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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2017-020930 on 7 April 2018. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 29, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020930 on 7 April 2018. Downloaded from Building motivation to participate in a Quality Improvement Collaborative; a qualitative participatory evaluation Journal: BMJ Open ManuscriptFor ID peerbmjopen-2017-020930 review only Article Type: Research Date Submitted by the Author: 05-Dec-2017 Complete List of Authors: Lalani, Mirza; Primary Care and Population Health Hall, Kate; UCLPartners Skrypak, Mirek; UCLPartners Laing, C; Royal Free Hospital, London, UCL Centre for Nephrology Welch, John; University College London Hospitals NHS Foundation Trust, Critical Care Department Toohey, Peter; UCLPartners Seaholme, Sarah; UCLPartners Weijburg, Thomas; UCLPartners Eyre, Laura; University College London Research Department of Primary Care and Population Health Marshall, Martin; University College London, Primary Care and Population Health http://bmjopen.bmj.com/ <b>Primary Subject Health services research Heading</b>: Secondary Subject Heading: Qualitative research Quality in health care < HEALTH SERVICES ADMINISTRATION & Keywords: MANAGEMENT, QUALITATIVE RESEARCH, HEALTH SERVICES ADMINISTRATION & MANAGEMENT on September 29, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 13 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020930 on 7 April 2018. Downloaded from 1 2 3 4 Building motivation to participate in a Quality Improvement 5 6 Collaborative; a qualitative participatory evaluation 7 Mirza Lalani,1* Kate Hall,2 Mirek Skrypak,2 Chris Laing,3 John Welch,4 Peter Toohey,2 Sarah Seaholme,2 8 Thomas Weijburg,2 Laura Eyre,1 Martin Marshall1 9 10 11 1 Research Department of Primary Care and Population Health, University College London, London, UK. 12 2 13 UCLPartners, London, UK. 3 14 The Royal Free London NHS Foundation Trust, London, UK. 4 15 University College London Hospitals NHS Foundation Trust, London, UK. 16 For peer review only 17 *Corresponding author: Mirza Lalani, Research Department of Primary Care and Population Health, Upper 18 19 Third Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, NW3 2PF; 20 [email protected]; 07388 220242. 21 22 23 Word count: 3981. 24 25 Keywords: Quality Improvement Collaboratives; Participatory Evaluation 26 27 28 29 30 31 32 http://bmjopen.bmj.com/ 33 34 35 36 37 38 39 40 on September 29, 2021 by guest. Protected copyright. 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 1 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 13 BMJ Open: first published as 10.1136/bmjopen-2017-020930 on 7 April 2018. Downloaded from 1 2 3 ABSTRACT 4 Objectives: This study explores the barriers and facilitators that impact on the motivation of 5 practitioners to participate in a Quality Improvement Collaborative. 6 7 Design: A qualitative and formative evaluation using a participative approach, the Researcher-in- 8 Residence model which embraces the concept of ‘co-producing’ knowledge between researchers 9 and practitioners using a range of research methods such as participant observation, interviews and 10 documentary analysis. The design, creation and application of newly generated evidence is 11 12 facilitated by the researcher through negotiation and compromise with team members. 13 Participants: Senior and middle managers, doctors and nurses. 14 15 Setting: Two hospitals in South East England participating in a Patient Safety Improvement 16 Collaborative andFor the facilitator peer (host) of the review collaborative, based only in central London. 17 18 Results: The evaluation has revealed facilitators and barriers to motivation categorised under two 19 main themes; inherent motivation and factors that influence motivation – inter and intra- 20 organisational features as well as external factors. Facilitators included collaborative ‘champions,’ 21 individuals who drove the quality improvement agenda at a local level, raising awareness and 22 inspiring colleagues. The collaborative itself acted as a facilitator, promoting shared learning as well 23 24 as building motivation for participation. A key barrier was the lack of board engagement in the 25 participating NHS organisations which may have affected motivation amongst frontline staff. 26 27 Conclusions: Collaboratives maybe an important way of engaging practitioners in quality 28 improvement initiatives. This study highlights that despite a challenging healthcare environment in 29 the UK, there remains motivation amongst individuals to participate in quality improvement 30 programmes as they recognise that improvement approaches may facilitate positive change in local 31 clinical processes and systems. Collaboratives can harness this individual motivation to facilitate 32 spread and adoption of improvement methodology and build engagement across their membership. http://bmjopen.bmj.com/ 33 34 35 36 STRENGTHS AND LIMITATIONS OF THIS STUDY 37 38 • There are relatively few studies in which a researcher has been embedded in a Quality 39 Improvement Collaborative as is the case in this study. 40 • The evaluation generated evidence that was mobilised by the researcher as the Patient on September 29, 2021 by guest. Protected copyright. 41 Safety Collaborative progressed, contributing to the development of the programme and to 42 meeting its objectives. 43 • The study develops our understanding of the barriers and facilitators that affect the 44 motivation of clinicians and managers to engage with quality improvement initiatives. 45 46 • A limitation of the study is that the researcher was only embedded in two hospital trusts, 47 raising questions of generalisability, nevertheless, we believe the concepts generated are 48 likely to be transferrable to the rest of the Improvement Collaborative and other similar 49 initiatives. 50 51 52 53 54 55 56 57 58 2 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 13 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2017-020930 on 7 April 2018. Downloaded from 1 2 3 BACKGROUND 4 Quality Improvement Collaboratives in healthcare bring together groups of health professionals, 5 managers and support staff either within an organisation or from several organisations, to work on a 6 common purpose, with the goal of improving health services.[1] Improvement Collaboratives have 7 8 become increasingly popular in the UK, with the NHS promoting them as a mechanism for change 9 across the healthcare system involving different types of organisations including GP surgeries, 10 hospitals and care homes.[2-4] Improvement Collaboratives frequently follow a Breakthrough Series 11 approach supporting organisations to close the gap between good care and usual practice in a short 12 time period (6-18 months).[5] During this time, teams meet to share learning on a topic (learning 13 sessions), to understand how to make improvements, to implement and test these improvements 14 (action periods), and to share their progress and results with the rest of the collaborative.[6] 15 Collaboratives provide an infrastructure for an inter-organisational support network from which 16 For peer review only 17 members can address common barriers and learn from others’ successes and challenges.[7] The 18 success of Improvement Collaboratives is determined by the influence of their inter-organisational 19 (shared learning) and intra-organisational features (culture, resources, leadership etc.).[8] 20 21 The evidence for the effectiveness of Improvement Collaboratives as interventions for improving 22 health outcomes is growing but is not as yet compelling. Indeed, collaboratives may have a greater 23 impact on changes to professional behaviour and care processes than on care quality or health 24 service outcomes.[9] This is in part due to the heterogeneity of contexts within which collaboratives 25 operate.[10] Additionally, research studies have focussed on demonstrating ‘what’ impact an 26 Improvement Collaborative has had, overlooking ‘why,’ ‘how’ and ‘what works for whom in what 27 context,’ with relatively few qualitative evaluations that can provide a rationale for their impact on 28 29 outcomes.[11] 30 Studies have explored factors influencing clinician engagement in quality improvement but have not 31 considered the role of motivation to participate, especially
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