title: Between and within-site variation in qualitative implementation research.
abstract: BACKGROUND
  Multisite qualitative studies are challenging in part because decisions regarding within-site and between-site sampling must be made to reduce the complexity of data collection, but these decisions may have serious implications for analyses. There is not yet consensus on how to account for within-site and between-site variations in qualitative perceptions of the organizational context of interventions. The purpose of this study was to analyze variation in perceptions among key informants in order to demonstrate the importance of broad sampling for identifying both within-site and between-site implementation themes.
  
  
  METHODS
  Case studies of four sites were compared to identify differences in how Department of Veterans Affairs (VA) medical centers implemented a Primary Care/Mental Health Integration (PC/MHI) intervention. Qualitative analyses focused on between-profession variation in reported referral and implementation processes within and between sites.
  
  
  RESULTS
  Key informants identified co-location, the consultation-liaison service, space, access, and referral processes as important topics. Within-site themes revealed the importance of coordination, communication, and collaboration for implementing PC/MHI. The between-site theme indicated that the preexisting structure of mental healthcare influenced how PC/MHI was implemented at each site and that collaboration among both leaders and providers was critical to overcoming structural barriers.
  
  
  CONCLUSIONS
  Within- and between-site variation in perceptions among key informants within different professions revealed barriers and facilitators to the implementation not available from a single source. Examples provide insight into implementation barriers for PC/MHI. Multisite implementation studies may benefit from intentionally eliciting and analyzing variation within and between sites. Suggestions for implementation research design are presented.
authors.affiliation: Department of Veterans Affairs, Center for Organization, Leadership, and Management Research, Boston, MA, USA. justin.benzer@va.gov
authors.forename: Justin K
authors.initials: JK
authors.lastname: Benzer
authors.forename: Sarah
authors.initials: S
authors.lastname: Beehler
authors.forename: Irene E
authors.initials: IE
authors.lastname: Cramer
authors.forename: David C
authors.initials: DC
authors.lastname: Mohr
authors.forename: Martin P
authors.initials: MP
authors.lastname: Charns
authors.forename: James F
authors.initials: JF
authors.lastname: Burgess
mesh_terms: D001291:Attitude of Health Personnel; D003625:Data Collection / Q000379:methods*; D003695:Delivery of Health Care / Q000592:standards; D006297:Health Services Accessibility / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008605:Mental Health Services / Q000592:standards*; D015588:Observer Variation; D010348:Patient Care Team / Q000592:standards / Q000706:statistics & numerical data; D010465:Perception; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000592:standards*; D011570:Psychiatry / Q000592:standards / Q000706:statistics & numerical data; D036301:Qualitative Research; D012017:Referral and Consultation / Q000592:standards* / Q000706:statistics & numerical data; D014218:Triage / Q000592:standards / Q000706:statistics & numerical data