boxes, Enhanced Security Mechanisms Now in All 50 States

WASHINGTON, D.C. – Today, the U.S Postal Service (USPS) and U.S. Postal Inspection Service (USPIS) announced an update on Project Safe Delivery, a joint initiative to protect postal employees and secure the nation’s mail and packages. The initiative was launched in May 2023 in direct response to rising crime across the nation that has led to increased threats and attacks on letter carriers and mail theft incidents.

In February, USPIS completed a second law enforcement surge in San Francisco as a part of this nationwide effort by USPIS and USPS to protect both postal employees and the integrity of the postal system. Since the launch of Project Safe Delivery, Inspection Service personnel have conducted more than 5,500 mail theft, and violent crime prevention activities nationwide.

“We have been unrelenting in our pursuit of criminals who target postal employees and the U.S. Mail. The efforts of our postal inspectors and law enforcement partners have yielded positive results,” said Postmaster General and Chief Executive Officer Louis DeJoy. “We are not done. Ensuring the well-being of our letter carriers and all postal employees remains of the utmost importance. We will continue to make major investments to secure the postal network while directing the full weight of our law enforcement resources to protecting our employees and the mail.”   

Postmaster General DeJoy also called for increased prosecution and strong sentences for individuals who perpetrate postal crimes, including letter carrier robberies, mail theft, and associated financial crimes saying, “Our nation’s letter carriers deserve to go to work without fear of harm from a robbery or attack. Letter carriers are hardworking, federal civil servants who deliver an essential service to communities across America. An attack on a letter carrier, or any postal employee, is also an attack on the very community they serve. Individuals who attack postal employees should be vigorously prosecuted and, if convicted, should receive penalties from the courts that reflect the seriousness of their crimes. The courts must take postal crimes seriously, and the criminals who perpetrate them must be held fully accountable under the law.”

“The results of physical security investments and enforcement efforts announced today demonstrate our continued progress with the Project Safe Delivery initiative,” said Chief Postal Inspector Gary Barksdale. “This includes the results of our targeted law enforcement operations in San Francisco, Chicago, and a number of locations in Ohio. These operations have advanced our investigations, secured postal assets, and raised awareness among postal employees about steps they can take to protect their safety.”

Arrests Associated with Letter Carrier Robberies Up 73%

For the 2024 Fiscal Year so far, the Postal Inspection Service has made 73% more arrests for letter carrier robberies over the same time period in the prior fiscal year. This increase is the direct result of the efforts made by the Postal Inspection Service and federal and local law enforcement partners to aggressively pursue those who rob our letter carriers and steal mail. Since May 2023, the Postal Inspection Service has made over 1,200 arrests for letter carrier robberies and mail theft nationwide.

Over the last five months, reported robberies of letter carriers have decreased by 19% and complaints received for mail theft are down 34%.

Law Enforcement Surge Operations

USPIS is working diligently to enforce the laws that protect USPS and the U.S. Mail. As part of these efforts, the Inspection Service is conducting targeted law enforcement surges across the country including in Chicago, San Francisco, and cities across Ohio. Additional surges are planned for 2024 in other cities across the United States.

Each surge leverages wide-ranging law enforcement partnerships, including with the Department of Justice, Postal Service Office of the Inspector General, other federal agencies, and local law enforcement. Initial surges have resulted in more than 20 arrests, more than 950 investigative actions, including the execution of arrest warrants, search warrants, and other court authorized law enforcement activities, and more than 400 prevention activities, including presentations to postal employees on employee safety and mail theft prevention. 

High-Security Blue Collection Boxes and Electronic Lock Mechanisms Deployed to All 50 States

Since the launch of Project Safe Delivery, USPS, in partnership with USPIS, has made significant investments in the physical security of its mail receptacles and is hardening blue collection boxes, making access to their contents more difficult for criminals in all 50 states. Since May 2023, tens of thousands of hardened blue boxes and electronic locking mechanisms have been and will be strategically deployed in high postal crime areas. This includes 15,000 hardened blue boxes, with another 8,500 ordered to be installed, and 28,000 electronic locking mechanisms installed in mail receptacles .

USPS, in partnership with USPIS, will continue to make significant, strategic physical security investments to USPS’s delivery network. These investments will help to modernize USPS’s infrastructure and ensure that the public can safely and securely send and receive mail. 

Action the American Public Can Take to Help Prevent Mail Theft  

Customers can take several steps to protect their mail and their letter carriers, including:

• Don’t let incoming or outgoing mail sit in your mailbox. You can significantly reduce the chance of being victimized by simply removing your mail from your mailbox every day.  
• Deposit outgoing mail at secure locations, including inside your local Post Office or at your place of business, or hand it directly to a letter carrier. 
• Sign up for Informed Delivery and get daily digest emails that preview your mail and packages scheduled to arrive soon. 
• Become involved and engaged in your neighborhood via neighborhood watches and local social media groups to spread awareness and share information. 
• Keep an eye out for your letter carrier. If you see something that looks suspicious, or you see someone following your carrier, call 911.   

