Anthropological Approaches Uncovering Unexpected Insights

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Anthropological Approaches Uncovering Unexpected Insights. About the Implementation and Outcomes of Patient Centered. Medical Home Models, This brief focuses on using anthropological approaches to evaluate patient centered medical home. PCMH models It is part of a series commissioned by the Agency for Healthcare Research and. Quality AHRQ and developed by Mathematica Policy Research under contract with input from. other nationally recognized thought leaders in research methods and PCMH models The series is. designed to expand the toolbox of methods used to evaluate and refine PCMH models The PCMH. is a primary care approach that aims to improve quality cost and patient and provider experience. PCMH models emphasize patient centered comprehensive coordinated accessible care and a. systematic focus on quality and safety,I An Anthropological Approach. The hallmark of anthropology is the exploration of the complexity and nuances of human interactivity. and culture As a research discipline anthropology combines humanist and social science strategies. The method that sets anthropology apart from other disciplines is ethnography the qualitative. process of exploring in depth the whys and hows of human culture behavior and expression Using. this ethnographic method anthropologists can uncover unexpected insights that are best gained by. studying a topic in person in situ over time and from diverse perspectives. The ethnographic method uses multiple data collection techniques including participant observation. interviews focus groups and textual analysis to construct a holistic and contextual view of the. phenomena under study During their research anthropologists make observations and pursue. perspectives from diverse angles and in diverse ways They observe and talk with people from different. social categories who have varying relationships to the phenomena under study and conceptualize and. respond to those phenomena in unique ways Anthropological inquiry combines information about. people s thoughts gathered through interviews with information collected by observing their behavior. and social interactions In the context of the PCMH this can include interviewing and observing. doctors nurse practitioners office managers and patients to explore the ways in which they experience. and understand concepts such as care coordination or quality improvement. Anthropologists immerse themselves in the rich largely qualitative data set that results from their. research and conduct iterative analyses to identify emerging themes and glean insights about the. meaning of the data The goal of an anthropological approach is a credible interpretation of the data. that is well described provides valuable insights and can be replicated. Anthropology has much to contribute to the field of PCMH evaluation in which researchers aim to. not only describe implementation and outcomes but also uncover contextual meaning and reasons. behind those descriptions within a rapidly evolving health care system An anthropological approach. can help researchers evaluating the PCMH identify transformations along with the underlying factors. in the practice among patients and in the community that drive how transformation decisions are. made how the changes occur and how the changes affect those involved The approach goes beyond. examining quantitative outcomes to explore the qualitative aspects of how the practice is transforming. why particular changes are or are not occurring in a given primary care practice and how all affected. parties conceptualize and experience the changes This approach necessitates investigation of issues. from multiple perspectives and by multiple means including collecting data as expressed by clinicians. other staff members and patients Anthropological evaluations are designed to identify the shared. cultural meanings between and among different groups of stakeholders such as providers staff and. patients and determine how culture is constructed at the practice A longitudinal evaluation from. an anthropological perspective involves documentation of the dynamic change in practice culture and. patients interactions with this change as PCMH transformation initiatives unfold. Data collection methods Typically an anthropological approach uses multiple qualitative methods. to collect data that are useful on their own as well as complementary to quantitative data in a mixed. methods study These qualitative methods enable PCMH evaluators to place themselves intimately. within the PCMH context and to use participant observation interviewing and focus group. techniques to uncover how the practice functions how patients providers and staff interact and. how these stakeholders describe their thoughts and experiences in their own words Four common. qualitative anthropological data collection methods are 1 participant observation 2 in depth. interviews 3 focus groups and 4 textual analysis, Participant Observation Participant observation is the quintessential fieldwork method in. anthropology Anthropologists use various degrees of participant observation from full participation. in ongoing activities to passive observation within the locations of interest Participant observation is. useful at multiple stages of an evaluation 1 initially to identify issues that need to be explored with. other data collection methods 2 ongoing as process evaluation and 3 following other types of data. collection to triangulate earlier findings and directly observe the specific phenomena that participants. have spoken about Participant observation allows the researcher to assess actual behavior in real time. information gathered in this way can strengthen interpretation of information collected through. interviews Large projects that employ multiple observers can use an observation template to guide. observers in taking notes about core phenomena and allow them to add notes about other phenomena. It is important to ensure that observations of any location take place at different times of the day and. week to identify patterns and differences, In Depth Individual Interviews In depth interviews using open ended questions aim to capture the. mental and experiential world of the informant Individual interviews allow participants to tell their. stories uninterrupted in a detailed and coherent manner without worrying about what their peers. may think as in a focus group Given the frequent requirement in PCMH evaluations for multiple. interviews often conducted by more than one interviewer and the desire to compare and contrast. responses of interviewees the most useful type of interview for PCMH evaluation is the semi. structured interview which combines consistency with flexibility A semi structured interview uses. an interview guide with a core list of open ended questions and anticipated followup questions to. ensure that researchers ask all participants a minimum set of identical questions in order to collect. reliable comparable qualitative data In addition this interview technique allows researchers to ask. spontaneously generated questions to probe for clarification of participants responses and to follow. new relevant topics that participants raise Semi structured interviews should be conducted by. someone trained in qualitative interviewing and comfortable using open ended questions to encourage. participants to expound on their thoughts The length of the interviews can vary and evaluators can. audio record and transcribe them PCMH evaluations include interviews with all types of participants. involved in the process of care patients registration clerks nurses medical assistants residents. physicians and allied health staff Collecting a range of viewpoints provides rich information and. often unexpected insights on the PCMH and its impact by exposing areas of challenge or success for. the practices, Focus Groups The focus group is a group interview method useful for obtaining information on.
