bmj open · analysis interview transcripts were analysed thematically using the framework approach....

For peer review only

Health Professionals’ Experiences of Tuberculosis Cohort Audit in the North West of England: a qualitative study

Journal: BMJ Open

Manuscript ID bmjopen-2015-010536

Article Type: Research

Date Submitted by the Author: 12-Nov-2015

Complete List of Authors: Wallis, Selina; Liverpool school of tropical medicine, International health Jehan, Kate; University of Liverpool, Department of Public Health and Policy Woodhead, Mark; Manchester Royal Infirmary, Respiratory Medicine Cleary, Paul; Public Health England, Field Epidemiology Service Dee, Katie; Public Health England, Deputy Director Farrow, Stacey; NHS Bolton McMaster, Paddy; North Manchester General Hospital

Wake, Carolyn; Public Health England Walker, Jenny; NHS Liverpool Community Health Squire, Bertie; Liverpool school of tropical medicine, Centre for Applied Health Research and Delivery & Department of Clinical Sciences; Royal Liverpool Hospital, Respiratory Medicine

<b>Primary Subject Heading</b>:

Qualitative research

Secondary Subject Heading: Communication, Infectious diseases, Nursing, Public health, Respiratory medicine

Keywords:

Clinical audit < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES, HEALTH SERVICES

ADMINISTRATION & MANAGEMENT, PUBLIC HEALTH, QUALITATIVE RESEARCH, THORACIC MEDICINE

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open on F

ebruary 13, 2020 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2015-010536 on 16 March 2016. D

ownloaded from

http://bmjopen.bmj.com/


1

Health Professionals’ Experiences of Tuberculosis Cohort Audit in the North West of

England: a qualitative study

Corresponding author Selina Wallis Researcher Capacity Research Unit Liverpool School Of Tropical Medicine Pembroke Place Liverpool L3 5QA Mobile Tel: +44(0)7821147990 E-mail: [email protected] Co authors Dr Kate Jehan Lecturer in Public Health Department of Public Health and Policy Whelan Building University of Liverpool Liverpool L69 3GB Mark Woodhead BSc DM FRCP FERS Honorary Clinical Professor of Respiratory Medicine, Faculty of Medical and Human Sciences, University of Manchester & Department of Respiratory Medicine, Central Manchester University Hospitals NHS Foundation Trust Manchester Academic Health Science Centre Manchester M13 9WL

Dr Paul Cleary Field Epidemiology Service Public Health England 5th Floor Rail House Lord Nelson Street Liverpool L1 1JF Katie Dee, Deputy Director, Public Health England, Cheshire and Merseyside Centre

Stacey Farrow TB Nurse Specialist NHS Bolton Dr Paddy McMaster Consultant in Paediatric Infectious Diseases North Manchester General Hospital Limbert House Manchester M8 5RB Carolyn Wake NW TB Coordinator Public Health England Jenny Walker TB Specialist Nurse NHS Liverpool Community Health Abercromby Health Centre Grove Street Liverpool L7 7HG Prof S B Squire Centre for Applied Health Research and Delivery & Department of Clinical Sciences, Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA UK

Key words: Tuberculosis, Cohort audit, Community of practice Word Count: 4174 No of Tables: 1 No of Boxes: 5 Number of references: 34

Page 1 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

on February 13, 2020 by guest. P

rotected by copyright.http://bm

jopen.bmj.com

/B

MJ O

pen: first published as 10.1136/bmjopen-2015-010536 on 16 M

arch 2016. Dow

nloaded from



2



S.Wallis1, K. Jehan2, M. Woodhead3, P. Cleary4,.K. Dee4, S. Farrow5, P. McMaster6, C.

Wake 4, J Walker7, S.B. Squire8

1. Department of Clinical Sciences and Centre for Applied Health Research & Delivery,

Liverpool School of Tropical Medicine

2. Department of Public Health and Policy, University of Liverpool

3. Manchester Royal Infirmary

4. Public Health England Field Epidemiology Service

5. Bolton NHS Trust

6. North Manchester General Hospital

7. Liverpool Community Health Trust 8. Department of Clinical Sciences and Centre for Applied Health Research & Delivery,

Liverpool School of Tropical Medicine & Royal Liverpool University Hospital

ABSTRACT

Objectives Tuberculosis cohort audit (TBCA), is an on-going, multidisciplinary, systematic

case review process, designed to improve clinical and public health practice, and was

introduced across the North West of the UK in 2012. TBCA has not previously been

introduced across such a large and socio-economically diverse area in the UK, nor has it

undergone formal, qualitative evaluation. This study explored health professionals’

experiences of the audit after 1,515 cases had been reviewed.

Design Qualitative study using semi-structured interviews. 26 purposively sampled

respondents were recruited from three groups involved in the NW TBCA: (a) TB nurse

specialists; (b) consultant physicians, and (c) public health practitioners. Data were

triangulated with further interviews with key informants from the TBCA Steering Group and

observation of TBCA meetings.

Analysis Interview transcripts were analysed thematically using the Framework Approach.

Results Participants described the evolution of a valuable ‘Community of Practice’ where

inter-professional exchange of experience and ideas has led to enhanced mutual respect

between different roles and a shared sense of purpose. This multidisciplinary, regional

approach to TB cohort audit has promoted local and regional team working, exchange of

good practices and local initiatives to improve care. There is strong ownership of the process

from Public Health, Nurses and Clinicians and they want it to continue. TB Cohort audit is

seen as a tool for quality improvement that improves patient safety.

Conclusions TB cohort audit provides peer support and learning for management of a

relatively rare, but important infectious disease through discussion in a no-blame

atmosphere. It is seen to enhance TB care, control, and patient safety and is an effective

quality improvement strategy. Continuing success will require increased engagement of

consultant physicians and public health practitioners, a secure and on-going funding stream

and establishment of reporting mechanisms within the new commissioning structures.

Page 2 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



3

ARTICLE SUMMARY

Article focus

How have health professionals experienced the introduction of a new model of TB cohort

audit introduced over a large and socio-economically diverse footprint?

Key messages

Health professionals who attend TB cohort audit in the North West of the UK describe the

development of a new and unique community of practice.

Strengths and limitations

Our qualitative dataset included a large and extensive number of stakeholders from three

main cadres that participate in TB cohort audit. The unique geographic configuration and

implementation of the NW TBCA may mean that the findings are not easily transferred to

other areas without careful adaptation.

Funding statement

This research was supported by Public Health England and the Centre for Applied Health

Research & Delivery, Liverpool School of Tropical Medicine (LSTM). The views and opinions

expressed are those of the authors and do not necessarily reflect those of Public Health

England or LSTM.

Competing interests’ statement

The following authors were members of the NW TB Cohort Audit Steering Group at the time

of the study: MW, PC, KD, SF, PMcM, CW, JW, SBS. They contributed to the study design

and the writing of the paper. However the interviewing and data analysis were the sole

responsibility of SW and KJ who were independent of all Cohort Audit processes. Otherwise

we have no conflicts of interest to declare.

