Author: Lynne S. Nemeth

The Data

Adapting an interview from the Institute of Medicine's study of Microsystems http://books.nap.edu/openbook.php?record_id=10096&page=74 , I specifically chose to home in on three areas of focus. These were level of performance, investment in improvement and leadership. I developed a specific interview guide http://www.implementationscience.com/content/3/1/3 to start the initial process of data collection (see Table 2) http://www.implementationscience.com/content/3/1/3/table/T2.

The Olympus DSS-330 digital voice recorder was essential to provide a record of each interview. Initially I thought I would use a voice transcription system to convert the interview recordings into a transcript to be analyzed. This proved much more difficult and too time-consuming to be effective, despite having purchased the software and headset for this process. To do voice transcription, one needed to train the software for many hours using your own spoken voice. This involved listening to the interview, stopping to speak the words I heard and recite it into the computer. The output was not close to what I had spoken and needed many edits to be able to create a good verbatim transcription of the interview. A transcriptionist would be needed to help make this data ready for coding with the NVivo 2.0 program that I had purchased. This was very frustrating and a difficult deviation from my initial plan to be efficient in transcribing my own interview files.

I also created a set of demographic questions to be able to describe my sample, their age, gender, roles in practice, etc. These were important to characterize my sample, and I created pseudonyms for my participants so that I could keep their identities anonymous. Table 1 in the manuscript http://www.implementationscience.com/content/3/1/3/table/T1 provides this detail. Only I had access to the names of the individuals, but this was never needed in the future.

A grounded theory http://en.wikipedia.org/wiki/Grounded_theory paradigm was chosen because I was so new to this practice setting, and there were not any published reports of how practices made change in practice. There were previous reports related to quality improvement interventions and the compelling need for quality improvement in health care that led to recent publication of a suggested a conceptual framework (Microsystems). The Microsystems approach was developed in large health care systems, not the primary care community small practices that were involved in the PPRNet-TRIP-II intervention. Using a purposive sample of participants from within each practice, including representatives of nursing staff, office staff and managers, physicians and nurse practitioners I sought a broad set of perspectives to help me to learn how different groups perceived the experience of implementing guidelines for cardiovascular disease prevention and how they used their electronic medical record system to help them. Throughout the interview process a theoretical sampling method was used to add diversity to the data being obtained. In theoretical sampling, one looks for instances of what has developed as a hunch in a previous data collection. The interviews evolved to provide data for emerging concepts, and new questions. My use of grounded theory included using a systematic set of procedures: coding and categorizing data, re-reading the interviews, recoding, and collapsing categories, writing memos and asking more questions of the data to construct meaning from what the participants had to say.

Having coded, and reduced data in an iterative process, examining memos, field notes and interview transcripts, a model developed that explained the phenomena. Using this method to analyze the qualitative data, key concepts emerged and enabled the relationships to be modeled. The usefulness of this modeling is the resulting framework, which allows future developers of evidence-based improvement projects to test an implementation strategy that engages team members to be actively involved.

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