QUALITY IMPROVEMENT RESEARCH Qualitative methods in ...

1 QUALITY IMPROVEMENT RESEARCHQ ualitative methods in RESEARCH on healthcare qualityC Pope, P van Royen, R Saf Health Care2002;11:148 152 There are no easy solutions to the problem of improvingthe QUALITY of care. RESEARCH has shown how difficult itcan be, but has failed to provide reliable and effectiveways to change services and professional performancefor the better. Much depends on the perspectives ofusers and the attitudes and behaviours of professionalsin the context of their organisations and healthcareteams. Qualitative RESEARCH offers a variety of methodsfor identifying what really matters to patients and carers,detecting obstacles to changing performance, andexplaining why IMPROVEMENT does or does not use of such methods in future studies could lead to abetter understanding of how to improve I went to see Roy Griffiths (architect of the 1984 NHSreforms and supermarket chief executive) in his office atSainsbury s and while I was talking to him his secretaryhanded him a piece of paper.

2 He looked at it and said: OK . I asked him: What do you mean OK? and he said: My organisation is OK today . It turned out he had justsix measures on that piece of paper and from those hecould tell what the state of Sainsbury s health had beenthe day before; things like the amount of money takenyesterday, the freshness quotient the amount of stuff onthe shelves the proportion of staff on duty and so on. NHS regional manager quoted in Strong above quote illustrates a view of manage-ment in the retail sector that was seen in the UKin the 1980s as a role model for health QUALITY of health care could be assured if wecould only develop good quantitative measuressuch as performance indicators, and thus identifyproblems, make changes, and improve healthservices.

3 This vision has been tempered with therealisation that the issue of QUALITY is morecomplicated and nebulous than this model ofmanagement implies, especially in the case ofcomplex health systems and services. The assess-ment of QUALITY of services can no longer be con-fined to simply monitoring such aspects as wait-ing time, but requires an understanding of theexperience of waiting for care for example, thenature of the clinical environment, the adequacyof communication by and with health profession-als, the context and manner in which treatment isdelivered, and whether services and care meetexpectations. Moreover, it is increasingly recog-nised that views of QUALITY depend on one sperspective: patients, providers, politicians, andthe public may all have contested views of whatconstitutes high or poor QUALITY concept of QUALITY in health care is multidi-mensional and complex and some of the ques-tions we want to ask about the QUALITY of care orservices may not be amenable to quantitativemeasurement.

4 Qualitative RESEARCH has come tothe fore in health and social RESEARCH by providingways of answering these sorts of questions,23bothin the form of stand alone or independentresearch projects and as a complement to quanti-tative use of Qualitative methods in qualitativeresearch involves the systematic collection, organ-isation, and analysis of textual material derivedfrom talk or observation. It is rooted in the inter-pretive perspectives found in the humanities andsocial sciences that emphasise the importance ofunderstanding, from the viewpoint of the peopleinvolved, how individuals and groups interpret,experience, and make sense of social is not possible here to elaborate on the originsand theoretical underpinnings of this distinctiveapproach to RESEARCH , but it is important to beaware that Qualitative RESEARCH is informed by aquite different paradigm to that which governsquantitative clinical and biomedical RESEARCH .

5 Theemphasis in Qualitative RESEARCH on understand-ing meanings and experiences makes it particu-larly useful for QUALITY assessment and forunpacking some of the complex issues inherent toquality IMPROVEMENT . This paper explores some ofthe Qualitative methods that can help to gatherinformation about the delivery of good qualityhealth care and explain variations in health METHODSQ ualitative researchers study phenomena andevents in their natural settings, often interpretingthem in terms of the subjective meaningsattached by the individual. Qualitative methodsfor collecting data include interviews, observa-tion, and analysis of documents. Different meth-ods may be appropriate to different situations anddifferent RESEARCH questions.

6 In some cases a sin-gle method may be used while in others a combi-nation of methods may be employed. In this paperwe focus on interview based and observationalmethods as these are the most commonly used inquality based methodsIndividual face to face interviews may be eithersemi-structured or in-depth. Semi-structuredinterviews are typically based on a flexible topicguide that provides a loose structure of openended questions to explore experiences andattitudes. In-depth interviews provide an oppor-tunity to obtain more detail about an issue orexperience, and are especially useful for exploringexperiences of care. Because this method elicitspeople s own views and accounts, it can have theSee end of article forauthors to:Dr C Pope, Lecturer inMedical Sociology,Department of SocialMedicine, University ofBristol, Bristol BS8 2PR,UK; on January 10, 2022 by guest.

7 Protected by Saf Health Care: first published as on 1 June 2002. Downloaded from additional benefit of uncovering issues or concerns that hadnot been anticipated or considered by the researchers. In orderto ensure that really detailed information is gathered,interview methods require experienced researchers with thenecessary sensitivity and ability to establish rapport withrespondents, to use topic guides flexibly and follow upquestions and groups are similar in structure to face to faceinterviews but they use the interaction of a group of, typically,6 8 people to generate data. This allows group members totalk to one another, argue and ask questions, and is especiallyuseful for finding out about shared experiences.

8 Focus groupshave been successfully used with users and staff. One adapta-tion of this method is the exploration group in which differ-ent healthcare providers who have direct contact with aparticular health problem review and discuss some materialsuch as audio or video taped cases or interviews in order todevelop an interpretative variant is the QUALITY circle . This convenes a smallgroup of healthcare providers and patients who meet at regu-lar times for a determined period to formulate hypotheses oraction points to improve QUALITY in health based methodsThe systematic observation of organisational settings, teambehaviour, and interactions is especially useful in studyingquality issues as it allows researchers to uncover everydaybehaviour rather than only relying on interview methods are increasingly used in the study of organis-ation and delivery of care6and can be especially useful inuncovering what really happens in particular healthcaresettings for example.

9 In the study of everyday work in labourwards7 and for formative evaluation of new based medicineNarrative based medicine is one of several patient centredapproaches that can give the physician access to the livedexperience of their patients. This is the context in which thephysician interprets symptoms and signs and in whichpersonal healthcare decisions are made. It can therefore be anapproach to understanding how healthcare decisions methods are designed to yield detailed and holis-tic views of the phenomena under aim of qualitativeresearch is not therefore to identify a statistically representa-tive set of respondents or to produce numerical RESEARCH questions tend to be exploratory and nottied to formal hypothesis testing, so the sampling strategiesused in Qualitative RESEARCH are purposive or theoretical ratherthan representative or probability means thatrespondents are sampled based on specific predetermined cri-teria in order to cover a range of constituencies for example,different age, social class.

10 And cultural backgrounds (see box1).9To locate hard to reach individuals or groups, researcherscan use convenience venues, informants, or social sample sizes for interview studies tend to be muchsmaller than those used in survey or more quantitativeresearch; they may include 30 50 respondents, although thiscan vary with the RESEARCH question asked. Similarly, observa-tional studies may be based on a single case study, perhapsfocusing on one organisational setting such as a clinic or analyses attempt to preserve the textual form ofthe data gathered and to generate analytical categories andexplanations. This may be done inductively that is, obtainedgradually from the data or deductively that is, with a theo-retical framework as background (box 2),10either at thebeginning or part way through the analysis as a way ofapproaching the are various software packages designed to assist withthe organisation and retrieval of Qualitative data.