INTRODUCTION

With pressure on the NHS to provide safe effective healthcare within a limited budget[1]

there is increasing interest in the ways that diverse multidisciplinary groups can work

together effectively.

Where infectious diseases such as tuberculosis are rare[2], issues can arise where public

health funds may be diverted to other purposes and clinicians may lack diagnostic skills or

knowledge of current treatment options.[3]

Tuberculosis predominantly affects vulnerable and hard to reach groups and requires the

coordination of multiple sectors and organisations for effective treatment, control and

prevention[4].

Tuberculosis cohort audit (TBCA; often called TB cohort review) was introduced across the

North West in 2012. TBCA has not previously been introduced across such a large and

socio-economically diverse area in the UK, nor has it undergone formal, qualitative

evaluation. There is increasing interest in TBCA as a means of improving patient safety,

Page 3 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



4

disseminating knowledge, facilitating the implementation of evidence-based practice and

improving staff morale. This paper aims to build a greater understanding of how TBCA in the

NW was perceived across a wide-geographic area dealing with a low incidence but high

consequence disease. Our findings will be of relevance to those interested in establishing

and supporting effective TBCA and in understanding some of the factors that contribute to

successful communities of practice in health care.

BACKGROUND

TBCA was first developed in Tanzania[5]. It was subsequently adapted for use in New York

during the 1990s, where it contributed to an increase in completion rates and a reduction in

TB and multi-drug-resistant (MDR) TB cases[6]. TBCA was first implemented in the UK in

North Central London (NCL) in 2010, and has been recommended in NICE guidance since

2012[7]. Evaluation of the London model of TBCA, where each area has a separate

process, found improvements in case management, contact tracing and identification of

service issues, but suggested that TBCA should be monitored after implementation[5].

The UK has one of the highest incidence rates of tuberculosis (TB) in Western Europe, with

particularly high rates mainly in metropolitan areas and linked to deprivation[8 9]. In the year

of this study (2014) London PHE Centre and West Midlands PHEC reported the highest TB

notification rates in the UK (30.1 per 100,000 and 13.7 per 100,000 [10]with a three-year

average number of TB case notifications (2012-14) for Birmingham of 35.2 per 100,000

population, and both cities run focussed, urban TBCA processes. Rates in parts ofthe North

West are lower at 9.1 per 100,000 in 2014 but the three-year average number of TB case

notifications (2012-14) for Manchester were 31.3 per 100,000 [10]TBCA was therefore

implemented in 2012 as a single, co-ordinated process across the whole range of rural,

urban and socio-economic contexts of the North West region[11].

TBCA process

As with other models of TBCA, the process engages key stakeholders in TB care and control

(nurses, doctors and public health staff) and in the North West (NW) is coordinated by a

steering group which has established a system of quarterly multi-disciplinary, cross-sector

meetings in four operational footprints: Cheshire & Merseyside (C&M), Cumbria &

Lancashire (C&L), North Manchester (NM) and South Manchester (SM), each covering both

urban and rural contexts and a number of NHS Trusts. Cases are identified by the TBCA Co-

ordinator from Enhanced Tuberculosis Surveillance (ETS) notifications during a three month

period ending six months before each TBCA meeting. TB nurse specialists complete a

bespoke, anonymised electronic data collection form for each case and present the

completed forms at each meeting. Challenges in case management, service strengths,

weaknesses and staff training needs are flagged for action at each meeting through the

steering group. Clinicians from outside the footprint act as chairs. Data are collated live by

Public Health England staff and results on outcome measures are fed back at the end of

each meeting[11].

TB nurse specialists are key to the process, and across this diverse range of rural, urban

and socio-economic contexts they are employed by a wide variety of employers on a variety

Page 4 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



5

of contract types ranging from full-time to part-time. For some, only a small percentage of

the workload is devoted to TB.

STUDY DESIGN

Study approach and data collection

The aim of this study was to explore and understand perceptions and experiences of TBCA

with three main stakeholder groups: TB nurse specialists, consultant physicians and public

health practitioners. A qualitative study design was chosen, enabling an in-depth exploration

of participants’ experiences from their own perspectives. The interpretivist epistemology

underpinning this study understands knowledge as subjective and prioritises the individual

meanings that participants assign to their own experiences, meanings which are

inaccessible through experimental methods.[12] Face-to-face, semi-structured interviews

were chosen as our primary data collection tool to enable flexible, in-depth exploration of the

issues. Interviews were conducted by SW, a researcher independent of TBCA. These

interviews were supplemented with additional key informant interviews with members of the

NW TBCA Steering Group.

Topic guides were developed for the interviews, based on discussion with the cohort audit

co-ordinator, steering group and a review of the existing literature. These were piloted and

refined in an iterative process throughout the study. Interviews were further triangulated by

observation undertaken by SW during TBCA meetings.

Sampling and participant recruitment

Twenty-eight participants were selected from the three groups using purposive sampling

among meeting participants across the four geographic ‘footprints’. For maximum variation,

both men and women were interviewed across a range of disciplinary backgrounds. Twenty-

six individuals were interviewed (one participant declined to take part and one was unable to

schedule time to be interviewed) in private rooms chosen by the participants. Numbers of

participants interviewed within the professional groups represented the proportions in which

they attend TBCA.

Ethics

Approval was obtained from the LSTM Research Ethics Committee (ref no 13.37). We

obtained informed consent prior to the start of the interviews, explaining the purpose of the

interview and interview process to participants, emphasising voluntary participation and

confidentiality. Interviews were audio recorded and supplemented with notes taken by the

researcher. Interviews were transcribed and saved in password protected files, with

transcripts sent to interviewees to affirm them as true records.

Analysis

The interview data were analysed using the Framework Approach, a matrix-based method to

classify and organise qualitative data[13]. Two researchers (SW and KJ) inductively

analysed the data, double coding the transcripts. Each main theme was charted within a

matrix of rows (individual cases) and columns (codes) with ‘cells’ of summarised data

providing a structure into which the data were systematically reduced. SW, KJ and SBS

discussed emergent concepts and agreed the main themes.

Page 5 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



6

RESULTS

Twenty-six interviews were conducted between 6th January and 14th March 2014 (see

Table 1) after 1,515 TB cases had been reviewed.

Table 1: Professional affiliation, geographical footprint of work and gender balance of

respondents

Group Profession Geographical Footprint of place of work Total Gender

ratio

North

Manchester

South

Manchester

Cumbria &

Lancashire

Cheshire &

Merseyside

M:F

a TB Nurse

Specialists

4 4 3 4 15 2:13

b Consultant

Physicians

2 2 1 2 7 6:1

c Public

Health

Practitioners

1 1 1 1 4 4:0

Responses were grouped into four main themes: Preconceptions, engagement with TBCA,

changes as a result of TBCA and perspectives for the future. Each theme is described in

detail below.

PRECONCEPTIONS: ‘WHAT DO YOU THINK IT’S GOING TO BE LIKE?’

Box 1 PRECONCEPTIONS ‘WHAT DO YOU THINK IT’S GOING TO BE LIKE?’

