Title: Understanding the Design of Health Care Organization: The Role of Qualitative Methods
1Understanding 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
2Aims 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)
3What is Our Collective Experience with
Qualitative Methods?
4Qualitative 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)
5Qualitative 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
6Quantitative 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
7Qualitative vs. Quantitative Research
- The goals of the researchers are similar
- to achieve a robust theory
8Qualitative 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
9(No Transcript)
10Percent of Diabetic Medicare Enrollees Receiving
Annual HbA1c Testing
11What 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)
12What Cant We Know From This Quantitative
Analysis?
- We dont know why there is variation in the care
- We dont know what the barriers are to providing
the required services - We dont 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
13Answering 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
14Behind every quantity there must lie a quality
- Gertrude Jaeger Selznick, PhD
15Fundamental 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
16Strengths 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
17Limitations 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
18Limitations 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
19Ethnography
- 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 - Peoples perceptions or thoughts as they go about
their work
20Ethnography
- Methods include
- Participant observations
- Interviews
- Focus Groups
21Observational 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
22Observational 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
23Interviews
- 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
24Focus 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
25Focus 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
26Moderating Focus Groups
- In the best focus groups, the moderators role
is more as a listener and a learnerso 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
27Types 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?
28What Are the Design Issues You Face?
- How might observations, interviews, or focus
groups provide insight in to these issues?