Objectives To explore hospital leaders' perceptions of organisational factors as barriers and/or facilitators in improving inpatient–outpatient (IP–OP) communication.

Design Semistructured in-person interviews.

Analysis Constant comparative method of qualitative data.

Setting Inpatient psychiatry units in 33 general medical/surgical and specialty psychiatric hospitals in California and Massachusetts (USA).

Participants Psychiatry chair/chief, service director or medical director.

Variables Importance to leadership, resources, organisational structure and culture.

Results A majority of hospital leaders rated the IP–OP communication objective as highly or moderately important. Hospitals with good IP–OP communication had structures in place to support communication or had changed/implemented new procedures to enhance communication, and anticipated clinicians would ‘buy in’ to the goal of improved communication. Hospitals reporting no improvement efforts were less likely to have structures supporting IP–OP communication, anticipated resistance among clinicians and reported a need for technological resources such as electronic health records, integrated IT and secure online communication. Most leaders reported a need for additional staff time and information, knowledge or data.

Conclusions For many hospitals, successfully improving communication will require overcoming organisational barriers such as cultures not conducive to change and lack of resources and infrastructure. Creating a culture that values communication at discharge may help improve outcomes following hospitalisation, but changes in healthcare delivery in the past few decades may necessitate new strategies or changes at the systems level to address barriers to effective communication.