relatively unstudied topics for which the full range of relevant domains is not known and the dynamic. interaction among participants is of interest Researchers choose focus groups over individual in depth. interviews when data acquisition will benefit from the dynamic that is created through group. discussion The discussion often elicits information and insights that might not be gained from an. individual interview including the colloquial ways in which participants speak with one another about. working in or seeking care from the practice, For example in the baseline assessment phase of a PCMH evaluation evaluators might use focus. groups to 1 enable practice personnel to grapple with their expectations for practice transformation. or 2 identify some issues to address early on and others to address later in the process To maintain. participants confidentiality and foster a comfortable environment for expressing ideas researchers. usually avoid including participants at different levels of status and within supervisory hierarchies in. focus groups, The following factors are critical to the success of focus groups. 1 Thoughtful creation of a list of open ended questions designed to draw participants into. discussion on desired topics, 2 Careful attention to recruitment of participants who have the desired characteristics or. experiences and who are comfortable with non hierarchical group discussion. 3 Skillful group facilitation by a trained focus group moderator. 4 The presence of an observer who keeps process notes operates the recording equipment and. assists the moderator as needed, Focus groups usually include 6 to 12 participants and last 1 to 2 hours Discussions are audio. recorded and transcribed with participants identities masked Each focus group is considered a unit of. analysis N 1 irrespective of the number of participants Moderators should strive to facilitate open. and dynamic dialogue among participants to allow opportunities for creative insights. Textual Analysis Practices produce a wide range of documents that provide valuable windows into their. operation values and mechanisms Anthropological methods can be used to examine the underlying. themes and patterns in documents such as practice mission statements informational brochures and. procedure manuals To understand the broader context in which the practice its employees and its. delivery of services exist researchers can conduct a systematic review of textual materials produced. by the practice for its staff its patients and the public to identify how stakeholders think about the. practice s overall mission services and transformation goals One less commonly considered type of. textual material that can provide useful insights into the practice environment is practice produced. narratives Evaluators can obtain rich insights into otherwise unarticulated beliefs motivations and. dreams about and for the practice culture if individuals and groups construct their own practice. narratives record their practice histories and even participate in re biography rewriting their stories. to reflect their transformations as part of the transformation process. Data analysis methods Data for qualitative analysis most often consist of interview and focus. group recordings and transcripts field notes written during participant observation sessions. textual documents and notes written about the data collection process itself The techniques used. for qualitative data analysis involve careful and repeated listening to the recordings and reading. of transcripts field notes and collected textual documents Anthropologists view this process as. becoming immersed in the data as they search for themes As the researchers listen to the recordings. and read the texts they commonly take notes on the content and on their developing analytic. thoughts Analysis is an ongoing process that begins as the first data become available and continues. to the end of data collection For large projects with teams of researchers individual review of the. data is followed by repeated group sessions for team members to discuss and compare their analyses. and to arrive at an agreed upon interpretation This process is especially helpful for comparison and. triangulation of findings from mixed methods studies that use multiple qualitative and quantitative. Projects using qualitative methods quickly amass large amounts of non numeric data that can become. difficult to manage In response to this private companies government agencies and open source. teams have created computer assisted qualitative data analysis software packages that allow researchers. to assign topical codes to chunks of text by using a codebook created in advance by the project team. and or generating codes as needed during the coding process An anthropological approach to data. analysis considers data within the context of the entire text in which they appear In this sense coding. in and of itself does not constitute the analysis but it is an efficient tool to facilitate later phases of. analysis during which coding is used to sort and locate data on specified topics. II Uses of an Anthropological Approach, Next we discuss ways of applying the anthropological approach to evaluations of PCMH models.
Study particular phenomena Anthropological methods have been used in evaluations of PCMH. models to study such phenomena as how practice employees interact to identify needed changes how. changes are implemented and communicated throughout the practice and to patients how practice. Anthropological Approaches Uncovering Unexpected Insights About the Implementation and Outcomes of Patient Centered Medical Home Models This brief focuses on using anthropological approaches to evaluate patient centered medical home PCMH models It is part of a series commissioned by the Agency for Healthcare Research and Quality AHRQ and developed by Mathematica Policy Research under

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