Customers are encouraged to report stolen mail as soon as possible by submitting an online complaint to the Postal Inspection Service at  www.uspis.gov/report  or calling 877-876-2455.  Additionally, individuals are encouraged to report allegations of Postal Service employee misconduct, including attempts to corrupt a Postal Service employee, to the USPS OIG at 1-888-877-7644 or  www.uspsoig.gov

The United States Postal Service is an independent federal establishment, mandated to be self-financing and to serve every American community through the affordable, reliable and secure delivery of mail and packages to 167 million addresses six and often seven days a week. Overseen by a bipartisan Board of Governors, the Postal Service is implementing a 10-year transformation plan, Delivering for America , to modernize the postal network, restore long-term financial sustainability, dramatically improve service across all mail and shipping categories, and maintain the organization as one of America’s most valued and trusted brands.

The Postal Service generally receives no tax dollars for operating expenses and relies on the sale of postage, products and services to fund its operations.

For USPS media resources, including broadcast-quality video and audio and photo stills, visit the USPS Newsroom . Follow us on Twitter , Instagram , Pinterest and LinkedIn . Subscribe to the USPS YouTube Channel and like us on Facebook . For more information about the Postal Service, visit usps.com and facts.usps.com .

Media contacts

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Printable version

This paper is in the following e-collection/theme issue:

Published on 26.3.2024 in Vol 26 (2024)

Designing and Implementation of a Digitalized Intersectoral Discharge Management System and Its Effect on Readmissions: Mixed Methods Approach

Authors of this article:

Original Paper

• Christoph Strumann 1 , PhD   ; 
• Lisa Pfau 1 , MD   ; 
• Laila Wahle 2 , MBA   ; 
• Raphael Schreiber 1 , MD   ; 
• Jost Steinhäuser 1 , Prof Dr Med, MD  

1 Institute of Family Medicine, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany

2 Lacanja GmbH Health Innovation Port, Hamburg, Germany

Corresponding Author:

Christoph Strumann, PhD

Institute of Family Medicine

University Medical Centre Schleswig-Holstein, Campus Lübeck

Ratzeburger Allee 160

Lübeck, 23538

Phone: 49 451 3101 8005

Email: [email protected]

Background: Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital.

Objective: This study aims to evaluate the implementation of a digitalized discharge management system, the project “Optimizing instersectoral discharge management” (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate.

Methods: A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group.

Results: Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: “optimization potential,” “barriers,” and “enablers.” On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital’s social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions ( P =.20).

Conclusions: This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system.

Introduction

Digital patient process systems offer several advantages over analog systems. On the one hand, this can lead to more systematic, targeted use of resources, and on the other hand, easier communication and transmission of data can enable better coordination of the various cooperating partners [ 1 ]. Patient records are becoming increasingly digitalized, with some countries being prototypes in this area, such as Latvia, Denmark, and Spain [ 2 ].

In Germany, there have been several governmental attempts to shape different elements of health care digitalization. A recent example is the Hospital Future Act (Krankenhauszukunftsgesetz) from 2020. It was designed to support digitalization in hospitals by promoting the technical equipment of hospitals through state-funded investments. The investments are expected to improve process organization, documentation, and communication (internal, sectoral, and intersectoral) [ 3 ]. The results suggest that the Hospital Future Act, together with the COVID-19 pandemic, led to an increase in the digital maturity of hospitals and, thus, reduced the digitalization backlog [ 4 ]. Another approach to promote health care digitalization is the introduction of an electronic health record (EHR) within a secure telematics infrastructure. The EHR should not only simplify rapid communication within and across different health care institutions but also enable further eHealth applications, for example, electronic prescriptions [ 5 ]. However, the introduction of EHRs as well as other reforms promoting health care digitalization have been accompanied with strong resistance underpinned by arguments of data protection and security as well as by technical problems. Especially in the outpatient sector, the latter has resulted in a perceived disproportionate administrative effort without adequate financial compensation for the care providers such as private practices [ 6 ]. As a result, Germany lags behind other industrialized countries in the digitalization of the health care system [ 7 , 8 ].

