The following additional data were collected and analysed:
l Documentary analysis (RQs 1, 3 and 4), including financial and business planning, governance, and implementation of process change, was used to identify key contextual features in each site.
l Hospital Episode Statistics data were used to describe aggregated patient data for each site.
l Data on costs of staff in each site (RQs 3 and 4), including typical staff mix, grades and sessions/hours worked at different times in each hospital, were used to estimate the cost of staffing EDs. It was not possible to quantify acute physician input owing to the complexity of shifts, rotas and job plans.
l Analysis of the quality of decisions on admissions (RQ 4) by clinical panels of four or five clinicians (senior doctors and nurses in ED and acute medicine) and two local PPI representatives focused on the quality of the decisions made, based on collated ethnographic and VSM case studies. Two panels were assembled and chaired by a chief investigator. The northern panel reviewed cases from the two southern sites (Porthaven and Churchtown), and the southern panel reviewed cases from the two northern sites (Underbridge and Waterbury). First, members individually scored cases for likely appropriateness of decision-making. The research team then identified cases scored as potentially inappropriate or where there was panel disagreement. The panels then met to review these selected ethnographic patient case studies and individual patient VSM ‘charts’ and to agree a consensus score for whether or not the decision to admit or discharge appeared to be appropriate, and to comment in detail if care might have been improved. The panel process is described in detail in Appendix 2.
Synthesis
Approach to the synthesis across component studies
A critical realist approach64,65provided the framework for integrating knowledge from each of the component studies, the stakeholder workshops, the clinical panels and the learning sets. We aimed to identify mechanisms that could explain how different outcomes arose in complex systems,66with the goal of producing multifaceted explanations about how frontline expertise and new models can safely reduce admissions. We used the approach of Pawson and Tilley’s57to identify potential mechanisms that result from the interaction of resource and opportunity with the reasoning of individuals and lead to behavioural change. In order to produce a more fine-grained analysis across the studies, we understood mechanisms as consisting of both reflexive and automatic responses.
Taking a realist perspective
Taking a realist perspective, the admission decision can be seen as a sequence, over time, of beliefs, knowledge and behaviours of the key actors: patients, carers and practitioners. The beliefs and actions of individual patients are affected by their immediate context, which can include both the cultural and structural context of their lives, family and home life, and their current state of physical and cognitive capacity. Patients and carers respond to the opportunities/resources provided (practitioners, acute care environment) with a variety of patterns of reasoning. It is the variety and detail of these patterns that we sought to understand.
Each of the practitioners involved in decision-making also has different beliefs and attitudes, based on previous training and experience that influence behaviours involved in the admission decision, such as further questioning, physical examinations, requesting tests or gathering opinions from other practitioners. Practitioner behaviour is also influenced by the organisational context in which the practitioners work: both structural – the teams, hierarchies, incentives, physical layout – and cultural – the norms and ideals of teamwork and professional conduct. Understanding how the immediate setting and wider hospital and health-care system beyond influence the individual practitioner’s reasoning is an important objective of the 3A study.
Individual practitioners also differ in their patterns of reasoning and capacity and respond differently to the same hospital and team environments, both in the immediate reasoning for the patient before them, and also over time in their acquisition of beliefs and cultural norms. This heterogeneity of practitioner responses may be one of the keys to understanding variations in acute admissions decision-making. In a contrastive way, we were also interested in seeing how practitioners as a group might respond to (1) the common and different resources and opportunities in existence at each of the four sites studied; (2) innovations that have been introduced, such as new types of teams, new diagnostic processes and pathways, or other innovations developed within the acute admissions system.
Integration of findings
We produced a set of analytic statements (see Appendix 13) from each study for presentation and discussion at researcher meetings and at the end-of-project stakeholder workshop. Wherever possible, we expressed these as causal ‘If . . . then’ statements that specified context, mechanism and outcome in relation to patient safety [i.e. appropriate (non-)admission decision]. For example, ‘If there is an acute bed shortage and pressure from management to decrease admissions (context) then clinicians may feel pressurised (mechanism) to discharge inappropriately (outcome)’.
However, in many instances it was necessary for the outcome stated to be a plausible stage on the decision-making route. For example, ‘If there is more than one team involved in the care of a patient (such as a specialist medical team) (context) then there can be confusion between practitioners (mechanism) about who is responsible for the care of the patient (outcome)’. Not all analyses or sources could support these types of causal statement. Where this was the case, we retained statements about context alone, for example, ‘Resource and time constraints may sway doctors towards admission as a safer option’. The statements were shared within and across teams so that an ongoing awareness of findings was cultivated.
This also underpinned the development of collaborative working relationships, which in turn facilitated criticism and refinement of the synthesis.
We found that the common language of the ‘If . . . then’ statements helped us to group and look across project component studies. Our integration of findings focused on identifying how practitioners, patients and carers responded to each other, as well as how each responded to the resources and opportunities of the acute care setting.
STUDY DESIGN AND METHODOLOGY
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In summary, the process was:
1. Based on the findings of each project component, ‘If . . . then’ statements (or other analytic statements or scenarios) were developed. A selection of these were further refined at the end-of-project workshop.
2. Refined statements were organised in tables by RQ and grouped by the participants in interactions (e.g. patient–carer–practitioner).
3. Through a process of reflection and discussion based on these refined statements (returning to the original data where necessary to clarify particular issues), we developed explanatory statements that incorporated all of the information in groups of refined statements (documents available on request from the authors). This typically involved the following tasks:
¢ reading through to ‘sensitise’ ourselves to the issues
¢ ‘sense making’ – asking ‘How can we explain what has been observed here?’ and how we could account for context or rival explanations asking ‘What if?’ questions (i.e. looking for
alternative explanations)
¢ seeking disconfirming cases.
The statements were then brought together in narrative form within themes based around practice and service design in a narrative form referencing the analytic statement (see Appendix 13). Finally, we undertook an exercise of transforming negative statements into positive ones and setting these out as principles of practice that were likely to achieve particular objectives.
We focused on identifying mechanisms and the ways in which they could operate differently within varying contexts, as distinct from the pattern of events.66We endeavoured to recognise heterogeneity of responses as an inherent phenomenon within the system,67acknowledging that, although social structures and culture have causal powers, people will interact with and respond differently to the same phenomena.68