Qualitative research is increasingly common in health services research (Shortell 1999; Sofaer 1999). Qualitative studies have been used, for example, to study culture change (Marshall et al. 2003; Craigie and Hobbs 2004), physician–patient relationships and primary care (Flocke, Miller, and Crabtree 2002; Gallagher et al. 2003; Sobo, Seid, and Reyes Gelhard 2006), diffusion of innovations and quality improvement strategies (Bradley et al. 2005; Crosson et al. 2005), novel interventions to improve care (Koops and Lindley 2002; Stapleton, Kirkham, and Thomas 2002; Dy et al. 2005), and managed care market trends (Scanlon et al. 2001; Devers et al. 2003). Despite substantial methodological papers and seminal texts (Glaser and Strauss 1967; Miles and Huberman 1994; Mays and Pope 1995; Strauss and Corbin 1998; Crabtree and Miller 1999; Devers 1999; Patton 1999; Devers and Frankel 2000; Giacomini and Cook 2000; Morse and Richards 2002) about designing qualitative projects and collecting qualitative data, less attention has been paid to the data analysis aspects of qualitative research. The purpose of this paper is to offer practical strategies for the analysis of qualitative data that may be generated from in-depth interviewing, focus groups, field observations, primary or secondary qualitative data (e.g., diaries, meeting minutes, annual reports), or a combination of these data collection approaches.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1475-6773.2006.00684.x

Qualitative data analysis for health services research: developing taxonomy, themes, and theory.

Keywords: a Vocabulary of Culture and Society

Two significant emerging policy directions put patients and consumers in a key role for influencing health care quality and costs. First, consumer-directed health plans rely on informed consumer choices to contain costs and improve the quality of care. This approach assumes that consumers will make more prudent health and health care choices when they are given financial incentives along with access to comparative cost and quality information. This approach also assumes that the combination of financial incentives and relevant information will increase their “activation” (Gabel, Lo Sasso, and Rice 2002). Second, the Chronic Illness Care Model (Bodenheimer et al. 2002) emphasizes patient-oriented care, with patients and their families integrated as members of the care team. A critical element in the model is activated patients, with the skills, knowledge, and motivation to participate as effective members of the care team (Von Korff et al. 1997).

A key health policy question is, what would it take for consumers to become effective and informed managers of their health and health care? What skills, knowledge, beliefs, and motivations do they need to become “activated” or more effectual health care actors? These are essential questions if we hope to improve the health care process, the outcomes of care, and control costs. This is true especially with regard to the 99 million Americans with a chronic disease. Because those with chronic illness need ongoing care, account for a large portion of health care costs, and must play an important role in maintaining their own functioning, encouraging their activation should be a priority.

Even though patient activation is a central concept in both the consumer driven health care approach and the chronic illness care models, it remains conceptually and empirically underdeveloped. There has been a lack of conceptual clarity regarding “activation,” and thus a lack of adequate measurement. There are a number of existing methods for assessing different aspects of activation, such as health locus of control (Wallston, Stein, and Smith), self-efficacy in self-managing behaviors (Lorig et al. 1996), and readiness to change health-related behaviors (DiClemente et al. 1991; Prochaska, Redding, and Evers 1997), but these measures tend to focus on the prediction of a single behavior. Moreover, there is no existing measure that includes the broad range of elements involved in activation, including the knowledge, skills, beliefs, and behaviors that a patient needs to manage a chronic illness.

In this paper we describe the development of the Patient Activation Measure (PAM), a measure of activation that is grounded in rigorous conceptualization and appropriate psychometric methods. The PAM was developed in four stages:


Stage 1.Conceptually defining activation involved a literature review, systematic consultation with experts using a “consensus method,” and consultation with individuals with chronic disease using focus groups.


Stage 2.Preliminary scale development began by building on the domains identified in stage one and operationalizing them with survey items within each domain. Steps included generating, refining, and testing a large item pool. We used Rasch psychometric methods to develop the scale and test the preliminary measure's psychometric properties.


Stage 3.Stage three involved exploring the possibility of extending the range of the measure, refining the response categories, and testing whether the measure could be used with respondents who had no chronic illnesses.


Stage 4.In the fourth and final stage a national probability sample was used to assess the performance of the measure across different subsamples in the population and to assess the construct validity of the measure.