An EHR could make treatment pathways more transparent and improve communication between different health care providers, including inpatient, outpatient and care facilities [ 9 ]. The exchange of information is particularly susceptible if a patient is discharged from hospital. With regard to the strongly pronounced sectoral separation in Germany [ 10 , 11 ], information loss is particularly high between inpatient and outpatient care. Moreover, owing to the accelerated tendency toward shortening the length of stay of patients in the inpatient sector as a result of the introduction of the diagnosis-related group–based reimbursement system [ 12 ], hospitals no longer provide care and treatment until full recovery [ 13 ]. Instead, parts of the treatment and recovery process are moved to the posthospital setting [ 14 ]. Similar developments have been observed after introducing the diagnosis-related group–based reimbursement system in other countries, for example, the United States [ 15 - 17 ]. Shortened length of stay and ineffectively designed transitions are associated with adverse events, higher risks of readmission, and higher costs [ 18 - 21 ]. Up to 1 (18%) in 5 patients are readmitted to the hospital within 30 days of discharge [ 22 , 23 ]. Individualized discharge management can reduce the number of readmissions of older patients with a health problem [ 24 ], leading to potential cost savings for the health care system [ 25 ]. To date, many strategies to improve discharge management have focused on structures within the hospital. However, to ensure a holistic and continuous treatment, the cooperation between different health care providers from the inpatient and outpatient sectors as well as care facilities should also be considered.

As there is still no EHR accessible to all caregivers in Germany, experience with digitalized health information systems has been gathered only in model projects, which are intended to provide insights into possible barriers and enablers for a successful implementation [ 5 , 26 - 30 ].

This study aims to explore the determinants of a digitalized discharge management system, to implement such a system within 1 area, and to evaluate its impact on the readmission rate.

The evaluation was done within the project “Optimizing intersectoral discharge management” (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements).

Study Design

A mixed methods design was chosen to evaluate SEKMA. Owing to the complexity of the intervention, the evaluation was based on the framework of developing tailored interventions [ 31 ]. This approach allows a detailed description and analysis of the components of the intervention that contributed to its effectiveness or ineffectiveness. For this purpose, this framework distinguishes between a development and an application phase. In the first step, barriers and enabling factors for a successful implementation of a digitalized discharge management system such as SEKMA were explored using qualitative research methods, that is, interviews. Second, strategies were developed for addressing these determinants. Third, these strategies were prioritized using a (quantitative) questionnaire, and a logic model was formulated to describe the logical linkages among the resources and activities needed to achieve the results. After the implementation (application phase), the congruence between the planned intervention (logic model) and the implemented intervention was evaluated. In this step, the fidelity of the use of the different strategies in the routine was examined [ 32 ]. Finally, the effectiveness of the implementation on the readmission rate (outcome) was evaluated based on routine data of hospital admissions.

The digitalized discharge management system was implemented at a medium-sized hospital (approximately 350 beds) in the northern German federal state Schleswig-Holstein in the Metropolitan area of Hamburg, the second-largest city in Germany. Before the intervention, the internal and external exchange of information was typically performed by phone, fax, and email. As the network between the various caregivers was rather weak, communication occurred only on request, tying up resources and causing delays in the transfer of information.

SEKMA aimed to develop and implement a digitalized, intersectoral discharge management system that considers the patient’s entire treatment pathway, from hospital admission to possible admission to a care facility, and the follow-up treatment by general practitioners (GPs). All information relevant to ongoing (postinpatient) treatment and care should be available quickly and easily to all care providers involved. This includes providers from the inpatient and outpatient sectors as well as care facilities. For this purpose, an ecosystem of hospital and postinpatient care facilities has been implemented within a digital infrastructure based on a standardized and harmonized IT system for data exchange [ 33 ]. The workflow of the digitalized, intersectoral discharge management can be described as follows:

• The hospital coordinates and organizes follow-up care in a timely manner based on the patient’s agreement with the hospital’s discharge management.
• A discharge plan for medication, follow-up care, and rehabilitation is created and all professionals in the hospital are involved. This includes admission staff, medical service, nursing service, social service, and the patient information system.
• In cooperation with the nursing staff and social service, the patient is informed and advised about care options and structures that correspond to their illness. The contents are prepared digitally.
• The patient is discharged from the hospital and transitions to outpatient, rehabilitative, or nursing care. All documents necessary for discharge and further treatment are available digitally and can be transmitted directly to the relevant sectors.
• If a patient contacts a primary care physician for outpatient follow-up treatment, the patient’s digital discharge documentation is already in the system of the private practice.
• In case of a query or deterioration of health status, the primary care physician can contact the hospital and previously treating physicians directly.
• If there is a readmission, the hospital can digitally access documentation on posttreatment care and procedures, as well as the medical history, at any time and continue treatment directly. The same applies to nursing and rehabilitation facilities.

The information transfer across the distinct health care provider is organized via KIM (Kommunikation im Medizinwesen) embedded in the telematics infrastructure. All organizations involved in the project have a KIM connection. Using KIM, participants can transmit documents in a secure and encrypted manner [ 34 ]. Overall, all communication processes have been digitalized compared with before the intervention. Since April 2022, optimized discharge management has been implemented in the department of vascular surgery.

