First among equals? Recommendations and guidelines for deciding who gets authorship credit.

Across all disciplines, the course of determining authorship does not always run smoothly. Emma-Louise Aveling and Graham Martin argue that with funders pushing for wider collaboration, dilemmas about how to allocate authorship fairly is set to intensify. They present guidelines for research teams to consider. To ensure all decisions remain transparent, start discussions on authorship credit early on in the research process

A qualitative method for analysing multivoicedness

‘Multivoicedness’ and the ‘multivoiced Self’ have become important theoretical concepts guiding research. Drawing on the tradition of dialogism, the Self is conceptualised as being constituted by a multiplicity of dynamic, interacting voices. Despite the growth in literature and empirical research, there remains a paucity of established methodological tools for analysing the multivoiced Self using qualitative data. In this article, we set out a systematic, practical ‘how-to’ guide for analysing multivoicedness. Using theoretically derived tools, our three-step method comprises: identifying the voices of I-positions within the Self’s talk (or text), identifying the voices of ‘inner-Others’, and examining the dialogue and relationships between the different voices. We elaborate each step and illustrate our method using examples from a published paper in which data were analysed using this method. We conclude by offering more general principles for the use of the method and discussing potential applications

Obstacles to implementation of an intervention to improve surgical services in an Ethiopian hospital: a qualitative study of an international health partnership project.

BACKGROUND: Access to safe surgical care represents a critical gap in healthcare delivery and development in many low- and middle-income countries, including Ethiopia. Quality improvement (QI) initiatives at hospital level may contribute to closing this gap. Many such quality improvement initiatives are carried out through international health partnerships. Better understanding of how to optimise quality improvement in low-income settings is needed, including through partnership-based approaches. Drawing on a process evaluation of an intervention to improve surgical services in an Ethiopian hospital, this paper offers lessons to help meet this need. METHODS: We conducted a qualitative process evaluation of a quality improvement project which aimed to improve access to surgical services in an Ethiopian referral hospital through better management. Data was collected longitudinally and included: 66 in-depth interviews with surgical staff and project team members; observation (135 h) in the surgery department and of project meetings; project-related documentation. Thematic analysis, guided by theoretical constructs, focused on identifying obstacles to implementation. RESULTS: The project largely failed to achieve its goals. Key barriers related to project design, partnership working and the implementation context, and included: confusion over project objectives and project and partner roles and responsibilities; logistical challenges concerning overseas visits; difficulties in communication; gaps between the time and authority team members had and that needed to implement and engage other staff; limited strategies for addressing adaptive-as opposed to technical-challenges; effects of hierarchy and resource scarcity on QI efforts. While many of the obstacles identified are common to diverse settings, our findings highlight ways in which some features of low-income country contexts amplify these common challenges. CONCLUSION: We identify lessons for optimising the design and planning of quality improvement interventions within such challenging healthcare contexts, with specific reference to international partnership-based approaches. These include: the need for a funded lead-in phase to clarify and agree goals, roles, mutual expectations and communication strategies; explicitly incorporating adaptive, as well as technical, solutions; transparent management of resources and opportunities; leadership which takes account of both formal and informal power structures; and articulating links between project goals and wider organisational interests.This research was supported by funding from a Wellcome Trust Senior Investigator Award [WT097899M]. The Wellcome Trust had no role in the design or conduct of the research.This is the final version of the article. It first appeared from BioMed Central at http://dx.doi.org/10.1186/s12913-016-1639-4

A mixed methods study of change processes enabling effective transition to team-based care

Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically-affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to understand practice transformation. Transformation efforts focused on team formation and capacity building for quality improvement. Using thematic analysis, we explored types of change processes undertaken and the relationship between change processes and effective team-based care. We identified three prototypical approaches to change: pursuing functional and cultural change processes, functional only, and cultural only. Practice sites prioritizing both change processes formed the most effective teams: simultaneous functional and cultural change spurred a mutually-reinforcing virtuous cycle. We describe implications for research, practice and policyThis research was supported by a grant from the Harvard Medical School Center for Primary Care and CRICO [362121]. MAK was supported by a Harvard Business School doctoral fellowship. ELA was supported by funding from a Wellcome Trust Senior Investigator Award [WT097899M]

Optimizing patient partnership in primary care improvement: A qualitative study

BACKGROUND: The need to expand and better engage patients in primary care improvement persists. PURPOSE: Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement co-design. METHODOLOGY: 23 semi-structured interviews with providers and patients involved in improvement efforts in seven U.S. primary care practices in the Academic Innovations Collaborative (AIC). The AIC aimed to implement primary care improvement, emphasizing patient engagement in the process. Data were analyzed thematically. RESULTS: Sites varied in their achievement of patient partnerships, encountering material, technical, and sociocultural obstacles. Time was a challenge for all sites, as was engaging a diversity of patients. Technical training on improvement processes and shared learning ‘on the job’ were important. External, organizational and individual-level resources helped overcome sociocultural challenges: the AIC drove provider buy-in; a team-based improvement approach helped shift relationships from providers and recipients towards teammates; and individual qualities and behaviors that flattened hierarchies and strengthened interpersonal relationships further enhanced ‘teamness’. A key factor influencing progress towards transformative partnerships was a strong shared learning journey, characterized by: frequent interactions; proximity to improvement decision-making; learning together from the ‘lived experience’ of practice improvement. Teams came to value not only patients’ knowledge, but changes wrought by working collaboratively over time. CONCLUSION: Establishing practice improvement partnerships remains challenging, but partnering with patients on improvement journeys offers distinctive gains for high quality patient-centered care. PRACTICE IMPLICATIONS: Engaging diverse patient partners requires significant disruption to organizational norms and routines, and the trend toward team-based primary care offers a fertile context for patient partnerships. Material, technical and sociocultural resources should be evaluated not only for whether they overcome specific challenges, but also for how they enhance the shared learning journey.This research was supported by a grant from the Harvard Medical School Center for Primary Care and CRICO [362121]. Emma-Louise Aveling’s contribution was supported by funding from a Wellcome Trust Senior Investigator Award (WT097899M)

