1. Understanding the Design of Health Care Organization: The Role of Qualitative Methods Julie K. Johnson, MSPH, PhD University of Chicago and the American Board of Medical Specialties

2. Aims of Presentation Provide an overview of qualitative research methods Discuss complementary roles of quantitative and qualitative methods Explore strengths and limitations of qualitative methods Delve more deeply into methods that are better suited to capture the “complexity” of healthcare (observations, focus groups, and interviews)

3. What is Our Collective Experience with Qualitative Methods?

4. Qualitative Research – Defined “An array of interpretive techniques which seek to describe, decode, translate, and otherwise come to terms with the meaning, not the frequency, of certain more of less naturally occurring phenomena in the social world.” To operate in a qualitative mode is to trade in linguistic symbols and, by so doing, attempt to reduce the distance between the indicated and the indicator, between theory and data, between context and action” (Van Maanen 1979)

5. Qualitative Research A process of inquiry into a social or human problem –data in the form of words –conducted in a natural setting emphasizing rich description and discovery –evaluated subjectively by systematically reducing data to themes and categories –emphasis is on theory development

6. Quantitative research A process of inquiry into a social or human problem –based on testing a theory composed of variables –data in form of numbers –analyzed objectively with descriptive and inferential statistics –emphasizes hypothesis testing and verification

7. Qualitative vs. Quantitative Research The goals of the researchers are similar –to achieve a robust theory

8. Qualitative vs. Quantitative Methods Most importantly, the method (qualitative or quantitative) depends on the question you want to answer Example from the 1999 Dartmouth Atlas of Health Care

10. Percent of Diabetic Medicare Enrollees Receiving Annual HbA1c Testing

11. What Can This Quantitative Analysis Tell Us About Diabetes Care? There is significant variation in HbA1c monitoring among diabetic Medicare enrollees –HbA1c monitoring (8.9% - 70.2%) Similar maps show significant variation in retinal exams and LDL monitoring –Retinal exams (25.1% - 66.1%) –LDL monitoring (6.8% - 68%)

12. What Can’t We Know From This Quantitative Analysis? We don’t know why there is variation in the care We don’t know what the barriers are to providing the required services We don’t have any ideas about how to change the results We know little about the systems of care (the interactions of people, information, technology, and the physical environment) that produced these results

13. Answering Those Types of Questions Requires Qualitative interviews and observations –To understand the system that is producing the results –To explore how interdependent individuals and groups function (or fail to function) –To connect the research to reality

14. “Behind every quantity there must lie a quality” Gertrude Jaeger Selznick, PhD

15. Fundamental Assumptions of Qualitative Research Holistic perspective –Seeks to develop a complete understanding of a phenomenon by studying it in its entirety Inductive approach –Begins with observations and moves toward developing patterns as they emerge from the case under study Naturalistic inquiry –Discovery oriented approach in the natural setting of the phenomenon

16. Strengths of Qualitative Methods Can be relatively inexpensive and quick to implement Do not need a lot of advance work Enable organizations to gain a deeper understanding of processes and phenomenon as they exist in its own unique environment Can also provide the cross-level or “meso” research that examines individual provider behavior within the context of the clinic or group that, in turn, may be embedded within a larger organizational structure such as an integrated health

17. Limitations of Qualitative Methods Labor intensiveness (and extensiveness) of collecting, coding, and processing data Data overload Possibility of researcher bias Adequacy of sampling Focus on individual cases may limit the generalizability of the findings

18. Limitations can be addressed through careful study design External validity –Study multiple cases Internal validity –Verify results with participants –Triangulate data collection Reliability –Careful documentation of data collection and analysis

19. Ethnography The most widely recognized types of qualitative research methods Evolved from cultural anthropology with a focus on cultural patterns of village life and asked questions about what can be learned from the people (or the natives) In health services research, the focus is on –Effects of culture on health care –Institutions or professional groups as a cultural setting –People’s perceptions or thoughts as they go about their work

20. Ethnography Methods include –Participant observations –Interviews –Focus Groups

21. Observational Studies The researcher –Spends time in the setting under study – a program, organization, or community –Makes firsthand observations of the activities and interactions –Take voluminous field notes, which are organized into readable narrative description with major themes, categories, and illustrative case examples

22. Observational Studies Decide what it is that you want to observe Pilot test observations to find out what the opportunities are Develop a method for your own use to make it easy to capture the data

23. Interviews To gain knowledge of individual perspectives –Informal conversational interview Questions flow from the immediate context, varies from interviewee to interviewee –Interview guide A list of questions or issues that are to be explored during the interview, everyone is asked about the same issues, but the questions may vary based on individual response –Standardized open-ended interview Asks the exact same questions of each person Minimizes interviewer effect

24. Focus Groups Originated in Business administration and is used to obtain a range of opinions on products, with the goal of enhancing market strategy Participants attitudes and perceptions are developed through interaction with each other

25. Focus Groups Data from interview questions reflect experience from the individual participants, but very different from one-on-one interviews because of the ability to interact with other participants around the focus group questions

26. Moderating Focus Groups “In the best focus groups, the moderator’s role is more as a listener and a learner…so that the group itself can seek out affirmation and feedback from each other. Thus, the group takes its own direction. As a result, more natural themes are brought out.” »David L. Morgan, 2004 »Conducting Focus Groups, U of M Summer Institute

27. Types of Questions Qualitative Methods Could Answer What is the role of noise and lack of sunlight in influencing patient moods, drug needs and outcomes? What is the role of adjacencies and space lay out in supporting team functions in complex health care settings? Why do hospitalized patients fall out of bed on their way to the bathroom? What happens when patients get transferred from one ward to another? What information is lost? What is the role of team members in ensuring safe delivery of care?

28. What Are the Design Issues You Face? How might observations, interviews, or focus groups provide insight in to these issues?