Individual Interviews

Enabling factors and barriers leading toward successful digital discharge management were identified through individual interviews with physicians, medical assistants, social workers and nurses at the hospital, GPs, and staff from nursing homes and care services. This was performed using the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines for qualitative studies ( Multimedia Appendix 1 provides details of the COREQ guidelines [ 35 ]). Originally, a combination of interviews and focus groups was planned. Owing to the COVID-19 pandemic, focus groups had to be abandoned.

The hospital, along with collaborating partners such as physician networks and nursing homes, conducted participant recruitment for interviews through face-to-face interactions, telephone calls, and emails. Previously developed partially standardized interview guidelines were used and pilot tested ( Multimedia Appendix 2 ). The interviews were conducted by telephone by a medical student (LP) between April 30, 2020, and October 9, 2020, at the workplace of the interviewees. A theoretical saturation effect in the statements made during the interviews resulted in the final number of interviewees.

The individual interviews were conducted in a protected setting and subsequently pseudonymized, thus providing the opportunity to explore the personal opinions of the interviewees beyond any possible social group pressures. The interviews were recorded using a digital dictaphone and were transcribed orthographically. The material was subsequently analyzed using structured content analysis according to Mayring [ 36 ]. The development of the categories was initially based on the questions (deductive) listed in the partially standardized interview guideline ( Multimedia Appendix 2 ). In addition, categories were extracted from the text (inductive). Five persons were involved in the development of the category scheme (LP: medical student [female researcher], JS: GP and experienced health service researcher including qualitative research [male researcher], CS: health economist with some experience in qualitative research [male researcher], a legal project advisor [female researcher], and a physiotherapist [female researcher]; all of them except LP were employed at the Institute of Family Medicine at the University of Lübeck at the time of the analysis). After individual coding, a coding scheme was discussed in a consensus meeting. The final coding scheme was applied to the interview material.

Development and Evaluation of Strategies

On the basis of the described processes for treating the patients, the optimization potential, and the determinants from the evaluated individual interviews as well as the workshop with clinicians and physicians in private practice, strategies for the implementation of optimized discharge management were developed. These strategies were developed in such a way that they addressed the determinants identified and were, thus, conducive to a successful implementation.

During a project meeting on February 3, 2022, employees of the Institute of Family Medicine at the University of Lübeck and the chief and senior physicians of the involved hospital discussed these results. Subsequently, the hospital’s chief or senior physicians were invited to evaluate each identified strategy according to its relevance and feasibility using a 6-point Likert scale (very high, rather high, high, rather low, low, and very low) to avoid the central tendency bias.

The resulting list of the ranked strategies formed the logic model. This model was finally compared with the list of strategies implemented in the project.

Routine Data Analysis

The focus of the evaluation of the optimized discharge management was the reduction of (unnecessary) readmissions. With the help of the evaluation of the routine admission data of the involved hospital, the effect of optimized discharge management on rehospitalization was analyzed.

Routine Data and Study Design

The hospital extracted routine data from its internal patient information system. The extracted data were provided by the hospital in an anonymized form. For each inpatient case, the data consisted of information on the date of admission and discharge, the reason for admission and discharge, diagnoses and conducted medical procedures, demographic information of the patients, and the department or departments where the patients had been treated.

Within the framework of a longitudinal study design, a pre- and postcomparison was performed. The intervention group was the department of vascular surgery, in which the optimized discharge management was implemented since April 2022. A case was assigned to the intervention group if the patient was admitted to or discharged from the department of vascular surgery. The outbreak of COVID-19 during the sample period might have affected the readmissions of the entire hospital. To minimize the risk of bias owing to the pandemic on the intervention effect, in addition to the pre-post comparison of the department of vascular surgery, a control group comparison was applied to enrich the empirical strategy. To ensure that the patients in the intervention group were as similar as possible to those in the control group, the departments of internal medicine (medical clinic) and cardiology formed the control group.

Statistical Analysis

The effect of the implementation was estimated using the difference-in-difference (DiD) approach. The sample covers the period from 2019 to August 2022. To counteract the possible COVID-19 pandemic bias, patients admitted between January 2020 and March 2022 were not considered in the analysis. To avoid any seasonal influences on the results, we restricted the preintervention period such that it covered exactly the period after the implementation, that is, from April to August. Therefore, the baseline period (T 0 ) consisted of April 1, 2019, to August 31, 2019, whereas the intervention period (T 1 ) started from April 1, 2022.

In addition to the bivariate analysis, a multivariate logistic regression model was applied. By including control variables, differences between patients from the intervention and control group were minimized. In the first step, risk factors for rehospitalization were determined by estimating separate bivariate logistic regression models. The identified risk factors served as control variables in the multivariate DiD regression analysis. A P value <.05 was considered statistically significant. Statistical analyses were performed with Stata (version 15; StataCorp LLC).

