Answer:
Efforts to improve the implementation of effective practice and to speed up improvements in quality and patient safety continue to pose challenges for researchers and policy makers. Organisational research, and, in particular, case studies of quality improvement, offer methods to improve understanding of the role of organisational and microsystem contexts for improving care and the development of theories which might guide improvement strategies.
Methods
This paper reviews examples of such research and details the methodological issues in constructing and analysing case studies. Case study research typically collects a wide array of data from interviews, documents and other sources.
Conclusion
Advances in methods for coding and analysing these data are improving the quality of reports from these studies.
Keywords: Quality improvement, case study, qualitative research, healthcare quality improvement, research
The gap between the knowledge of what works and the widespread adoption of those practices has become a major preoccupation of researchers and a challenge for funders and policy makers.1–3 Recognition of this ‘quality chasm’ (the term that the US Institute of Medicine used to describe the distance ‘between the healthcare we have and the care we could have’4) has led to an increased focus on quality improvement and implementation science to advance understanding of how to promote evidence-based practice. In turn, the focus on implementation has led to the development of multiple theories and frameworks to guide implementation,5–7 but no framework has demonstrated widespread results in practice.
There seems to be no immutable formula for successful implementation of innovations. While rational decision-makers would like the effectiveness of new technologies (including new work routines, devices and medications) to be the primary determinant of their adoption, research suggests otherwise. Healthcare systems are complex and variable. While some teams or organisations provide a ‘receptive context’ for innovation,8 others resist, having limited interest or abilities to implement new ideas. Decades of research in organisational and social sciences suggest that the nature of the innovation and the organisational, professional and health system contexts into which they are introduced influence their adoption.7 9–11 Thus, creating more effective, evidence-based care relies not just on developing and disseminating the evidence, but also on building knowledge of the ways in which innovations can be embedded into ongoing practice. Understanding the structures and processes of change is as critical as the knowledge of what works. In this paper, we outline how case study research can contribute a more detailed understanding of how to improve care. Case study methods are underutilised in quality improvement research, and given the growing calls to understand how innovation works in different contexts12–14 these methods could be a valuable addition to current approaches. We begin by illustrating the insights from case study research, and then examine the contribution of case study research to theory. Next we discuss strategies for analysing case study data and the scientific soundness of such information, ending with a discussion of the need for case studies to enhance the scientific understanding of quality improvement.
