Graham Martin
As far as possible within the terms of publishers' copyright/licence agreements, I have made my sole- and lead-authored papers available for download on this site, in their revised form following peer review. If you have electronic access, you can also get the published versions via the journals' websites - links are provided. If you don't have electronic access to these journals, and for other papers which I've authored or co-authored but which aren't available for download here, please e-mail me and I'll be happy to send you a copy.
Phone: 0116 252 3207
Phone: 0116 252 3207
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Papers by Graham Martin
METHODS: We interviewed 30 trustees from 16 CHCs in 14 different states, asking extensively about decision-making processes at their CHC related to services and finances, as well as perceived advantages and disadvantages of consumer governance.
RESULTS: Respondents described mission-dominant, margin-dominant, and balanced decision-making philosophies, and different decision-making pathways for service provision and finances. Consumer trustees were lauded for their role in informing the board of service quality and community needs, but criticized for being professionally unskilled and exhibiting a lack of objective decision-making.
CONCLUSIONS: While CHC boards do play a role in navigating the tension between mission and margin, executive directors and staff appear to be more influential.
Methods: The data, collected from 82 semistructured interviews in the English NHS, were drawn from two components of a wider study of culture and behavior around quality and safety in the English system. Analysis was based on the constant comparative method.
Findings: Our analysis highlights how local, pragmatic adjustments to the walkrounds approach could radically alter its character and the way in which it is received by those at the front line. The modification and expansion of walkrounds to increase the scope of knowledge produced could increase the value that executives draw from them. However, it risks replacing the main objectives of walkrounds—specific, actionable knowledge about safety issues, and a more positive safety culture and relationship between ward and board—with a form of surveillance that could alienate frontline staff and produce fallible insights.
Conclusion: The study’s findings suggest some plausible explanations for the mixed evidence for walkrounds’ effectiveness in creating a safety culture. On a practical level, they point to critical questions that executives must ask themselves in practicing interventions of this nature to ensure that adaptations align rather than conflict with the intervention’s model of change.
Based on our synthesis of the literature, we propose an analytical distinction between instrumental and transformative partnerships, arguing that it is transformative partnerships that can deliver the unique advantages set out in theory. Comparative analysis of the cases illustrates that although both were able to achieve some valuable successes, they fell short of realising their transformative potential. We identify five common issues that impeded or facilitated transformative partnership-working, at micro, meso- and macro-levels: starting conditions; programme set-up; funding asymmetries and interdependence; accountability mechanisms; and relationships and distance from the field. Through systematic comparison we offer a more nuanced understanding of how programmes themselves create particular architectures for partnership, how underlying globalised institutional logics of managerialism promote instrumental partnerships, and how local-level, interpersonal relationships may help to overcome barriers to partnership’s transformative potential.
Methods: We interviewed 107 stakeholders with close involvement with quality and safety as professionals, managers, policy makers or commentators. Analysis was based on the constant comparative method.
Results: Participants identified the crucial role of leadership in ensuring safe, high quality care. Consistent with the academic literature, participants distinguished between traditional hierarchical “concentrated” leadership associated with particular positions, and distributed leadership involving those with particular skills and abilities across multiple institutional levels. They clearly and explicitly saw a role for distributed leadership, emphasising that all staff had responsibility for leading on patient safety and quality. They described the particular value of leadership coalitions between managers and clinicians. However, concern was expressed that distributed leadership could mean confusion about who was in charge, and that at national levelit risked creating a vacuum of authority, mixed messages, and conflicting expectations and demands. Participants also argued that at organisational level, hierarchically based leadership was needed to complement distributed leadership at organisational level, not least to provide focus, practical support and expertise, and managerial clout.
Conclusions: Strategic-level stakeholders see the most effective form of leadership for quality and safety as one that blends distributed and concentrated leadership. Policy and academic prescriptions about leadership may benefit from the sophisticated and pragmatic know-how of insiders who work in organisations that remain permeated by traditional structures, cleavages and power relationships.
Patient and public involvement in healthcare planning, service development and health-related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work is more limited. We aimed to characterize patient involvement in three improvement projects and to identify strengths and weaknesses of contrasting approaches.
Methods
Three case study quality improvement projects were purposively sampled from a broader programme. We used an ethnographic approach involving 126 in-depth interviews, 12 weeks of non-participant observations and documentary analysis. Data analysis was based on the constant comparative method.