Ethical Considerations

The study was approved by the ethics committee of the University of Lübeck before recruitment commenced on December 11, 2019 (approval number 19-387). This study was conducted in accordance with the Declaration of Helsinki.

All participants provided verbal and written informed consent for their participation in the interviews and surveys. The participants were informed that they could withdraw their consent at any time. No identifiable information was recorded to ensure the confidentiality of the participants. No compensation was paid for participation.

For the analysis of routine hospital data, only anonymized data were transferred to the evaluating institution. Owing to the anonymization of the data, no additional informed consent was required to perform the routine data analysis in accordance with German law, ethical standards, and the Declaration of Helsinki. No data requiring informed consent will be presented in the routine data analysis. The ethics committee of the University of Lübeck waived the requirement for informed consent owing to the retrospective nature of this study.

A total of 26 interviews were conducted. These consisted of 14 employees of the hospital (3 doctors, 4 nurses, 4 social workers, and 3 administrative staff), 9 employees from nursing homes or mobile nursing services, and 3 GPs. The average age of the participants was 42.4 (SD 8.9; range 25-65) years, and the proportion of female participants was 54% (14/26). The average interview duration was 33 minutes and 11 seconds. An overview of the characteristics of the interview participants is provided in Table S1 in Multimedia Appendix 3 .

A total of 21 determinants were explored with various subcategories for the introduction of successful digitalized discharge management. These could be divided into 3 categories: “optimization potential,” “barriers,” and “enablers.” The aspects mentioned for optimizing the discharge process covered all areas from admission to follow-up and included inter- and intrasectoral transmission of information ( Textbox 1 ).

Category and subcategories

• Preliminary discharge letter before discharge
• Final discharge letter at the time of discharge
• Digital transmission (mail, chat, and video call)
• Platform for information exchange
• Standardized information
• Increased readiness to communicate
• Information exchange at admission
• Consent to discharge management
• Awareness of the existence of discharge management in the hospital
• Timely completion of the discharge process
• Continuous preparation for (unplanned) discharge
• Improvement of patient communication
• Faster approvals by health insurances
• Discharge in the morning of the working day
• Material transfer, issuing of prescriptions and incapacity certificate
• Nursing services accompany discharge from hospital
• Increase in the availability of patient transport
• Visits to general practitioner after discharge
• More aftercare places
• Training on discharge
• Digital checklist
• Standardized processes
• Clarified responsibilities
• Knowledge of the performance and processes at other facilities
• Evaluation of criticism or review
• Supervision
• Ethics committee

In the German health care system, the discharge letter is at the center of information transmission between the inpatient and outpatient sectors. Participants saw a need for improvement in the early, or at least timely, delivery of this letter. In the best case, information would already be transmitted during the hospital stay to the follow-up service providers such as private practices or care facilities:

To have all the information and data, everything before the patient arrives here. That would be the absolute dream. [...] You can just admit the person better[...] if you just have preliminary information. [P03]

Digital transmission of data was also perceived as beneficial; the participants could imagine using conventional media such as email or video calls as well as via a platform provided specifically for this purpose:

If you could even find some other common platform where information can be exchanged. [P01]

Furthermore, the potential for optimization was seen in the standardization of the information. The information to be communicated should be transmitted through a central entity, and at the same time, selected contacts who can be reached on demand and who can provide information about the patients would be beneficial:

Yes, standard, standard, standard. So, that you try to agree on what information I need and then it has to appear—in a structured form, so in principle already like my patient information. [P10]

Some participants also noted that, in principle, a greater willingness to communicate between the individual players would improve the transmission of information.

Participants noted that for a seamless discharge, information about the patient should already be available at the time of admission to the hospital:

Discharge or discharge planning and a good discharge process starts at admission. [...] The important thing is not to think about discharge on the day of discharge, but already on admission. [P25]

Improved patient communication was also considered important by interviewees:

And that is certainly a wish that I would have that the patients in the hospital are also informed about what they actually have, what has happened and what the next steps are. [P01]

An optimal discharge should ideally take place in the morning on a working day, and the handing over of medication and required materials should be regulated. This is considered to be the case by nursing homes and outpatient care services as well as by hospital staff:

From 9 or 10 a.m onwards, the number of patients in the emergency room increases and drops again from 8 p.m onwards. And during this peak time, there are few beds available in the hospital. Afterwards, however, when we are closed, the hospital finally loses cases and at night we have more free capacity again. And that is a mismatch between demand and capacity which can be improved. [P20]

Textbox 2 shows the barriers and enabling factors for intersectoral collaboration in the context of optimizing discharge management. In addition to the technical aspects and subjective reasons, there were concerns about data protection and fear that a change in the discharge process would require more time:

Time pressure is always an issue, both in the hospital and in outpatient care. We just often don’t have the time for some processes that we would all consider useful. [P01]

