title: Combining qualitative and quantitative operational research methods to inform quality improvement in pathways that span multiple settings.
abstract: BACKGROUND
  Improving integration and continuity of care across sectors within resource constraints is a priority in many health systems. Qualitative operational research methods of problem structuring have been used to address quality improvement in services involving multiple sectors but not in combination with quantitative operational research methods that enable targeting of interventions according to patient risk. We aimed to combine these methods to augment and inform an improvement initiative concerning infants with congenital heart disease (CHD) whose complex care pathway spans multiple sectors.
  
  
  METHODS
  Soft systems methodology was used to consider systematically changes to services from the perspectives of community, primary, secondary and tertiary care professionals and a patient group, incorporating relevant evidence. Classification and regression tree (CART) analysis of national audit datasets was conducted along with data visualisation designed to inform service improvement within the context of limited resources.
  
  
  RESULTS
  A 'Rich Picture' was developed capturing the main features of services for infants with CHD pertinent to service improvement. This was used, along with a graphical summary of the CART analysis, to guide discussions about targeting interventions at specific patient risk groups. Agreement was reached across representatives of relevant health professions and patients on a coherent set of targeted recommendations for quality improvement. These fed into national decisions about service provision and commissioning.
  
  
  CONCLUSIONS
  When tackling complex problems in service provision across multiple settings, it is important to acknowledge and work with multiple perspectives systematically and to consider targeting service improvements in response to confined resources. Our research demonstrates that applying a combination of qualitative and quantitative operational research methods is one approach to doing so that warrants further consideration.
authors.affiliation: Clinical Operational Research Unit, University College London, London, UK.
authors.forename: Sonya
authors.initials: S
authors.lastname: Crowe
authors.affiliation: Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Katherine
authors.initials: K
authors.lastname: Brown
authors.affiliation: Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Jenifer
authors.initials: J
authors.lastname: Tregay
authors.affiliation: Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Jo
authors.initials: J
authors.lastname: Wray
authors.affiliation: Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK.
authors.forename: Rachel
authors.initials: R
authors.lastname: Knowles
authors.affiliation: Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Ridout
authors.affiliation: Great Ormond Street Hospital NHS Foundation Trust, London, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Bull
authors.affiliation: Clinical Operational Research Unit, University College London, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Utley
mesh_terms: D003266:Continuity of Patient Care; D006330:Heart Defects, Congenital / Q000628:therapy; D006801:Humans; D009874:Operations Research; D010346:Patient Care Management / Q000458:organization & administration; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D012107:Research Design; D018511:Systems Integration
keywords: Healthcare quality improvement; Implementation science; Quality improvement methodologies