Transcript Qualitative Research with Diverse Populations: Lessons

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
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)
What is Our Collective
Experience with
Qualitative Methods?
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)
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
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
Qualitative vs. Quantitative
Research
• The goals of the researchers are similar
– to achieve a robust theory
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
Percent of Diabetic Medicare Enrollees
Receiving Annual HbA1c Testing
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%)
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
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
“Behind every quantity there
must lie a quality”
Gertrude Jaeger Selznick, PhD
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
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
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
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
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
Ethnography
• Methods include
– Participant observations
– Interviews
– Focus Groups
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
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
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
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
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
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
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?
What Are the Design
Issues You Face?
• How might observations, interviews, or
focus groups provide insight in to these
issues?