/pdf/development-of-the-patient-activation-measure-pam-50q63ng0ok.pdf

Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers

The selection of appropriate outcomes is crucial when designing clinical trials in order to compare the effects of different interventions directly. For the findings to influence policy and practice, the outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. It is now widely acknowledged that insufficient attention has been paid to the choice of outcomes measured in clinical trials. Researchers are increasingly addressing this issue through the development and use of a core outcome set, an agreed standardised collection of outcomes which should be measured and reported, as a minimum, in all trials for a specific clinical area. Accumulating work in this area has identified the need for guidance on the development, implementation, evaluation and updating of core outcome sets. This Handbook, developed by the COMET Initiative, brings together current thinking and methodological research regarding those issues. We recommend a four-step process to develop a core outcome set. The aim is to update the contents of the Handbook as further research is identified.

/pdf/the-comet-handbook-version-1-0-19giui0eqg.pdf

The COMET Handbook: Version 1.0

Appropriate prescribing in elderly people: how well can it be measured and optimised?

Before we can take steps to improve the quality of health care, we need to define what quality care means. This article describes how to make best use of available evidence and reach a consensus on quality indicators

https://www.who.int/management/district/ResearchMethodsQualityIndicatorsPHC.pdf

Research methods used in developing and applying quality indicators in primary care

Quality indicators have been developed throughout Europe primarily for use in hospitals, but also increasingly for primary care. Both development and application are important but there has been less research on the application of indicators. Three issues are important when developing or applying indicators: (1) which stakeholder perspective(s) are the indicators intended to reflect; (2) what aspects of health care are being measured; and (3) what evidence is available? The information required to develop quality indicators can be derived using systematic or non-systematic methods. Non-systematic methods such as case studies play an important role but they do not tap in to available evidence. Systematic methods can be based directly on scientific evidence by combining available evidence with expert opinion, or they can be based on clinical guidelines. While it may never be possible to produce an error free measure of quality, measures should adhere, as far as possible, to some fundamental a priori characteristics (acceptability, feasibility, reliability, sensitivity to change, and validity). Adherence to these characteristics will help maximise the effectiveness of quality indicators in quality improvement strategies. It is also necessary to consider what the results of applying indicators tell us about quality of care.

https://qualitysafety.bmj.com/content/qhc/11/4/358.full.pdf

Health system reforms have until recently tended to focus primarily on structural change. The introduction of managed care in the United States (Miller and Luft 1997), the establishment of standard-setting bodies such as the National Institute for Clinical Excellence (Department of Health 1998) in the United Kingdom, the development of medical error reporting systems in Australia (Wilson et al. 1995), and the restructuring of primary care in the United Kingdom and Canada (Hutchison, Abelson, and Lavis 2001) are examples of this approach. However, recent studies show that structural changes alone do not deliver anticipated improvements in quality and performance in health care (Le Grand, May, and Mulligan 1998; Shortell, Bennett, and Byck 1998). As a result, we hear calls for “cultural transformation” to be wrought alongside structural change in order to deliver improvements in quality and performance. This call has been prominent in the United States (Institute of Medicine 2001) and also as a central component of the recent reforms of the National Health Service (NHS) in the United Kingdom (Department of Health 2000; 2002).

A theory of organizational culture emerges from a combination of organizational psychology, social psychology, and social anthropology. The development of organizational culture as a subject of study can be seen as an elaboration of the human relations (Roethlisberger and Dickson 1939) and social systems approaches (Parsons 1977); which in turn developed as correctives to the scientific management techniques of Frederick Winslow (“Speedy”) Taylor, and his successor Frank B. Gilbreth. The study of organizations has been conducted from within various different theories or paradigms (Burrell and Morgan 1979). The term “organizational culture” first appeared in the academic literature in an article in Administrative Science Quarterly by Pettigrew (Pettigrew 1979; Hofstede et al. 1990)—though Jacques refers to the culture of a factory as early 1952 (Jacques 1952). Its constituent themes can be traced to earlier literature on organizational analysis. Pettigrew's own empirical study of a private British boarding school appears strongly influenced by Burton Clarke (Clarke 1970). Both trace the influence of the strong, idiosyncratic individuals who founded the organizations. This concern with the role of leaders and leadership in turn underlines the influence of Selznick's Leadership in Administration (Selznick 1957). Selznick distinguishes between two ideal types of enterprise: on the one hand, a rational instrumental organization and, on the other hand, the value-infused institution. According to Selznick, the term “organisation” suggests a technical instrument to harness human energies and direct them towards set aims, while the term “institution” suggests an organic social entity, or culture.

