Improving the way we do action research in quality improvement

Figures & data

Figure 1. Aligning problem resolving action research (PRAR) model (Piggot-Irvine 2009) and collaborative action research (CAR) model (Kemmis and McTaggart 2005) with the plan, do, study, act cycle. X.1: Problem Resolving Action Research (PRAR) model and Plan, Do Study, Act cycle. X.2 Collaborative Action Research (CAR) model and Plan, Do Study, Act cycle.

Table 1. Overview of QI cases.

	Case 1 – right first time: improving the quality of referrals to community-based children services (Griffiths et al. 2022)	Case 2 –using quality improvement methodology to support, enhance and develop health visitors’ access to therapies in the early years
Project team	Multi-disciplinary including nurses, physiotherapists, occupational therapists, speech & language therapists & dietetics.	Multi-disciplinary including physiotherapists, occupational therapists & speech & language therapists.
Role of researcher in residence	Seconded quality improvement coach & facilitator	Seconded quality improvement coach & facilitator
Project type	Part of a quality improvement collaborative run by the case organization (2019–2020) – all 9 education sessions delivered face to face with other improvement teams (n = 10)	Part of a quality improvement collaborative run by the case organization (2021–2022) – all 9 education sessions delivered virtually with a small number of other improvement teams (n = 5 – due to Covid pandemic and need for social distancing).
Project team meetings	Face-to-face	Virtual and face-to-face
Problem statement	25% Of requests for help (referrals) received were not appropriate for several reasons, including the use of old forms and incomplete information.	Receiving an increasing number of Requests for Help which are not considered appropriate for several reasons – including inadequate information, quality of information is not enough to determine need and/or information provided does not indicate a need for concern. Data captured on the time spent processing/triaging requests for help.
Aim of the project	To reduce in appropriate referrals by 25% over a 6-month period	To reduce the number of returned requests for help to therapy services by 60% over a 9-month period.
Plan	Consult the published literature re: referrals and the request for help model (Malcomess 2005a, 2005b) Baseline referral data were collected for each profession/service. Improvement tools (e.g. process maps, fishbone diagrams) were used to understand the possible reasons as to why capacity was not meeting demand, which led to the improving the referral process.	Consulted existing policy documents. Review published literature on improving triage of referrals across various services/therapies. Collect baseline data on the number of referrals received and returned to Health visitors (main referrer to services). Time taken to process and triage referrals captured.
Do	Several improvement small cycles of change were introduced. For example, education awareness sessions on the request for help forms.	The first PDSA cycle was the running of focus groups with Health visitors (HVs) in one area. This enabled the improvement team to understand what issues HVs were experiencing with policy documents (e.g. developmental delay tool) and where there were gaps in education and awareness of therapy services. Feedback from HVs requested smaller check list and another quick reference checklist,
Study	Run charts were used to monitor the number of requests for help and those that were inappropriate/incomplete for each test of change. Two services saw a reduction of % in poor quality referrals over a four-month period.	Run charts used to monitor the quality of requests for help. Before and after skills assessment were undertaken to measure the impact of training sessions.
Act	A second plan-do-study-act cycle of change was designed to involve families in the co-creation of the request for help pro-forma.	PDSA 2 – development of an online App – and training packages for HVs. PDSA 3 – training package for HVs delivered via Microsoft Teams channel – feedback and reflection lead to different approach to future training. PDSA 4 – revised training packages and trial of the App.
Outcomes	Reduction of poor-quality request for help (referrals).	Increased awareness of the early years’ therapies and documentation Reduction of time to process and triage request for help from the main referrer (HVs).
Action Research model	PRAR	CAR

Table 2. Similarities and differences between PRAR and CAR models.

Attribute of AR	PRAR	CAR
Reflective cycle	✓	✓
Collaboration between academics and practitioners	✓	✓
Iterative in design	✓	✓
Promotes learning and development		✓
Problem definition	✓
Evaluates outcomes	✓
Clear action planning	✓	✓
Promotes change and improvement		✓

Table 3. Benefits and challenges of using AR in healthcare improvement.

