# 46 Research Abstract Format
PROJECT NAME: Mixed Methods Qualitative
Research as a Means for Effective Quality
Improvement Research
Institution: UT Southwestern
Primary Author: Stephen Inrig
Secondary Author: Jasmin Tiro
Other Authors: Simon Craddock Lee; Bijal Balasubramanian
Project Category: Research
Please complete the following sections. Submission is limited to a maximum word
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Background:
As the second highest cause of cancer death in the US, colorectal cancer (CRC) is an
important health problem. CRC screening and appropriate diagnostic follow-up is essential to
reducing CRC incidence and mortality, but screening rates are low in the US, particularly among
uninsured, low-income minorities in safety-net systems. The complex CRC screening process
occurs at multiple levels within a system and involves numerous steps and transitions within and
between multiple services. No single data collection method adequately captures this complexity,
so improving cancer care delivery requires new ways of observing and measuring these complex
care processes and multilevel influences. Our safety-net based research team (The Parkland-UT
Southwestern PROSPR Center) is part of an NCI-funded network (PROSPR, or Population-based
Research Optimizing Screening through Personalized Regimens) that is assessing factors that
influence cancer screening completion across numerous health systems. One of our projects’ aims
is to apply a mixed methods research design to observe these multi-level, multi-step processes in
order to determine optimal intervention points that will improve this complex care delivery
process.
Methods:
Our multi-phase mixed-methods study triangulated methods, data sources, and investigators to
comprehensively characterize the screening process and evaluate it through quantitative analyses
[Figure 1; Table 1]. Organizational variables (like policies, protocols, or culture) vary between
primary care clinics or vary longitudinally either at the clinic- or system-level. We will use
hierarchical random intercept logistic regression modeling to identify which organizational and
patient-level characteristics predict CRC screening completion and follow-up. Our multi-level
modeling strategy accounts for the nesting of patients within providers and clinics as well as the
random variation across clusters of patients, physicians, and clinics. We will evaluate two main
outcomes: a) completion of CRC screening among primary care patients at average risk for CRC,
and b) completion of CRC diagnostic evaluation among patients with abnormal screening results.
Through a series of cross-tabulations, we will explore which intermediate steps are associated
with the highest number of failures to complete screening.
Phase 1
Phase 2
EMR Abstraction to Rank Order Clinics
Phase 3
Organizational
Survey
Document
Analysis
Semi-structured
Interviews
Participant
Observation
Participant
Observation
Hierarchical Models (Qualitative and Quantitative-EMR Abstraction)
Figure 1: Multi-phase Mixed Methods Design
Table 1: Mixed Methodology Listing
Method
Purpose
Examples of Products
EMR abstraction

Identify primary care clinics with highest and
lowest completion rate for entire CRC screening
process
Identify screening process steps and interfaces with
largest number of failures
Understand origins, development, implementation,
and prioritization of CRC screening
Characterize organizational culture, structure, and
formal protocols of the CRC screening process,
including guideline dissemination and training of
care teams
Describe organizational structure, a broad range of
clinical and non-clinical care behaviors as they relate
to organizational protocols for CRC screening
processes
Evaluate functionality of the system for referring
patients with abnormal screening tests
Clarify observations and understand organizational
culture (values, beliefs, and norms)
Elucidate decision-making pathways for CRC
screening processes at the network- and clinic levels
Explore experiences and perceptions of whether
organizational protocols are compatible with the
situation of socially disadvantaged, safety-net
patients

Supplement the qualitative measurement of
organizational culture and processes in the primary
care clinics with highest and lowest completion rate
Measure organizational culture, CRC screening
processes, and protocols in all 11 primary care clinics


Document
Analysis


Participant
Observation


Semi-structured
interviews with
leaders and care
teams



Organizational
survey













Rank order and select clinics for qualitative
analysis
Selection of problematic steps and interfaces
for qualitative analysis
Photocopies of documents scanned into
database using Optical Character Recognition
Chronology of CRC screening policy
implementation
Comprehensive report outlining CRC
screening-related policies
Detailed descriptive field notes, transcribed
as text and entered into database
Flowcharts depicting team members roles,
responsibilities, relationships, and behaviors
across range of CRC steps and interfaces
Audio-recordings and transcripts
Understanding of practice member
experiences with CRC screening process and
their beliefs about the value of EMR to
improve delivery of screening processes
Clarify processes not easily observed, or
confusing during participant-observation
(e.g., values, beliefs, and attitudes regarding
CRC screening process)
Identify variations in use of CRC screening
protocols across 11 clinics & between staff within
the clinics
Assess degree of agreement between participantobservation with clinic staff perspectives
Evaluate how these variables modify the
relationship between patients’ degree of social
disadvantage and completion of guideline-based
CRC screening and follow-up
Results:
Thus far we have chronicled the CRC care continuum as it exists in Parkland’s safety-net
setting and begun determining clinic-level variation in CRC screening completion [Figure 2]. Our
mixed methods design has identified several likely nodes where screen failure and patient dropoff can occur.
Figure 2: CRC Care Continuum Model
Conclusions:
Using multi-phase mixed methods, we are capturing an otherwise opaque system that has
evolved in response to changing healthcare systems, technologies, staff, resources, and care
delivery methods. This will allow us to identify small but significant nuances of care delivery and
systems functioning that influence CRC screening delivery.
The need for in-depth understanding of such processes and systems is clear, particularly
for Quality Improvement interventions. In the era of Health Reform, researchers and QI
professionals must find more effective ways to promote health and organize care. Mixed
Methods Designs will play an important role describing, comparing, intervening in, and evaluating
outcomes of complex healthcare systems and we urge researchers, policy makers, and others to
employ them as a means of maximizing efficiency, reducing costs, and improving patient-centered
outcomes.