Study element | Participants and scheduling | Setting | Focus of research | Analytic approach |
---|---|---|---|---|
1. Stakeholder interviews | 107 semi-structured telephone interviews with those closely involved in quality and safety | Acute trusts, ambulance trusts, mental health trusts, community trusts, foundation trusts, primary care trusts, strategic health authorities, general practices and healthcare commissioning organisations | Understanding of vision of high-quality and safe care; what is required to make it happen; theories of change; plans to implement quality and safety improvement, enhance leadership and promote staff engagement; views on what quality improvement means, how it could best be secured, and obstacles | Analysis based on constant comparative method Use of QSR NVivo 8 software |
2. Ethnographic case studies: observations and interviews | Comparative case studies across seven purposively chosen cases 650 h of observation; 197 semi-structured interviews with executive and board-level staff and frontline staff | Four hospital trusts; a quality improvement collaborative; a large-scale quality improvement programme involving dozens of organisations; one primary care provider involving a chain of practices | Assessing culture and behaviour in relation to quality, staff engagement with quality, leadership for quality, quality improvement, practical actions for promoting cultures of high-quality care | Analysis based on constant comparative method Coding within and across cases, systematically searching for where clusters of codes formed a pattern Combining data from interviews across cases and stakeholders to form a single dataset |
3a. Patient and public involvement: survey | 715 survey responses Cross-sectional | Patient participation groups | The survey consisted of 14 statements about patient experience. Open text box provided for each statement | Quantitative analysis—largely descriptive Open-ended responses subject to content analysis to derive themes inductively |
3b. Patient and public involvement: focus groups and interviews | Two focus groups and 10 interviews | Patient and carer organisations | Interpret the findings of the survey Assessing views on obstacles to delivering improved quality and safety and greater accountability in the NHS | Qualitative analysis of key themes |
4a. NHS staff and patient surveys: patient satisfaction survey data | 165 acute trusts—data from 2007, 2009, 2011 | Acute trusts | Patient satisfaction came from the National Acute Inpatient Survey, using the data on patients’ overall ratings of care | Descriptive statistics and paired sample t tests |
4b. NHS staff and patient surveys: national staff survey data | 309 NHS trusts from 2007, 2009, 2011 national staff survey | Primary care, ambulance, acute care and mental health trusts | Staff engagement, organisational climate, job satisfaction, manager support, job design, errors and reporting, work pressure, bullying, harassment and abuse, team working, training, appraisal, stress | Descriptive statistics and paired sample t tests |
4c. NHS staff and patient surveys: outcome measures | 2005–2009 | Primary care, ambulance, acute care and mental health trusts | Patient mortality (acute sector only) (hospital standardised mortality ratio); quality of services and use of resources (Annual Health Check ratings by Healthcare Commission between 2005/2006 and 2008/2009); infection rates (MRSA) per 10000 bed days; staff absenteeism; staff turnover | Detailed correlation analysis between staff survey and inpatient survey; multiple and multilevel regression analysis, using HR practice variables to predict engagement; regression and ordinal logistic regression analysis to predict patient satisfaction, patient mortality, staff absenteeism, staff turnover, infection rates, and Annual Health Check ratings, controlling for trust type, size and location; latent growth curve modelling to predict outcomes |
5. Clinical teams functioning, effectiveness and innovation | 621 teams (4604 responses) Aston Team Performance Inventory Cross-sectional data with data on team changes collected from 388 teams (1299 individuals) 3 months later Team performance data from team leaders/external raters | 51 trusts (13 acute, 17 mental health, 10 ambulance and 11 primary care trusts) | Team functioning: task design, team effort and skills, organisational support, resources, objectives, participation, creativity, conflict, reflexivity, task focus, leadership, satisfaction, attachment, effectiveness, inter-team relationships, innovation Leaders’/external raters’ evaluations of effectiveness Innovations introduced by teams Sources of frustration and resilience | Descriptive analysis, ANOVA, regression and relative importance analysis Analysis and ratings from domain relevant experts Open-ended responses subject to content analysis to derive the themes |
6a. Objectives and team working of trust boards | 34 boards (306 individuals) Administered processes section of Aston Team Performance Inventory Details of board objectives | Primary care, ambulance, secondary care and mental health trusts | Team processes and content: objectives, participation, reflexivity, task focus (lack of team) conflict, creativity and innovation Clarity and challenge of board objectives | Descriptive analysis, regression and relative importance analysis Analysis and ratings from domain relevant experts |
6b. Trust board innovation | 71 NHS trust boards 793 sets of minutes Minutes from 18 months of board meetings | Primary care, ambulance, secondary care and mental health trusts | Innovations introduced by boards and domain of focus (e.g. productivity, targets, organisational effectiveness, quality, safety, patient complaints, clinical effectiveness) | Analysis and ratings from domain relevant experts |
6c Quality and safety in trust boards | Detailed analysis of minutes for eight boards | Primary care, ambulance, secondary care and mental health trusts | Board discussions of quality and safety | Ethnographic content analysis and summative analysis |
ANOVA, analysis of variance; HR, human resources; MRSA, methicillin-resistant Staphylococcus aureus; NHS, National Health Service.