An ethnographic study of improving data collection and completeness in large-scale data exercises.

Background: Large-scale data collection is an increasingly prominent and influential feature of efforts to improve healthcare delivery, yet securing the involvement of clinical centres and ensuring data comprehensiveness often proves problematic. We explore how improvements in both data submission and completion rates were achieved during a crucial period of the evolution of two large-scale data exercises. Methods:  As part of an evaluation of a quality improvement programme, we conducted an ethnographic study involving 90 interviews and 47 days of non-participant observation of two UK national clinical audits in a period before submission of data on adherence to clinical standards became mandatory. Results: Critical to the improvements in submission and completion rates in the two exercises were the efforts of clinical leaders to refigure "data work" as a professionalization strategy. Using a series of strategic manoeuvres, leaders constructed a cultural account that tied the fortunes of the healthcare professions to the submission of high-quality data, proposing that it would demonstrate responsibility, transparency, and alignment with the public interest. In so doing, clinical leadership deployed tactics that might have been seen as unwarranted managerial aggression had they been imposed by parties external to the profession. Many residual challenges were linked not to principled objection by clinicians, but to mundane problems and frustrations in obtaining, recording, and submitting data. The cultural framing of data work as a professional duty was important to resolving its status as an abject form of labour. Conclusions: Improving data quality in large-scale exercises is possible, but requires cooperation with clinical centres. Enabling professional leadership of data work may offer some significant advantages, but attention is also needed to mundane and highly consequential obstacles to participation in data collection

Factors Influencing Team Behaviors in Surgery: A Qualitative Study to Inform Teamwork Interventions.

BACKGROUND: Surgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members' nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations suggests that team behaviors are also contingent on psychosocial, cultural, and organizational factors. This study examined factors influencing surgical team behaviors to inform more contextually sensitive and effective approaches to optimizing surgical teamwork. METHODS: This qualitative study of cardiac surgical teams in a large United States teaching hospital included 34 semistructured interviews. Thematic network analysis was used to examine perceptions of ideal teamwork and factors influencing team behaviors in the operating room. RESULTS: Perceptions of ideal teamwork were largely shared, but team members held discrepant views of which team and leadership behaviors enhanced or undermined teamwork. Other factors affecting team behaviors were related to the local organizational culture, including management of staff behavior, variable case demands, and team members' technical competence, and fitness of organizational structures and processes to support teamwork. These factors affected perceptions of what constituted optimal interpersonal and team behaviors in the operating room. CONCLUSIONS: Team behaviors are contextually contingent and organizationally determined, and beliefs about optimal behaviors are not necessarily shared. Interventions to optimize surgical teamwork require establishing consensus regarding best practice, ability to adapt as circumstances require, and organizational commitment to addressing contextual factors that affect teams

Optimising the community-based approach to healthcare improvement: Comparative case studies of the clinical community model in practice

a b s t r a c t Community-based approaches to healthcare improvement are receiving increasing attention. Such approaches could offer an infrastructure for efficient knowledge-sharing and a potent means of influencing behaviours, but their potential is yet to be optimised. After briefly reviewing challenges to communitybased approaches, we describe in detail the clinical community model. Through exploring clinical communities in practice, we seek to identify practical lessons for optimising this community-based approach to healthcare improvement. Through comparative case studies based on secondary analysis, we examine two contrasting examples of clinical communities in practice e the USA-based Michigan Keystone ICU programme, and the UK-based Improving Lung Cancer Outcomes Project. We focus on three main issues. First, both cases were successful in mobilising diverse communities: favourable starting conditions, core teams with personal credibility, reputable institutional backing and embeddedness in wider networks were important. Second, top-down input to organise regular meetings, minimise conflict and empower those at risk of marginalisation helped establish a strong sense of community and reciprocal ties, while intervention components and measures common to the whole community strengthened peernorming effects. Third, to drive implementation, technical expertise and responsiveness from the core team were important, but so too were 'hard tactics' (e.g. strict limits on local customisation); these were more easily deployed where the intervention was standardised across the community and a strong evidence-base existed. Contrary to the idea of self-organising communities, our cases make clear that vertical and horizontal forces depend on each other synergistically for their effectiveness. We offer practical lessons for establishing an effective balance of horizontal and vertical influences, and for identifying the types of quality problems most amenable to community-based improvement