• Data transmission security
• Legal uncertainties
• Leaving known structures and processes
• Lack of electronic data processing experience
• Higher time consumption
• Lack of personnel
• Limitation of one’s own competence
• Unclear communication processes
• No perceived benefit
• Low appreciation for discharge management
• No priority of discharge management
• No consequences for noncompliance
• User-unfriendly system
• Electronic data processing errors
• Interface problems
• Outdated technical equipment
• Lack of education or communication
• Lack of networking among health care providers
• Clear responsibilities, instructions, contact persons, or responsibilities
• Surveillance
• Introduction or training of new processes
• No overload and enough time
• Regular exchange for networking
• Time saving
• Workload reduction
• Improved exchange of information
• Feedback loops
• Priority in the management
• Communicating the advantages
• Involvement of employees

In contrast, a possible reduction in workload owing to digitalized processes was seen as conducive:

Digitalization must not be an end in itself, in my opinion, but it must really mean an advantage for the processes, increase safety, increase communication, but it must not be a question of just because it is digital, that it is better in every case and is then associated with the fact that medical or nursing working time is lost or additionally created. [P23]

For the changeover to be successful, the communication of the advantages associated with optimized discharge management was emphasized above all as part of change management.

On the basis of the surveyed processes, the optimization potential, and the determinants from the evaluated individual interviews as well as the workshop with clinicians and physicians in private practice, 19 strategies for the implementation of optimized discharge management were developed. To rank these strategies, chief physicians of the hospital were invited to rate their relevance and feasibility.

A total of 11 physicians participated in the survey to evaluate the strategies ( Table 1 ). The strategies of always sending the discharge letter to the GP, equipping the hospital’s social service with mobile devices (eg, laptops and tablets), generating individual medication plans in the format of the national medication plan, and exclusively using the federal medication plan received the highest ratings. In contrast, the introduction of a chat function used exclusively by physicians for direct exchange between hospital and office-based physicians received the lowest rating.

a Mean over participants (6=very high, 5=rather high, 4=high, 3=rather low, 2=low, and 1=very low).

b GP: general practitioner.

c Not part of the intervention but planned for the future by the hospital.

On the basis of these ratings, the hospital staff discussed which of these strategies were already being implemented or planned for implementation in the near future. Of the 19 strategies, 6 (31%) were assessed as already implemented, 7 (37%) were assessed as planned, and 6 (31%) were assessed as not feasible to implement in the project. The 7 strategies rated highest in the development of the logic model (planned implementation) have been implemented or will be implemented in the near future as part of SEKMA.

To summarize, by April 2022, at the department of vascular surgery, (1) discharge letters were continuously updated digitally, (2) they were always sent, (3) they were sent electronically to the GP (via the infrastructure of KIM), (4) the hospital social service was equipped with mobile devices, (5) individual medication plans were in the format of the national medication plan, (6) the discharge management consent process at admission was standardized, and (7) a hotline for direct communication between hospital physicians and primary care physicians was implemented. The information transfer via the discharge letter was oriented by the standard of medical information objects (MIOs) eArztbrief. The development of this standard was initiated in 2022 by the National Association of Statutory Health Insurance Physicians and the German Hospital Association. It defines a standard for the electronic hospital discharge letter within the EHR ensuring the transition of relevant information from inpatient to subsequent care in a structured and secure manner [ 37 ]. The MIO eArztbrief was not yet ready during the project; however, the current status of the MIO was incorporated into the letter as much as possible.

Fidelity Analysis

After the implementation of the optimized discharge management into the routine in the department of vascular surgery as well as at the external partners in April 2022, the stakeholders participating in the project were asked in a fidelity analysis in September 2022 to what extent the identified strategies were implemented in practice. The survey showed that many of these strategies were not yet widely applied.

A total of 14 individuals responded to the survey (Table S2 in Multimedia Appendix 2 ). Of the 14 individuals, 11 (79%) were employed at the hospital and 1 (7%) each at an outpatient nursing service, nursing home, and private practice. Employees from social services and medical assistants did not participate in this survey. Of those surveyed, >30% (4/13) stated that they were satisfied with the implementation of the change in discharge management.

There are differences in the fidelity of use among the strategies implemented (Table S3 in Multimedia Appendix 3 ). Although sending or receiving an electronic discharge letter was always or sometimes used in their routine by only a quarter of respondents, approximately 85% (11/13) of the respondents indicated that medication plans from the hospital were always in the format of the federal medication plan at discharge.