“Whenever you hear about things like that, you think 'Oh for goodness sake,' you know 'what more do they want us to do?' (ID8 female, group a-TB nurse specialist) “My concern was getting Trusts to accept it as a valuable or valid part of our work” (ID21 male, group a-TB nurse specialist) “I couldn't imagine how that's going to be useful or have an impact until I attended” (ID7 male, group b-Consultant physician) “[I thought] it was a perfect change agent for us” (ID10 female, group a-TB nurse specialist) “I was very pleased to see that there [would be a] multi-disciplinary forum” (ID25 male, group c Public health practitioner)

Page 6 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



7

As illustrated by quotes in Box 1 there were a number of preconceptions about TBCA

ranging from concerns about time for form-filling and anxiety about scrutiny to optimism

about its potential.

ENGAGEMENT WITH TBCA: ‘WHAT IS IT LIKE?’

Box 2 ENGAGEMENT WITH TBCA: ‘WHAT IS IT LIKE?’

Reasons for attendance/non-attendance

“It’s just become part of practice now, and I do appreciate it very much, what it offers” (ID9 female, group a-TB nurse specialist) “It wasn’t a witch hunt [the audit process]; it's about trying to get the outcome at the end of it” (ID6 female, group a-TB nurse specialist) “People say "Well, I did this," or "I did that,” and so you think, 'Oh, I might try that next time'.” (ID29 female, group a-TB nurse specialist) “You have to make your job pay [...] that's the difficult choice of whether you go to cohort review, which earns nothing — nothing [of] monetary value — but a heck of a lot in other ways.” (ID21 male, group a-TB nurse specialist) Changes in perspective on TBCA after attendance

“I have always thought they were beneficial and I still think they are beneficial; perhaps at the beginning I didn’t appreciate from a learning point of view how much.” (ID5 female, group a-TB nurse specialist) Presenting cases

“It was refreshing just to go through patients from all over the region and see the TB nurses presenting their patients, how much work they put in to achieving good outcomes” (ID34 male, group b-Consultant physician) “When they are going through the case you get more of an appreciation of what is actually going on and all these things obviously help when it comes to our outbreak support” (ID2 male, group c-Public health practitioner) Buy in from colleagues

“I’ve suggested my junior trainees and registrars come, this could help in their career progression.” (ID27 male, group b-Consultant physician) If you're going on your own and you've got nobody else there with you, supporting you, it's like; you [consultant physicians] don’t really care what we do” (ID6 female, group a-TB nurse specialist)

Page 7 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



8

Box 2 presents quotes relating to the theme of engagement with and experience of TBCA.

The TB nurse specialists interviewed had attended all or most of the audits. By contrast, half

of the consultant physicians had attended half of the audits and half had attended one audit

only. Public health practitioners’ attendance varied, with consultants in disease control

attending most or all audits in their region and epidemiologists/analysts attending fewer

audits.


Part time TB nurse specialists had more problems finding time for both preparation and actual attendance. Some TB nurse specialists felt that managers did not understand the importance of TBCA. Consultants more than TB nurse specialists cited time as an issue in their attendance and emphasised the importance of knowing dates in advance. Public health practitioners had the fewest problems in attending as their diaries were less constrained by clinical commitments. Changes in perspective on TBCA after attendance

Initial fears about preparation time, presenting and scrutiny of practice were not realised.

Those who had initially felt positive about the idea of audit actually found it surpassed their

expectations. Those who had seemed unsure about the content and purpose of cohort audit

before they attended felt it was a useful process.

Presenting cases

Early TBCA meetings were perceived as more formal and a change towards a more relaxed

and supportive atmosphere was noted over time. TB nurse specialists who worked in areas

of high prevalence were occasionally challenged by the number of cases they had to

present, but with practice, the presentation of simple cases had become routine. For

complicated cases however, TB nurse specialists found it more difficult deciding what to

include or leave out of their presentations. The Chair’s role was seen as crucial in

maintaining pace and pertinence. The most useful aspect of meetings was perceived to be

the discussion arising from cases. Discussion was perceived to take place less often when

fewer consultant physicians attended.

While public health practitioners said TBCA was important, some expressed mixed feelings

about the need for public health to participate in TBCA meetings, with some expressing

ambivalence about the clinical focus.

Buy in from colleagues

Attendance by consultant physicians was seen as important in changing and improving

practice: without their participation, TB nurse specialists felt unsupported. Both TB nurse

specialists and consultant physicians felt that public health attendance at TBCA was

important. Public health practitioners who did participate stated that they were still working

on strategies to encourage more colleagues to participate in TBCA meetings.

Page 8 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



9

CHANGES DUE TO NW TBCA: ‘WHAT HAS CHANGED?’

Perception of personal benefits and costs of attending TBCA

TB nurse specialists felt TBCA led to a wider understanding and appreciation of their role.

This, in turn, has increased motivation to improve outcomes.

Box 3 CHANGES DUE TO NW TBA: ‘WHAT HAS CHANGED?’


“It makes me think about what I am doing, the care I am giving, it makes me sure I tick those boxes but I also know why I am ticking them boxes and why it is important“(ID5 female, group a-TB nurse specialist) Perceived benefits/costs of TB audit to service/footprint

“It's been good to help push the Trust in the way that TB patients should be cared for - and how the service should be managed, I've been able to use it as leverage to say 'this is what's needed R because you're being watched now,'” (ID21 male, group a-TB nurse specialist) “If something’s presented at cohort which is not meeting an adequate standard then intervention will occur. It got picked up because of audit, it got highlighted because of audit, and action took place because of audit” (ID19 female, group a-TB nurse specialist) Community of practice

“It's sort of built this idea of collegiate working, you know that you want to work together, that you are colleagues and you can help each other out” (ID19 female, group a- TB nurse specialist) “It just builds bridges really, it's a lot easier free-flowing information and they’ll help us, and we’ll help them”.(ID10 female, group a- TB nurse specialist) “I think it’s developed into much more than just data collection, it’s ensuring that the patients are getting what the patient deserves, getting the treatment that is the right treatment, in a timely manner, with the best outcomes.” (ID1 male, group a-TB nurse specialist) Changes of Practice

“It's also about reminding people for the best investigations, for example thoracoscopy for pleural TB rather than just pleural aspirations so some of the improvement is documented and some of it isn't.”(ID32 male, group b- Consultant physician) “For the patients it means that their treatment has been gone through a recognised panel of people or a cohort of a panel which is quality assurance really” (ID3 male, group b-Consultant physician) “It’s sort of a reflective learning exercise for us and the TBNSs to see what could have been done better or what could have been done differently” (ID7 male, group b-Consultant physician) “There's a collective sort of ownership that, we as a group of people involved in TB control, public health, TB services (agree targets) and so they're meeting their own targets that we've all set, they're not meeting something that I, from outside have imposed on them, or even that their bosses have imposed on them” (ID13 male, Group c Public health practitioner)

Page 9 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



10

BOX 3 illustrates participants perceptions of changes resulting from TBCA, which was

described as providing support, reassurance and a place to ask questions which was

especially important for new members of staff, and especially for TB nurse specialists

working on their own in a service (some TB nurse specialists working in the community did

not regularly meet with consultant physicians). TB nurse specialists identified opportunities

for reflective practice and regular ring-fenced time together with peers as particular benefits.

