Table 1

Summary of elements of the research programme

Study elementParticipants and schedulingSettingFocus of researchAnalytic approach
1. Stakeholder interviews107 semi-structured telephone interviews with those closely involved in quality and safetyAcute trusts, ambulance trusts, mental health trusts, community trusts, foundation trusts, primary care trusts, strategic health authorities, general practices and healthcare commissioning organisationsUnderstanding 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 obstaclesAnalysis based on constant comparative method
Use of QSR NVivo 8 software
2. Ethnographic case studies: observations and interviewsComparative 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 practicesAssessing culture and behaviour in relation to quality, staff engagement with quality, leadership for quality, quality improvement, practical actions for promoting cultures of high-quality careAnalysis 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: survey715 survey responses
Cross-sectional
Patient participation groupsThe survey consisted of 14 statements about patient experience. Open text box provided for each statementQuantitative analysis—largely descriptive
Open-ended responses subject to content analysis to derive themes inductively
3b. Patient and public involvement: focus groups and interviewsTwo focus groups and 10 interviewsPatient and carer organisationsInterpret 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 data165 acute trusts—data from 2007, 2009, 2011Acute trustsPatient satisfaction came from the National Acute Inpatient Survey, using the data on patients’ overall ratings of careDescriptive statistics and paired sample t tests
4b. NHS staff and patient surveys: national staff survey data309 NHS trusts from 2007, 2009, 2011 national staff surveyPrimary care, ambulance, acute care and mental health trustsStaff engagement, organisational climate, job satisfaction, manager support, job design, errors and reporting, work pressure, bullying, harassment and abuse, team working, training, appraisal, stressDescriptive statistics and paired sample t tests
4c. NHS staff and patient surveys: outcome measures2005–2009Primary care, ambulance, acute care and mental health trustsPatient 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 turnoverDetailed 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 innovation621 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 boards34 boards (306 individuals) Administered processes section of Aston Team Performance Inventory
Details of board objectives
Primary care, ambulance, secondary care and mental health trustsTeam 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 innovation71 NHS trust boards
793 sets of minutes
Minutes from 18 months of board meetings
Primary care, ambulance, secondary care and mental health trustsInnovations 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 boardsDetailed analysis of minutes for eight boardsPrimary care, ambulance, secondary care and mental health trustsBoard discussions of quality and safetyEthnographic content analysis and summative analysis
  • ANOVA, analysis of variance; HR, human resources; MRSA, methicillin-resistant Staphylococcus aureus; NHS, National Health Service.