Benefits	Challenges
AR encourages and facilitates change within a specific environment.	Potential for limited generalizability
Researcher in residence encouraged practitioners to review published materials to inform the design of their study and ground interpretations/outcomes in theory	Researcher in residence needs time to assimilate the specific project environment.
Researcher created time for reflection and assisted with the design of the PDSA	Researcher in residence unable to access organization’s IT systems.
Researcher assisted with data analysis and presentation of results.	Practitioners lose ownership of the findings
Practitioners have insight and understanding of organizational politics	Practitioners need to test and challenge their own assumptions

Figure 2. Framework for collaborative action research.

Table 4. Role of the researcher in residence.

Role of researcher in residence in AR	Examples from case studies
Gatekeeper	A multi-level activity with no single ‘gate’ and no single gatekeeper (Bennett and Brunner 2022). Researcher in conjunction with the project team negotiated access to other stakeholders within and outside of the organization (e.g. HV- case 2).
Negotiator	Negotiating time and space within busy and complex operational areas to undertake data collection and analysis. Also needed to negotiate the scope of the project. This required the realignment of the expectations of the project team and managers in what could be achieved within the time of the QI programme.
Researcher	Advise on research methods and data collection appropriate for the improvement project. Assist in scoping the parameters of an appropriate literature search and develop themes to inform the study design.
Collaborator	Develop sustainable relationships with the project team, line managers and other key stakeholders.
Facilitator	Organize and facilitate project meetings and ensure time is protected to complete the project and write up the AR.
Theorist	Analysis of previous literature and clearly articulate to project team possible theoretical contribution of the AR project.
Translator	Translate research terms and academic narrative to something that is meaningful to all involved in the AR project.
Critical friend	Constructively challenge existing work practices and rituals associated with the AR project and improvements.
Motivator	The iterative nature of improvement (PDSA cycles) and action research requires resilience by all involved in the improvement activities. The researcher in residence may assume the role of motivating teams especially during times of operational pressures and limited resources.

Table 5. Reporting guidelines for action research in healthcare operations management.

Guideline	Description	Origin
1. Plan	Plan the organisation and structure of the report at the same time of planning the project/initiative. e.g. as part of the PDSA cycle	PAR
2. Title	Ensure the title reflects the nature of the improvement project/initiative Where possible include action research in the title	SQUIRE & PAR
3. Abstract	Provide an overview of the AR improvement project. Use a structured abstract where possible	SQUIRE
4. Introduction	Outlining the problem the improvement project is addressing and why AR is being used to investigate this problem. A summary what is currently known about the area of improvement including any previous studies or relevant theories to be tested. Define the aims and objectives of the project.	SQUIRE & PAR
5. Methods	Describe the context of the study e.g. case study and how AR will be used for the study. Clarify the roles of the embedded researcher and participants and details of the interactions/collaboration. Provide details and justify data collection methods employed and any ethical considerations.	SQUIRE & PAR
6. Intervention – using the PDSA cycle	Plan: Describe the key elements of the project e.g. How the project and the collaboration with the case organisation were set up; Details of the timeframe for the project and predicted changes expected.	SQUIRE & PAR
7. Results	Do: Details of the cycles of change tested; Study: Details of the outcomes of the study Act: Reflection and learning from the study and recommendations for improvement. The writing of the report/article needs to reflect the iterative nature of AR and the voices of those involved in the AR. Outcomes of the study are evaluated.	SQUIRE & PAR
8. Discussion and conclusion	Discuss the ‘real life’ changes and improvements made by the study in relation to previous research. Clearly state the theoretical contributions of the research. Any learning (positive/negative) from undertaking the study in terms of improvement and/or AR. Outline the limitations of the study and areas of further research.	SQUIRE & PAR

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