Consultants enjoyed receiving feedback on their practice and felt more involved with TBCA

when their own patients were presented. Most consultants in areas of low prevalence

recognised the importance of TBCA in assessing their current practice. One doctor felt

frustrated that TBCA does not provide an arena for more in depth discussion which could

improve the service, even though TBCA was seen as educational and providing the ‘bigger

picture’.

Both TB nurse specialists and consultant physicians felt grateful for support from senior

colleagues at TBCA (including the chair) with complex cases or queries about practice, and

were reassured that the chair of the TBCA would address any issues that were potentially

putting patients at risk.

Public health practitioners felt that attendance at TBCA provided them with a stronger link to

clinical practice than existed previously as well as deeper intelligence about local

epidemiology.

Perceived benefits/costs of TB audit to service/footprint

TBCA was thought by all groups to provide learning about practices in areas with differing

resource availability and patient demographics which affect complexity and contact

screening decisions. This cross-learning also helped in using TBCA as evidence for change

with management at service or Trust level.

Community of practice

All the groups interviewed felt that the ‘community of practice’ for TB in the NW had

changed. Greater contact with the wider team created mutual respect between different

roles. Individuals felt more able to ask for help when required or to collaborate between

catchment areas to ensure better patient care. Public health practitioners explained that

previous attempts to link public health with TB teams had not been successful.

Changes in Practice

Several service changes were identified as a result of TBCA targets including increased HIV

testing and increased speed of notification to ETS (Enhanced Tuberculosis Surveillance).

TB nurse specialists felt that TBCA empowered them to question consultant physicians after

attending TBCA and found TBCA provided evidence to their managers of their performance.

They had all changed documentation procedures, describing the use of the TBCA form as a

checklist to ensure everything from diagnosis to discharge is managed correctly. There was

a perception of increased contact tracing activity.

Consultants generally described fewer changes to practice than TB nurse specialists and

viewed TBCA as a promising forum for quality improvement.

Page 10 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



11

Public health practitioners were less willing to attribute changes in practice to TBCA until

more evaluation has been done but did describe TBCA as creating more interest and a

higher profile for TB care. They noted that data quality and timeliness of reporting has

improved markedly as a result of TB nurse specialists’ effort and commitment. Like the

consultant physicians, they questioned whether lessons learnt were being adequately

collated and disseminated and thought data from TBCA will be a rich source for research

and national intelligence.

TBCA was not seen by any group as a ‘tick box’ or data collection exercise.

LOOKING AHEAD: ‘WHAT IF IT STOPPED?’

As illustrated by Box 4, all groups of participants wanted TBCA to continue and felt heavily

invested in the process.

When asked how they would feel if TBCA stopped, TB nurse specialists said it would be a

missed opportunity. The biggest impact was thought to be on new and isolated staff. Failure

Box 4 LOOKING AHEAD: WHAT IF IT STOPPED?’

“TB is a condition that can't just be looked at locally, it has to be looked at on a bigger picture, regionally, nationally and internationally, and they all feed into each other, and they're all interdependent of each other, and so to go back to just being in that one little pot you lose so much, we can't put a fence around [our area] and say ‘that's us done, on your way’ “(ID19 female, group a- TB nurse specialist) “[How would you feel if TBCA stopped?] “Gutted really” (ID5 female, group a-TB nurse specialist) “I feel like it's a safety net” (ID25 female, group a-TB nurse specialist) I think if the cohort review wasn't there, there is the possibility that it would slip and other things take over and patients slip through the net, 'cause it's human nature, it will happen; I think cohort review keeps us on track and I think it really has a direct impact on patient safety (ID10 female, group a- TB nurse specialist) “I think it would be a disaster” (ID7 male, group b-Consultant physician) “The consequences of getting TB care wrong are so high - even in costs terms alone - not to mention the impact on the patient of course, but the cost of treating someone for MDR TB for example are so much higher than a case of standard TB that we just can't afford not to do things properly, and if the cohort review is what it takes then I'm sure that's a highly cost effective way of preventing even a single case of MDR TB in a year, and that, you know that would more than pay for the costs of the meeting and the administration and everything” (ID32 male, group b-Consultant physician ) “ If cohort review becomes part and parcel and owned by, if you like, the local health economy, that ownership I think makes it possibly more likely that it will feed into commissioning” (ID13 male, Group c Public health practitioner)

Page 11 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



12

to continue with TBCA in the NW was seen as a short sighted and backwards step which

would probably reduce patient safety and quality of care.

Consultants noted it was ‘still early days’ and that TBCA was only really now getting properly

established. It was considered too soon to be sure of the difference it was making, but that,

as it stands, loss of TBCA would be a loss to the North West and that without TBCA, more

mistakes would be made.

Public health practitioners thought that more evaluation needed to be done before the

impact of TBCA could be assessed. They felt that keeping a NW structure is important but

that there needed to be a mechanism to feed data into wider service improvement and

commissioning pathways.

Key Informants

Results of the eight interviews with key informants (Box 5) were compared with the results

from the three main respondent groups as a method of validation. The key informants

differed from the main respondents in that they had more in-depth understanding of the

context and process of TBCA because of their participation in the TBCA Steering Group

and/or their experience of chairing TBCA meetings.

Key informants corroborated the views of other groups. There was optimism about the

potential of TBCA to improve care in the North West, especially in areas of lower incidence

where it was felt care may be less effective. There was concern about the practicalities and

about the extent to which consultant physicians would continue to engage in the process.

Key informants described the setting up of TBCA as a systematic and strategic process that

involved the establishment of a steering group, a detailed engagement strategy, and

appointment of a dedicated co-ordinator; these were felt to be critical to the perceived

success of the NW TBCA.

TBCA was thought to be a good way to look at workforce generally across a footprint and to

understand the difficulties facing a diverse workforce. The geographical isolation of some TB

nurse specialists in the North West made TBCA more relevant and important.

Box 5 KEY INFORMANTS

“You’re saving lives, you can really see that you've influenced practice; it's incredible to see. I just think it's really powerful, it's really rare in public health to see such improvement so quickly” (ID31 female Key informant) There have been specific instances where it's made a radical change to the way a patient’s been treated. And then there's been a more collective changes, [for example] if you look at treatment completion rates “(ID24 male, key informant) “The biggest failing is that we haven't been able to do the reporting structure ;”( ID31, female, key informant)

Page 12 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



13

TBCA was described as an innovative system similar to the new field of sector-led-

improvement[14] and that it is the increased sense of community of practice which has been

the most surprising and potentially the most important improvement from TBCA.

Realising the true potential of TBCA in the North West will be dependent on securing funding

into the long term. Participants strongly suggested that if TBCA is discontinued, it would be

difficult or impossible to start up again and that serious financial and patient risk issues could

result.