Results
The three projects differed in the ways they involved patients in their quality improvement work, including their rationales for including patients. We characterized three very different models of patient involvement, which were each influenced by project context. Patients played distinctive roles across the three projects, acting in some cases as intermediaries between the wider patient community and clinicians, and sometimes undertaking persuasive work to convince clinicians of the need for change. We identified specific strategies that can be used to help ensure that patient involvement works most effectively and that the enthusiasm of patients to make a difference is not dissipated.
Conclusion
Patient involvement in quality improvement work needs careful management to realize its full potential.
Methods: Thirty paired English NHS trusts participated in facilitated reciprocal site visits. An ethnographic study of six pairs was undertaken involving non-participant observations of site visits and ILCOP programme activities, documentary collection, and 46 in-depth interviews. Analysis was based on the constant comparative method.
Results: RP2PR was generally a positive experience for participants. It provided stimulus and direction for improvement, including the production of quality improvement plans. Five key features were identified as important in the ILCOP model: the core team; peers and pairing methods; structure of discussion sessions; the facilitator role; and credibility of the process. All but one of the participating teams produced quality improvement plans, but implementation was challenging for some. Support from the ILCOP core team and managerial commitment from participating sites was essential. RP2PR appears to be optimised when: it is well organised; a safe environment for learning is created; credibility is maximised; and implementation and impact are supported.
Discussion: RP2PR may have a valuable role in improvement alongside other more established methods. Facilitated reciprocal peer review is seen as credible and legitimate by lung cancer teams and can act as a powerful stimulus to produce focused quality improvement plans and to support implementation. Our findings have identified how RP2PR may be optimised to provide a constructive, open space for identifying opportunities for improvement and solutions. Challenges to ensuring follow through were identified."
Methods: The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.
Results: The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.
Discussion: Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.
Design: We draw on in-depth qualitative interview data from the first round of an ongoing evaluation of one CLAHRC to understand the views of different stakeholders on its progress so far, challenges faced, and emergent solutions.
Findings: The breadth of CLAHRCs’ missions seems crucial to mobilise the diverse stakeholders needed to succeed, but also produces disagreement about what the prime goal of the Collaborations should be. A process of consensus building is necessary to instil a common vision among CLAHRC members, but deep-seated institutional divisions continue to orient them in divergent directions, which may need to be overcome through other means.
Originality/value: Our analysis suggests some of the key means by which those involved in joint enterprises such as CLAHRCs can achieve consensus and action towards a current goal, and offers recommendations for those involved in their design, commissioning and performance management.
METHODS: We interviewed 30 trustees from 16 CHCs in 14 different states, asking extensively about decision-making processes at their CHC related to services and finances, as well as perceived advantages and disadvantages of consumer governance.
RESULTS: Respondents described mission-dominant, margin-dominant, and balanced decision-making philosophies, and different decision-making pathways for service provision and finances. Consumer trustees were lauded for their role in informing the board of service quality and community needs, but criticized for being professionally unskilled and exhibiting a lack of objective decision-making.
CONCLUSIONS: While CHC boards do play a role in navigating the tension between mission and margin, executive directors and staff appear to be more influential.
Methods: The data, collected from 82 semistructured interviews in the English NHS, were drawn from two components of a wider study of culture and behavior around quality and safety in the English system. Analysis was based on the constant comparative method.
Findings: Our analysis highlights how local, pragmatic adjustments to the walkrounds approach could radically alter its character and the way in which it is received by those at the front line. The modification and expansion of walkrounds to increase the scope of knowledge produced could increase the value that executives draw from them. However, it risks replacing the main objectives of walkrounds—specific, actionable knowledge about safety issues, and a more positive safety culture and relationship between ward and board—with a form of surveillance that could alienate frontline staff and produce fallible insights.
Conclusion: The study’s findings suggest some plausible explanations for the mixed evidence for walkrounds’ effectiveness in creating a safety culture. On a practical level, they point to critical questions that executives must ask themselves in practicing interventions of this nature to ensure that adaptations align rather than conflict with the intervention’s model of change.
Based on our synthesis of the literature, we propose an analytical distinction between instrumental and transformative partnerships, arguing that it is transformative partnerships that can deliver the unique advantages set out in theory. Comparative analysis of the cases illustrates that although both were able to achieve some valuable successes, they fell short of realising their transformative potential. We identify five common issues that impeded or facilitated transformative partnership-working, at micro, meso- and macro-levels: starting conditions; programme set-up; funding asymmetries and interdependence; accountability mechanisms; and relationships and distance from the field. Through systematic comparison we offer a more nuanced understanding of how programmes themselves create particular architectures for partnership, how underlying globalised institutional logics of managerialism promote instrumental partnerships, and how local-level, interpersonal relationships may help to overcome barriers to partnership’s transformative potential.