Organizational culture has been variously defined (Ott 1989; Schein 1990; Davies, Nutley, and Mannion 2000). It denotes a wide range of social phenomena, including an organization's customary dress, language, behavior, beliefs, values, assumptions, symbols of status and authority, myths, ceremonies and rituals, and modes of deference and subversion; all of which help to define an organization's character and norms. Unsurprisingly in view of this diverse array of phenomena, little agreement exists over a precise definition of organizational culture, how it should be observed or measured, or how different methodologies can be used to inform routine administration or organizational change. While some commentators see the task in terms of specific and measurable variables, traits or processes, others see it as a global challenge to capture culture as an intrinsic property of the social milieu that forms whenever people are brought together in common enterprise. A third approach sees organizational culture as an anthropological metaphor or a paradigm (Burrell and Morgan 1979; Burrell 1996) to analyze organizations as microsocieties (Morgan, Frost, and Pondy 1983; Smircich 1983; Morgan 1986).

According to Edgar Schein,

Organizational culture is the pattern of shared basic assumptions—invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration—that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems (Schein 1985a).

This definition captures one of the basic challenges faced by any culture to reconcile the often divergent aims and actions of its members. It also points to the difficulty of addressing that challenge. Its emphasis on the role of shared basic assumptions influencing beliefs and behavior suggests that organizational culture denotes much more than just “the way things are done around here” (Davies, Nutley, and Mannion 2000). Changing the way things are done appears, on the functional level of systems redesign, relatively easy. Attempting to understand why things are done in their distinctive ways, the factors underlying resistance to change attempts, and the extent to which new practices are sustained is far more challenging. To successfully engender change in organizational behavior we need to understand the collective thought processes informing that behavior at both conscious and unconscious levels. This is where a deeper analysis and understanding of organizational culture may be productive.

Advocates of strategic cultural change typically make a number of implicit assumptions. First, health organizations possess discernible cultures, which affect quality and performance. Second, although cultures may be resistant to change, they are to some extent malleable and manageable. Third, it is possible to identify particular cultural attributes that facilitate or inhibit good performance and it should therefore be feasible for managers to design strategies for cultural change. Finally, it is assumed that any benefits accruing from the change will outweigh any dysfunctional consequences. Although there is as yet little empirical evidence to support these assumptions, some academics and many policymakers are showing renewed interest in the quantitative measurement of organizational culture in order to determine its relationship with performance and quality of care (Davies, Nutley, and Mannion 2000; Shortell et al. 2000; Shortell et al. 2001). A range of tools designed to measure organizational culture have been developed and applied in industrial, educational, and health care settings over the last two decades. In this paper we describe the results of an extensive review of these instruments and examine their usefulness for health service researchers. The review forms part of a larger study into the relationship between organizational culture and the performance of health organizations (Scott et al. 2001, In press).

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1475-6773.00154

The quantitative measurement of organizational culture in health care: A review of the available instruments

Objectives. To review some of the key debates relating to the nature of organizational culture and culture change in health care organizations and systems. 

Methods. A literature review was conducted that covered both theoretical contributions and published studies of the processes and outcomes of culture change programmes across a range of health and non-health care settings. 

Results. There is little consensus among scholars over the precise meaning of organizational culture. Competing claims exist concerning whether organizational cultures are capable of being shaped by external manipulation to beneficial effect. A range of culture change models has been developed. A number of underlying factors that commonly attenuate culture change programmes can be identified. Key factors that appear to impede culture change across a range of sectors include: inadequate or inappropriate leadership; constraints imposed by external stakeholders and professional allegiances; perceived lack of ownership; and subcultural diversity within health care organizations and systems. 

Conclusions. Managing organizational culture is increasingly viewed as an essential part of health system reform. To transform the culture of a whole health system such as the UK National Health Service would be a complex, multi-level, and uncertain process, comprising a range of interlocking strategies and supporting tactics unfolding over a period of years.

/pdf/implementing-culture-change-in-health-care-theory-and-4sdgltufxe.pdf

Implementing culture change in health care: theory and practice.

Objective: To review the evidence for a relationship between organisational culture and health care performance.Methods: Qualitative comprehensive review: all empirical studies exploring a relationship between organisational culture (broadly defined) and health care performance (broadly defined) were identified by a comprehensive search of the literature. Study methods and results were analysed qualitatively to provide a narrative review with integrative discussion.Results: Ten studies met the inclusion criteria. There was considerable variation in the design, study setting, quality of reporting and aspects of culture/performance considered. Four of the ten studies reviewed in detail claimed to have uncovered supportive evidence for the hypothesis that culture and performance are linked. All the other studies failed to find a link, though none provided strong evidence against the hypothesis.Conclusions: There is some evidence to suggest that organisational culture may be a relevant factor in health care p...

Martin Marshall

Papers

Research methods used in developing and applying quality indicators in primary care

Research methods used in developing and applying quality indicators in primary care

The quantitative measurement of organizational culture in health care: A review of the available instruments

Implementing culture change in health care: theory and practice.

Does organisational culture influence health care performance? A review of the evidence.