DISCUSSION

Summary of key findings

Our study is the first to evaluate the implementation of TBCA using qualitative methods to

explore attendees’ perceptions of the impact of TBCA and also the first to evaluate

implementation of TBCA over a large geographic area in the UK. The key finding was a

description of collaborative working and the development of a community of practice with a

common purpose. Tuberculosis services across the UK have reported weaknesses in

communication between sectors with fewer than half of TB services having local

arrangements to work with local authorities and social care services[15]. Lack of

communication and collaboration in healthcare teams has negative effects on patient

outcomes with failure of communication being the primary cause for the majority of errors[16]

and outbreaks of TB have been shown to frequently originate from clinical mistakes in

diagnosing and treating TB[17]. Reducing the burden of TB in the UK requires the co-

ordinated action of many partners, working together across local authority and NHS

boundaries[18].

Communities of practice have been described as 'groups of people who share a concern, a

set of problems, or a passion about a topic, and who deepen their knowledge and expertise

in this area by interacting on an ongoing basis'[19]. They have been found to break down

professional, geographical and organisational barriers, reduce professional isolation and

facilitate the implementation of new processes and technology. Significant improvements in

the delivery of healthcare and patient experience have been found when clinicians work

across the patient pathway and span organisational boundaries[20] therefore the

demonstration of an effective and robust community of practice originating from attendance

at the NW TBCA is a significant finding.

TB nurse specialists in this study came from a wide variety of working patterns and many

were in under-resourced teams. Nonetheless, they described how they felt increased

acknowledgement of their practice, and they experienced support and reassurance which

increased their morale. TBCA was felt to be especially important for those nurses who did

not work in a TB team, both to raise morale and improve standards. Empowerment as a

result of closer linkage to colleagues both across footprints and between sectors was

described in this study and has previously been shown to improve job satisfaction and

patient outcomes[21].

Page 13 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



14

Clinicians saw TBCA primarily as a way of preventing mistakes and improving individual

practice. Contemporary data looking at avoidable harm demonstrate that NHS staff do not

speak out often enough and that this can be rectified[22].

Public health practitioners were able to attend TBCA but some found the clinical focus off-

putting (although this contradicted the value they placed on TBCA as a link to clinical

practice). This may have led to some disengagement[23]. Successful involvement of multiple

professional groups requires understanding of clear shared purpose and processes[24] and

this will require more contribution from the public health perspective[25].

Participant experiences of TBCA made it clear that the voices and opinions of all attendees,

irrespective of role or experience are actively encouraged and valued which is one

component of successful improvement collaboratives.[26]

Interviews with key informants detailed meticulous planning by the steering group which

ensured key players were involved from the beginning, and many individuals within the

participant groups expressed they had subsequently encouraged colleagues to attend,

taking it upon themselves to champion change. Other participants described a process of

engagement which was facilitated by encouragement from these ‘local change champions’

whose importance has been cited elsewhere[27].The emphasis by TBCA leaders (Chairs

and Steering Group) on inclusiveness may have been a key factor in promoting the

‘psychological safety’ of participants in cross-disciplinary engagement[28].

Weaknesses within TBCA described by study participants included the lack of planned on-

going funding for what needs to be a long term process. At the time of data analysis, the lack

of a report for outside dissemination on the TBCA’s outcomes was seen as a failing by

participants, affecting on-going issues with engagement and funding. A report on outcomes

has since been published[29]. The delay in producing a report was due to lack of

infrastructure and funding to provide technical assistance and analysis to TBCA. Initiatives

like TBCA that span geographical and disciplinary boundaries need background resources

and structure to facilitate and embed improved integration of services[30].

Strengths and weaknesses of the study

Although the effectiveness of TBCA had previously been evaluated using quantitative

methods analysing clinical outcomes of TB treatment, no studies have been written looking

at contextual factors in the successful implementation and maintenance of TBCA or looking

at participant experience. The use of in depth one-to-one interviews allowed us to explore a

complex process by examining the perceptions and shared experiences of TBCA[31].

Our dataset included a large and extensive number of stakeholders from the three main

cadres who participate in TBCA, across four geographic footprints, purposely sampled to

attain a wide range of disciplines and working practices. Data analysis found recurrent

themes that indicated saturation[32], especially within the TB nurse specialist profession.

Triangulation through observation at TBCA and interviews with key informants was used to

ensure a deeper understanding of the experience and process of TBCA, to feed into

interview topic guides, inform analysis of participant interviews and elicit data relating to the

implementation of the NW TBCA.

Page 14 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



15

The themes evolving from framework analysis of the data were further validated[33] by the

use of two researchers to double code the transcripts and discussion with a further author on

emergent themes.

Limitations of this study are the comparatively smaller dataset from the consultant physician

and public health practitioner professions which means that there may be important

perceptions of TBCA within these groups that were missed.

The unique geographic configuration and implementation of the NW TBCA may mean that

the findings are not easily transferred to other areas without careful adaptation.

Comparison with other data

Our findings support those of the report on staff experience of the North Central London

(NCL) TB Service TBCA in 2010 from an online questionnaire[5]. In agreement with our

findings, staff at NCL felt TBCA identified gaps in services and training needs, and a majority

felt their working practice had changed due to attendance at TBCA (mainly through an

increased focus on contact tracing and improved documentation).

Implications of our findings

Linking in to commissioning can provide an opportunity to move the agenda from identifying

whole service problems, to solving them. PHE’s new TB Strategy[18] promotes a

coordinated approach to TB, involving NHS commissioners, providers, local government and

PHE through TB Control Boards which should be harnessed to sustain TBCA in the North

West.

The fact that TBCA resulted in collaborative working and the development of a community of

practice with a common purpose is a significant finding and suggests that the NW model of

TBCA can be an important means of quality improvement in similar contexts.[34]

Conclusion

The Northwest TBCA model has enabled cross-sectoral collaboration and the establishment

of a community of practice which has facilitated a culture of shared experience, open

communication, respect and appreciation. This community of practice is vital as a tool for

continued quality improvement in TB control.

The paper demonstrates what works to create a powerful and robust community of practice

across multiple professions and across a wide geographical area. It can therefore can inform

the establishment of effective TB cohort audits across the new TB Control Board footprints

(as established by PHE’s new TB Strategy).

Acknowledgements

We thank all those who took part in this work and especially those who set aside time to

participate in the in-depth interviews.

Page 15 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



16

Abbreviations

ETS Enhanced tuberculosis surveillance

MDR TB Multi-drug resistant tuberculosis

TB Tuberculosis

TBCA Tuberculosis Cohort Audit

-Authors’ contributions

The study was conceived and designed by SBS and KD with support from MW, PC, SF,

PMcM, CW and JW. The protocol was finalised by SW who collected all the data. Analysis

was conducted by SW and KJ. SW led the writing guided by KJ and SBS, with additional

comments from the remaining authors. All authors read and approved the final manuscript.