Readmissions

In total, 12,407 patients were admitted to the hospital as inpatients during the study period (from April 2019 to August 2019 and from April 2022 to August 2022), corresponding to 14,854 cases treated. The internal medicine department (medical clinic) treated most of the cases (4175/14,854, 28.11%). Cases treated in the interventional group (vascular surgery) accounted for 5.11% (759/14,854) of all inpatient cases. Overall, 8.73% (994/11,386) of the patients were readmitted after 30 days. In terms of treated cases, the readmission rate was 9.07% (1222/13,477). The rates increased to 17.1% (1542/9016) for patients and 18.85% (1975/10,478) for cases when considering a longer time horizon for the readmission (90 days). Readmission rates were generally higher in the intervention group (80/705, 11.3%) at 30 days and 28.8% (161/560 at 90 days) than in the hospital as a whole and the control group. Table S4 in Multimedia Appendix 3 provides the number of admitted patients and cases treated as well as the readmissions after 30, 60, and 90 days for the total hospital cases and the departments involved.

Risk Factors

Risk factors for readmission were identified to take the differences between patients from different departments into account for the evaluation of the project’s implementation effect.

Older patients, as well as cases with a length of stay of >6 days, had a significantly higher risk of readmission. Similarly, discharge time influenced the readmission risk: patients discharged during the night (9 PM to 5 AM) had a higher risk of readmission. Similarly, there were significant differences in readmissions between cases with different ICD-10 ( International Statistical Classification of Diseases , Tenth Revision ) chapters of principal and secondary diagnoses (Table S5 in Multimedia Appendix 3 ).

Intervention Effect

Table 2 shows the implementation effects on the readmission rate after 30, 60, and 90 days (DiD) of the bivariate analysis. In the intervention group, the 30-day readmission rate increased by 2.33 percentage points from 10.4% (45/431) to 12.8% (35/274) after SEKMA was implemented. For the 60- and 90-day readmission rate, the increase was even higher (60 days: 2.25 and 90 days: 3.94). These increases have been smaller in the control group. Therefore, a reduction effect of the intervention on the readmission rate (ie, a negative DiD estimate) cannot be observed. Concentrating the analysis on patients aged ≥65 years revealed similar results (Table S6 in Multimedia Appendix 3 ). As a robustness check, the preintervention period was extended to include admissions between 2011 and 2019. These results confirm the previous findings.

a Only admissions between April 2019 and August 2019 and between April 2022 and August 2022 were considered.

b DiD: difference-in-difference, Δ: Difference between the readmission rates of the intervention and the control group at T 0 and T 1 , respectively.

c Intervention period (T 1 ): from April 1, 2022.

d N/A: not applicable.

e Baseline period (T 0 ): April 1, 2019, to August 31, 2019.

The results of the multivariate logistic regression model ( Table 3 ) confirm the results of the bivariate analysis that there were higher readmission rates in the intervention group and that there was no significant effect of the optimized discharge management on readmissions in the available data. This result was also confirmed for patients aged >65 years (Table S7 in Multimedia Appendix 3 ). Furthermore, the insignificance of the effect of the implementation of SEKMA on readmission rates was also confirmed in a pre-post comparison estimated by a multivariate logistic regression based on vascular surgery cases only (Table S8 in Multimedia Appendix 3 ). Finally, the estimated effects remained very similar if the preintervention period began in 2011 and ended at the end of 2019.

b In addition to the variables listed here, the International Statistical Classification of Diseases, Tenth Revision chapters of the principal and secondary diagnoses were also included as control variables.

d DiD: difference-in-difference.

This study aims to explore the barriers and enablers of a digitalized discharge management system, to implement such a system using a logic model developed from these determinants, and to evaluate its impact on the readmission rate.

Determinants and Implementation Strategies

The importance of the transmission of information for improved discharge management is also highlighted in the high rating of the strategies regarding the discharge letter, that is, developing an electronic discharge letter, continuously entering information into the letter, and always sending it to the GP. The discharge letter is the standard communication tool between inpatient and ambulatory care and found to be a source for deficits in information transfer [ 38 ]. In particular, delay and incompleteness of medication-related information endanger patients’ safety [ 39 , 40 ], leading to an increased risk of hospital readmission [ 41 ]. As shown for a sample of 20 Dutch hospitals, discharge letters vary in quality depending on patient and admission characteristics [ 42 ]. A standardized discharge letter can reduce transcription time and improve medical communication between physicians [ 43 ]. In addition, GPs prefer that discharge letters be written in a clear, concise, and understandable manner [ 44 ]. An electronic discharge letter generated from a computer-based document not only avoids transcription errors and lacks standardization but also ensures timely delivery [ 45 ]. In Germany, the discharge letter played a central role in approaches to creating a standard for intersectoral information exchange. For example, the VHitG (derived from the German “Verband der Hersteller von IT-Lösungen im Gesundheitswesen”) initiative “Intersectoral Communication” developed an implementation to facilitate the exchange of discharge letters between sectors, which is integrated into the existing IT system [ 46 ]. Another example is the recent approach by the National Association of Statutory Health Insurance Physicians and the German Hospital Association to create a standard for the electronic hospital discharge letter within the EHR [ 37 ].