Methods: We interviewed 107 stakeholders with close involvement with quality and safety as professionals, managers, policy makers or commentators. Analysis was based on the constant comparative method.
Results: Participants identified the crucial role of leadership in ensuring safe, high quality care. Consistent with the academic literature, participants distinguished between traditional hierarchical “concentrated” leadership associated with particular positions, and distributed leadership involving those with particular skills and abilities across multiple institutional levels. They clearly and explicitly saw a role for distributed leadership, emphasising that all staff had responsibility for leading on patient safety and quality. They described the particular value of leadership coalitions between managers and clinicians. However, concern was expressed that distributed leadership could mean confusion about who was in charge, and that at national levelit risked creating a vacuum of authority, mixed messages, and conflicting expectations and demands. Participants also argued that at organisational level, hierarchically based leadership was needed to complement distributed leadership at organisational level, not least to provide focus, practical support and expertise, and managerial clout.
Conclusions: Strategic-level stakeholders see the most effective form of leadership for quality and safety as one that blends distributed and concentrated leadership. Policy and academic prescriptions about leadership may benefit from the sophisticated and pragmatic know-how of insiders who work in organisations that remain permeated by traditional structures, cleavages and power relationships.
Patient and public involvement in healthcare planning, service development and health-related research has received significant attention. However, evidence about the role of patient involvement in quality improvement work is more limited. We aimed to characterize patient involvement in three improvement projects and to identify strengths and weaknesses of contrasting approaches.
Methods
Three case study quality improvement projects were purposively sampled from a broader programme. We used an ethnographic approach involving 126 in-depth interviews, 12 weeks of non-participant observations and documentary analysis. Data analysis was based on the constant comparative method.
Results
The three projects differed in the ways they involved patients in their quality improvement work, including their rationales for including patients. We characterized three very different models of patient involvement, which were each influenced by project context. Patients played distinctive roles across the three projects, acting in some cases as intermediaries between the wider patient community and clinicians, and sometimes undertaking persuasive work to convince clinicians of the need for change. We identified specific strategies that can be used to help ensure that patient involvement works most effectively and that the enthusiasm of patients to make a difference is not dissipated.
Conclusion
Patient involvement in quality improvement work needs careful management to realize its full potential.
Methods: Thirty paired English NHS trusts participated in facilitated reciprocal site visits. An ethnographic study of six pairs was undertaken involving non-participant observations of site visits and ILCOP programme activities, documentary collection, and 46 in-depth interviews. Analysis was based on the constant comparative method.
Results: RP2PR was generally a positive experience for participants. It provided stimulus and direction for improvement, including the production of quality improvement plans. Five key features were identified as important in the ILCOP model: the core team; peers and pairing methods; structure of discussion sessions; the facilitator role; and credibility of the process. All but one of the participating teams produced quality improvement plans, but implementation was challenging for some. Support from the ILCOP core team and managerial commitment from participating sites was essential. RP2PR appears to be optimised when: it is well organised; a safe environment for learning is created; credibility is maximised; and implementation and impact are supported.
Discussion: RP2PR may have a valuable role in improvement alongside other more established methods. Facilitated reciprocal peer review is seen as credible and legitimate by lung cancer teams and can act as a powerful stimulus to produce focused quality improvement plans and to support implementation. Our findings have identified how RP2PR may be optimised to provide a constructive, open space for identifying opportunities for improvement and solutions. Challenges to ensuring follow through were identified."
Methods: The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.
Results: The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.
Discussion: Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.
Design: We draw on in-depth qualitative interview data from the first round of an ongoing evaluation of one CLAHRC to understand the views of different stakeholders on its progress so far, challenges faced, and emergent solutions.
Findings: The breadth of CLAHRCs’ missions seems crucial to mobilise the diverse stakeholders needed to succeed, but also produces disagreement about what the prime goal of the Collaborations should be. A process of consensus building is necessary to instil a common vision among CLAHRC members, but deep-seated institutional divisions continue to orient them in divergent directions, which may need to be overcome through other means.
Originality/value: Our analysis suggests some of the key means by which those involved in joint enterprises such as CLAHRCs can achieve consensus and action towards a current goal, and offers recommendations for those involved in their design, commissioning and performance management.