Data Sharing Statement

No additional data available

REFERENCES

1. England N. Five year forward view. London: HM Government 2014 2. Belay ED, Monroe SS. Low-incidence, high-consequence pathogens. Emerging infectious

diseases 2014;20(2):319 3. Jereb J. Progressing toward tuberculosis elimination in low-incidence areas of the United

States. Morb Mortal Wkly Rep 2002;51:1-16 4. Lönnroth K, Migliori GB, Abubakar I, et al. Towards tuberculosis elimination: an action

framework for low-incidence countries. European Respiratory Journal 2015;45(4):928-52

5. Anderson C, White J, Dart S, et al. Evaluation of the implementation of cohort review by North Central London TB Service: Health Protection Agency, 2011.

6. Munsiff S, Ahuja S, King L, et al. Ensuring accountability: the contribution of the cohort review method to tuberculosis control in New York City. The International Journal of Tuberculosis and Lung Disease 2006;10(10):1133-39

7. Identifying N. managing tuberculosis among hard-to-reach groups (PH 37). London, UK: NICE 2012

8. England PH. Tuberculosis in the UK: 2014 report. Public Health England: London 2014 9. Ploubidis GB, Palmer MJ, Blackmore C, et al. Social determinants of tuberculosis in

Europe: a prospective ecological study. European Respiratory Journal 2012;40(4):925-30

10. England PH. Tuberculosis in England: 2015 report. 2015 11. Summit TT. North West TB Regional Audit - Cohort Review Handbook. 2013 12. Green J, Thorogood N. Qualitative methods for health research: Sage, 2013. 13. Gale NK, Heath G, Cameron E, et al. Using the framework method for the analysis of

qualitative data in multi-disciplinary health research. BMC medical research methodology 2013;13(1):117

Page 16 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



17

14. Holmes D, Brookes C. Sector-led improvement in children's services: a lever for evidence-informed practice? Evidence & Policy: A Journal of Research, Debate and Practice 2014;10(4):513-25

15. Abubakar I, Lipman M, Anderson C, et al. Tuberculosis in the UK—time to regain control. BMJ 2011;343:d4281

16. Arnaudova A. Eighth Futures Forum: On Governance of Patient Safety: World Health Organization, 2005.

17. van der Werf MJ, Blasi F, Giesecke J, et al. Lessons learnt in Europe on tuberculosis surveillance, outbreaks and BCG vaccination in 2011. European Respiratory Journal 2013;41(4):767-71

18. England PH. Collaborative tuberculosis strategy for England: 2015–20. 2015 19. Wenger E, McDermott RA, Snyder W. Cultivating communities of practice: A guide to

managing knowledge: Harvard Business Press, 2002. 20. Woodard F, Weller G. An action research study of clinical leadership, engagement and

team effectiveness in working across NHS boundaries. Work Based Learning e-Journal 2011;1(2):80-119

21. Hughes R. Chapter 2. Nurses at the ‘Sharp End’ of patient care in Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AORN Journal 2009;90(4):1-30

22. Reid J. Speaking up: a professional imperative. Journal of perioperative practice 2013;23(5):114-18

23. Martin-Misener R, Valaitis R, Wong ST, et al. A scoping literature review of collaboration between primary care and public health. Primary health care research & development 2012;13(04):327-46

24. Raine R, Xanthopoulou P, Wallace I, et al. Determinants of treatment plan implementation in multidisciplinary team meetings for patients with chronic diseases: a mixed-methods study. BMJ quality & safety 2014:bmjqs-2014-002818

25. Santana C, Curry LA, Nembhard IM, et al. Behaviors of successful interdisciplinary hospital quality improvement teams. Journal of Hospital Medicine 2011;6(9):501-06

26. Hulscher ME, Schouten LM, Grol RP, et al. Determinants of success of quality improvement collaboratives: what does the literature show? BMJ quality & safety 2013;22(1):19-31

27. Kirchner JE, Parker LE, Bonner LM, et al. Roles of managers, frontline staff and local champions, in implementing quality improvement: stakeholders' perspectives. Journal of evaluation in clinical practice 2012;18(1):63-69

28. Nembhard IM, Edmondson AC. Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior 2006;27(7):941-66

29. Group NWTCAS. NORTH WEST TB COHORT AUDIT

2014 REPORT. 2014 30. Nasir L, Robert G, Fischer MD, et al. Facilitating knowledge exchange between health-

care sectors, organisations and professions: A longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality. Health Service Delivery Research 2013;1(7)

31. DiCicco‐Bloom B, Crabtree BF. The qualitative research interview. Medical education

2006;40(4):314-21 32. Ritchie J, Lewis J, Elam G. Designing and selecting samples. Qualitative research

practice: A guide for social science students and researchers 2003;2:111-45 33. Jonsen K, Jehn KA. Using triangulation to validate themes in qualitative studies.

Qualitative Research in Organizations and Management: An International Journal 2009;4(2):123-50

34. Urquhart R, Cornelissen E, Lal S, et al. A community of practice for knowledge translation trainees: an innovative approach for learning and collaboration. Journal of Continuing Education in the Health Professions 2013;33(4):274-81

Page 17 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



18

Page 18 of 18


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from




Journal: BMJ Open

Manuscript ID bmjopen-2015-010536.R1


Date Submitted by the Author: 27-Jan-2016


Wake, Carolyn; Public Health England Walker, Jenny; NHS Liverpool Community Health Sloan, Derek; Liverpool school of tropical medicine, International health; Liverpool Heart and Chest Hospital NHS Trust Squire, Bertie; Liverpool school of tropical medicine, Centre for Applied Health Research and Delivery & Department of Clinical Sciences; Royal Liverpool Hospital, Respiratory Medicine




Keywords:

Clinical audit < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES, HEALTH SERVICES ADMINISTRATION & MANAGEMENT, PUBLIC HEALTH, QUALITATIVE RESEARCH, THORACIC MEDICINE


BMJ Open on F


http://bmjopen.bm

j.com/

BM


jopen-2015-010536 on 16 March 2016. D

ownloaded from



1




Dr Paul Cleary Consultant Epidemiologist Field Epidemiology Service Public Health England 5th Floor Rail House Lord Nelson Street Liverpool L1 1JF Katie Dee, Deputy Director, Public Health England, Cheshire and Merseyside Centre 5th Floor Rail House Lord Nelson Street Liverpool L1 1JF Stacey Farrow TB Nurse Specialist

NHS Bolton Dr Paddy McMaster Consultant in Paediatric Infectious Diseases North Manchester General Hospital Limbert House Manchester M8 5RB Carolyn Wake NW TB Coordinator Public Health England Greater Manchester Jenny Walker TB Specialist Nurse NHS Liverpool Community Health Abercromby Health Centre Grove Street Liverpool L7 7HG Dr Derek Sloan Senior Lecturer and Consultant Physician Department of Clinical Sciences, Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA UK Prof S B Squire Centre for Applied Health Research and Delivery & Department of Clinical Sciences, Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA UK

Key words: Tuberculosis, Cohort audit, Community of practice Word Count: 5192 No of Tables: 2 Number of references: 54

Page 1 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



2




Wake 4, J Walker7, D. Sloan1,8, S.B. Squire1,9





4. Public Health England

5. Bolton NHS Trust


7. Liverpool Community Health Trust 8. Liverpool Heart and Chest Hospital

9. Royal Liverpool University Hospital

ABSTRACT

Objectives Tuberculosis cohort audit (TBCA), was introduced across the North West (NW)

of England in 2012 as an on-going, multidisciplinary, systematic case review process,

designed to improve clinical and public health practice. TBCA has not previously been

introduced across such a large and socio-economically diverse area in England, nor has it


experiences of the process after 1,515 cases had been reviewed.