To improve the standardization of the transmitted medication information, the use of the format of the nationwide medication plan was considered an important strategy in this study. In Germany, several projects have shown that physicians, pharmacists, and patients realize the benefits and accept the nationwide medication plan [ 47 - 49 ]. It can serve for the health care providers as a promising tool to improve the interdisciplinary and multiprofessional collaboration, especially as a digital solution that can realize its full potential [ 50 ]. Similar results have been reported in other countries [ 51 , 52 ]. In this study, participants suggested transferring medication-related information electronically and always in the format of the national medication plan. In the participating hospital, this strategy has been implemented during the project. For older patients in particular, shared medication records have the potential to reduce hospital readmissions [ 51 ].

Concerns about technical and temporal integrability were identified as an important barrier to the implementation of optimized discharge management. This includes an expected higher time consumption for the introduction of digitalized processes, a general fear of contact (owing to leaving known structures and a lack of electronic data processing experience), and further technical aspects (as a user-unfriendly system, electronic data processing errors, and interface problems). Similar barriers were identified in related eHealth projects [ 53 - 57 ]. Although the digitalization of processes was expected, in general, to be associated with time advantages, many of those involved associate the introduction with additional work effort. To overcome these concerns, successful implementation requires streamlining, simplifying, and redesigning the existing health care practices as a first step [ 58 ]. The strategy of introducing a physician-only hotline and a chat function for direct communication between the hospital and GPs could be seen as a simplification of communication instead of relying solely on the legally required discharge letter.

Effect on Readmissions

A possible explanation for the low level of fidelity as well as the insignificant effect of SEKMA on readmissions could be the relatively short application period of half a year (from April 2022 to September 2022). Complex implementations such as those elaborated in SEKMA may require a longer time before they are applied in daily routines. Another reason for the insignificant effect on readmissions could be the rather good baseline level of the outcome in national comparison. Although other studies in Germany showed readmission rates, for example, of 18.1% (30 days) to 35.4% (90 days) for older patients (aged >65 years) [ 22 ], these rates were substantially lower for the patients in this study, that is, 11.8% (30 days) to 23.6% (90 days).

Limitations

Our study had several limitations. First, the restrictions that existed owing to the COVID-19 pandemic might have affected the effectiveness of the implementation. All stakeholders involved in SEKMA faced a high workload owing to the pandemic as well as the requirements and measures resulting from the pandemic. However, the study results show that even under the special circumstances of the pandemic, it was possible to develop and implement an intersectoral optimization of discharge management. The infrastructure for the intersectoral care of patients created by the project has great potential to increase the quality of care, even if this could not yet be demonstrated with regard to readmissions. Future research should analyze the routine hospital data over the next 5 years.

Although the study included all relevant health care providers and considered the entire patient care pathway, the number of respondents from some professions may be rather small. For example, only 3 GPs were interviewed. However, the theoretical saturation effect in the statements made during the interviews suggests that this number is sufficient to identify the optimization potential as well as determinants.

Conclusions

Creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors and to promote rapid information exchange between the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system.

Acknowledgments

This study was financially supported by the Ministry of Justice and Health (Ministerium für Justiz und Gesundheit), Schleswig-Holstein. This study was conducted independently.

Data Availability

The data sets generated during and analyzed during this study are not publicly available due to the votum of the Ethics Committee of the University of Lübeck.

Authors' Contributions

CS contributed to conceptualization, formal analysis, investigation, methodology, and validation; prepared the original draft; and reviewed and edited the manuscript. LP participated in methodology, conducted and analyzed the interviews, and reviewed and edited the draft. LW participated in conceptualizing the digital discharge system and reviewed and edited the draft. RS was involved in conceptualization and reviewing and editing the draft. JS contributed to conceptualization, investigation, methodology, and validation and reviewed and edited the draft. All authors have read and approved the final manuscript.

Conflicts of Interest

LW was a hospital manager with a focus on digitalization at the hospital under study during the time of the project, Sektorübergreifende Optimierung des Entlassmanagements (SEKMA). LW is the founder of the company Lacanja GmbH Health Innovation Port, Hamburg, Germany, and is a member of several committees, including the expert group of the Gematik IOP (Interop) Council. All other authors declare no other conflicts of interest.

COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist.

Interview guide.

Supplemental tables with results of supplemental analyses.

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Abbreviations

Edited by T Leung; submitted 09.03.23; peer-reviewed by P Nohl-Deryk, S Meister; comments to author 21.04.23; revised version received 13.06.23; accepted 31.01.24; published 26.03.24.

©Christoph Strumann, Lisa Pfau, Laila Wahle, Raphael Schreiber, Jost Steinhäuser. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.03.2024.

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