Documentary Review

At the outset of the study, the intention was to base the classification of ‘types’ of improvement work on a documentary review of the application forms and project reports submitted by participants on the various Health Foundation leadership schemes. The application forms gave an overview description, provided by the applicant, of the improvement work they wished to pursue during their time on the leadership programme. The project reports, submitted halfway through the leadership scheme, and on completion, were intended to provide a more detailed account of what improvements had been made, and what leadership learning had been derived during the scheme.

It was important to be clear about the purpose of reviewing these documents. As stated by Platt (1981), documentary research,

‘can hardly be regarded as constituting a method, since to say that one will use documents is to say nothing about how one will use them.’(p.31, original emphasis)

The research methods literature highlights many potential purposes of documentary review, including situating contemporary accounts into an historical context; providing

insight into how events occurred and why; for comparison with other data sources and providing material upon which to investigate further. (May 2001).

The last purpose in this non-exhaustive list most closely fits the purpose of the documentary review in this study, namely to provide an initial dataset about types of NHS improvement work, which could then be followed up and explored further. The intention was to use the documents to extract typical examples of improvements made. The primary purpose was to use these data to feed into the development of typology categories. A secondary purpose was to potentially provide a basis for examining actual case studies of Award Holders enacting their improvements, in behavioural leadership terms, later on in the study.

All the relevant documentation, for each separate leadership scheme, was reviewed, trawling for data which would be pertinent to classifying different ‘types’ of improvement work. From this, it became apparent that the level of detail with which different improvement initiatives were described varied enormously amongst the different schemes: some schemes were explicitly linked to service improvement projects identified by participants in their application, whilst others stated an intention or aspiration, identified in a relatively vague way, which was difficult or impossible to quantify. In addition, it was discovered that (for a variety of reasons internal to the THF) project reports had only been completed by a small minority of Award Holders. This meant that the extent of data about improvement type emerging from the documentary review was much more limited than had been envisaged. Nevertheless, some useful participant information about intended service improvements was recorded, as a basis for the typology development.

The most comprehensive taxonomy of improvements in healthcare available at this stage of the study was that emerging from the THF Quest for Quality and Improved Performance (QQUIP) research initiative undertaken by Leatherman and Sutherland (2007). This work included the development of a taxonomy of ‘quality-enhancing interventions’(QEI) for healthcare, shown in Appendix 1. This QEI taxonomy was not specifically developed for the purpose of comparing different types of improvement work. Rather, its purpose was to provide categories of improvement as a basis for reviewing the evidence about each category in terms of the effect they have on healthcare processes and patient outcomes. Sutherland and Leatherman (ibid) describe it as ‘a taxonomy to organize the available evidence of potential quality- enhancing interventions’. (p.334)

There were some limitations to the QEI taxonomy in its usefulness for this study. The most evident drawback was a lack of description, either in the THF brochure which was created to disseminate it (Leatherman et al, 2008), or in the associated peer-reviewed paper (Leatherman & Sutherland 2007) as to how it was developed, and how the categories were derived. Had this detail been available, it might have provided a useful basis for designing the typology for this study. Nevertheless, the QEI taxonomy seemed a robust, current and relevant framework with which to begin the work on differentiating types of improvement work.

The data about THF participants’ improvement work, which had been extracted from the documentary review, were analysed by the author using the classifications from Leatherman and Sutherland’s QEI taxonomy (2007). This is referred to in Appendix 2. However, as noted in Appendix 2, reducing the data down into pre-determined

categories before it had been considered it in its raw form, seemed prematurely reductive, and the analysis proved inconclusive.

As an alternative approach, examples of intended service improvements drawn from the documentary analysis, were listed, and the author attempted to group them into categories of ‘type’ (as detailed in Appendix 2). Whilst this exercise differentiated the service improvement examples more effectively, it also highlighted the methodological drawbacks of attributing sometimes multi-faceted service improvements to one single ‘type’ category. In several cases, one improvement example would fall into several ‘type’ categories. It proved difficult (and potentially counter-productive) to be attributing such items to a single ‘type’ category, given their complexity. Other examples did clearly fit into a single type. The author’s notes to research team colleagues, highlighting this as an issue, are shown in Appendix 2. It can be seen from these notes that at this early stage in the study, the documentary review had surfaced a key issue:

‘It seems to me that many of the examples incorporate several ‘types’ and are more complex than a single dimensional typology would suggest.’ (Appendix 2, p.1)