Design Qualitative study using semi-structured interviews. Respondents were purposively

sampled from three groups involved in the NW TBCA: (a) TB nurse specialists; (b)

consultant physicians, and (c) public health practitioners. Data from the 26 respondents were


through observation of TBCA meetings.







from public health professionals, nurses and clinicians; all groups want it to continue. TBCA

is regarded as a tool for quality improvement that improves patient safety.

Conclusions TBCA provides peer support and learning for management of a relatively rare,

but important infectious disease through discussion in a no-blame atmosphere. It is seen as

an effective quality improvement strategy which enhances TB care, control, and patient

safety. Continuing success will require increased engagement of consultant physicians and

public health practitioners, a secure and on-going funding stream and establishment of clear

reporting mechanisms within the public health system.

Page 2 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



3

ARTICLE SUMMARY


• This study is the first to formally evaluate the perceptions of participants at TB cohort audit (TBCA)

• Our qualitative dataset included a large and extensive number of stakeholders from three main cadres that participate in TBCA.

• The unique geographic configuration and implementation of the NW TBCA may mean that the findings are not easily transferred to other areas without careful adaptation.

INTRODUCTION

Growing pressure on the National Health Service (NHS) to provide safe effective healthcare

within a limited budget [1] has focussed attention on ways to promote efficient working of

diverse multidisciplinary groups.

Where infectious diseases such as tuberculosis are rare,[2] issues can arise where public


knowledge of current treatment options.[3] Countries with a low incidence of TB need to

ensure they have continuing and adequate vigilance systems to detect and treat TB cases

and thereby prevent transmission.[4]



prevention.[4]


North West of the UK in 2012. TBCA has not previously been introduced across such a large

and socio-economically diverse area in the UK, nor has it undergone formal, qualitative



improving staff morale.[5 6]

In order for health services to be effective and translate into meaningful patient care

outcomes it is necessary to evaluate not only summative but also formative outcomes to

assess if, how and why implementation is effective in a specific setting. Individual beliefs

govern behaviour change and ultimately determine whether there is engagement with

change initiatives.[7]

This paper aims to build a greater understanding of how TBCA in the NW was perceived by

groups of differing health professionals, across a wide-geographic area, dealing with a low

incidence but high consequence disease. Our findings will be of relevance to those

interested in establishing and supporting effective TBCA and in understanding some of the

factors that contribute to successful communities of practice in health care.

BACKGROUND

TBCA was first developed in Tanzania in the 1990’s and rapidly became an integral part of

the international tuberculosis control effort.[8]It was subsequently adapted for use in New

Page 3 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



4

York during the 1990s, where it contributed to an increase in completion rates and a

reduction in TB and multi-drug-resistant (MDR) TB cases.[9] TBCA was first implemented in

the UK in North Central London (NCL) in 2010, and has been recommended in NICE

guidance since 2012.[10] Evaluation of the London model of TBCA, where each area has a

separate process, found improvements in case management, contact tracing and

identification of service issues, but suggested that TBCA should be monitored after

implementation.[11]


particularly high rates in metropolitan areas and linked to deprivation.[12 13] In the year of

this study (2014), London PHE Centre and West Midlands PHE Centre reported the highest

TB notification rates in the UK (30.1 per 100,000 and 13.7 per 100,000), [14]. Both cities run

focussed, urban, TBCA processes. The average rate across the North West was low at 9.1

per 100,000 but urban Manchester’s notification rate was 31.3 per 100,000 (three year

average annual rate 2012-2014).[14]

Due to these pockets of high incidence of TB in the NW, TBCA was implemented (in line

with international and national best practice[8 10 15]) in 2012 as a single, co-ordinated

process across the whole range of rural, urban and socio-economic contexts of the

region.[16] Objectives of the NW TBCA relate to case management and TB control but also

include provision of ongoing training and education for staff and provision of a forum for

open discussion.[17]

STUDY DESIGN

Context of the health care system

Tuberculosis care in the UK is co-ordinated by lead TB consultant physicians who work

within secondary care hospital and community trusts which are part of the NHS. This is a

system of universal free health care funded through taxation. Once TB is confirmed, TB

treatment is initiated either in the community or in hospital, depending on the clinical severity

or complexity of each case. Once stabilised, patients are supported in the community by TB

nurse specialists. Each case undergoes a standardised risk assessment and direct

observation of therapy is reserved for the most complex cases.

TBCA process and costs


(nurses, doctors and public health staff). The budget lines of TBCA in the model described

here have been identified, but not yet formally costed. They include the salary of an 80%

FTE co-ordinator, the hire of meeting venues, the purchase of refreshments and the travel

costs of TBCA Chairs (see below). There are also travel costs for the meetings of the TBCA

Steering Group which established, and continues to monitor and develop the system of

quarterly multi-disciplinary meetings in four operational footprints: Cheshire & Merseyside,

Cumbria & Lancashire, North Manchester and South Manchester, each covering both urban

and rural contexts and a number of NHS Trusts. The time devoted to preparation of cases

and participants’ time in meetings are regarded as part of service delivery and quality

assurance.

Page 4 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



5

Cases are identified by the TBCA Co-ordinator from Enhanced Tuberculosis Surveillance

(ETS) notifications during a three month period ending six months before each TBCA

meeting. TB nurse specialists complete a bespoke, anonymised electronic data collection

form for each case and present the completed forms at each meeting.

TBCA meetings are chaired by clinicians (some now co-chaired by TB nurse specialists)

from outside the footprint represented in a given meeting. The chairperson opens the

meeting with introductory slides outlining results of programme performance from all four

operational footprints against 10 pre-specified outcome measures.[18] TB nurses then

present the cases. During and after each case key data are checked and corrected.

Challenges in case management, service strengths, weaknesses and staff training needs

emerge from the discussion that surrounds each case and are flagged for action through the

steering group by the Chair. Data are collated live by Public Health England staff and results

on outcome measures are fed back at the end of each meeting.[14] Thus TBCA differs from

conventional multi-disciplinary case conferences in that all cases are discussed

retrospectively with a public health focus on a pre-specified set of outcome measures rather

than a focus on solving individual case management problems for selected, difficult cases.

TB nurse specialists are key to the process; across the NW they have a wide variety of

employers and contract types ranging from full-time to part-time. For some, only a small

percentage of the workload is devoted to TB.


TBCA is considered a complex intervention and it is recognised that evaluations of this type

of initiative should include qualitative design to enable in-depth exploration of participants’

experiences from their own perspectives.[19] The aim of this study was therefore to

qualitatively explore and understand perceptions and experiences of TBCA with three main

stakeholder groups: TB nurse specialists, consultant physicians and public health

practitioners. The epistemology underpinning the study is interpretivist, understanding

knowledge as subjective and prioritising the individual meanings participants assign to their

own experiences, knowledge that is inaccessible through experimental methods.[20 21]

Face-to-face, semi-structured interviews were considered the most suitable primary data

collection tool to access this knowledge and to enable flexible, in-depth exploration of the

issues.[22] Interviews were conducted by SW, a public health researcher trained in

qualitative research, independent of TBCA. These interviews were supplemented with

additional key informant interviews with members of the NW TBCA Steering Group.

Interviews for this study took place in Jan-Mar 2014 (approx. two years after TBCA was

implemented in the region and after 1,515 TB cases had been reviewed). Topic guides were

developed for the interviews, based on discussion with the cohort audit co-ordinator, steering

group and a review of the existing literature. These were piloted and refined in an iterative

process throughout the study. Interviews were further triangulated by observation

undertaken by SW during TBCA meetings.[23]

The study is presented in line with the Consolidated Criteria for Reporting Qualitative

Research (COREQ)[24] (see online supplement file A).


Page 5 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



6

Maximum variation purposive sampling was used to select potential staff participants and

gain perspectives from a broad range of representative healthcare professionals.[25]

Sampling was intended to include: gender balance; professionals working in high and low

incidence areas; mix of professional roles and working patterns; mix of regular and less

regular attendance at cohort. On the contact list for the TBCA there are approximately 125

clinicians (92M/33F) , 49 nurses (3M/46F), 43 other – PHE leads, Epidemiologists, LA leads,

PH leads, Admin, other TB leads (12M/31F).

The larger share of female nurses and male consultants in the sample reflects national

recruitment patterns to these professions nationally.[26] Twenty-eight participants were

originally selected from the three groups across the four geographic ‘footprints’ and

contacted by the researcher by email. Twenty-six individuals were interviewed (one

participant declined to take part and one was unable to schedule time to be interviewed) in

private rooms chosen by the participants. Numbers of participants interviewed within the

professional groups represented the proportions in which they attend TBCA. Duration of the

interviews were approximately one hour, audio recorded and supplemented with notes taken

by the researcher.

Key informants were individuals with a strategic in-depth knowledge of TBCA[27] who were

instrumental in running of TBCA – (Chairs, epidemiologists/ PHE TB leads, steering group

members) and were purposively sampled from across the four geographic sub-footprints.

Eight participants were selected, two from each footprint.

Ethical procedure

Approval was obtained from the LSTM Research Ethics Committee (ref no 13.37). No risks

to interviewees were anticipated from participation in the study. We obtained informed

consent prior to the start of the interviews, explaining the purpose of the interview and

interview process to participants, emphasising voluntary participation and confidentiality.

Interviews were transcribed and saved in password protected files, with transcripts sent to

interviewees to affirm them as true records.

Analysis

As the aim was to explore and understand perceptions and experiences of TBCA from a

wide range of stakeholders, thematic qualitative analysis was considered the most

appropriate means by which to identify areas of commonality and difference across the data.

In particular, the Framework approach to thematic analysis–a systematic, matrix-based

method to classify and organise qualitative data–was chosen as the specific thematic

approach.[28] The transparency of Framework’s analytical method and its step-by-step

approach was considered most suitable to an interdisciplinary team and to a policy-oriented

study hoping to inform practice. Two researchers (SW and KJ) inductively analysed the data,

double coding the transcripts. Each main theme was charted within a matrix of rows

(individual cases) and columns (codes) with ‘cells’ of summarised data providing a structure

into which the data were systematically reduced. SW, KJ and SBS discussed emergent

concepts and agreed the main themes. An example of the analysis process is provided in

the appendix.

RESULTS

Page 6 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



7




respondents


ratio

North

Manchester

South

Manchester

Cumbria &

Lancashire

Cheshire &

Merseyside

M:F

a TB Nurse

Specialists

4 4 3 4 15 2:13

b Consultant

Physicians

2 2 1 2 7 6:1

c Public Health

Practitioners

1 1 1 1 4 4:0

d Key

Informants

2 2 2 2 8 6:2


changes as a result of TBCA and perspectives for the future. Illustrative quotes for the key

themes are presented in Table 2.

Page 7 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



8

Table 2: Key themes, findings interpreted and illustrative quotes

Themes Findings Illustrative quotes

Preconceptions Views varied widely. Negative

views were mainly concerns about

time and scrutiny of practice

(relating to individuals)

“Whenever you hear about things like that, you think 'Oh for goodness sake,' you know 'what more do

they want us to do?' (ID8 TB nurse specialist)

“My concern was getting Trusts to accept it as a valuable or valid part of our work” (ID21 TB nurse

specialist)

“I couldn't imagine how that's going to be useful or have an impact until I attended” (ID7 Consultant

physician)

Positive views expressed optimism

about the potential to improve

practice and outcomes

“[I thought] it was a perfect change agent for us” (ID10 TB nurse specialist)

“I was very pleased to see that there [would be a] multi-disciplinary forum” (ID25 Public health

practitioner)

Engagement

with TBCA

Participants listed a number of

reasons for their attendance/non-

attendance at TBCA. Participants

found that attendance brought

them a sense of community and

enlarged their sphere of influence

and support

“It’s just become part of practice now, and I do appreciate it very much, what it offers” (ID9 TB nurse

specialist)

“It wasn’t a witch hunt [the audit process]; it's about trying to get the outcome at the end of it” (ID6 TB

nurse specialist)

“People say "Well, I did this," or "I did that,” and so you think, 'Oh, I might try that next time'.” (ID29 TB

nurse specialist)

"Sometimes you feel a little bit isolated and I think this helps with the isolation” (ID25 TB nurse

specialist)

“You have to make your job pay [...] that's the difficult choice of whether you go to cohort review, which

earns nothing — nothing [of] monetary value — but a heck of a lot in other ways.”

(ID21 TB nurse specialist)

Page 8 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960

on February 13, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2015-010536 on 16 March 2016. Downloaded from



9


There were changes in participants

perspective on TBCA after

attendance, mainly due to a

reassessment of the value of

attendance; many expressed that

their fears prior to attendance were

unjustified

“I have always thought they were beneficial and I still think they are beneficial; perhaps at the beginning I

didn’t appreciate from a learning point of view how much.” (ID5 TB nurse specialist)

"I was looking forward to the next one from a point of view of you know professional practice, it's very

stimulating” (ID11 Public health practitioner)

Participants conveyed a range of

experiences of attending audit and

presenting cases. Over time people

became more confident and

relaxed. Consultants felt engaged

when their patients were

presented

“It was refreshing just to go through patients from all over the region and see the TB nurses presenting

their patients, how much work they put in to achieving good outcomes”

(ID34 male, Consultant physician)

"Sometimes it becomes a little bit tiring and stressful when you don't have anything to highlight during

them" (ID7 Consultant physician)

“When they are going through the case you get more of an appreciation of what is actually going on and

all these things obviously help when it comes to our outbreak support”

(ID2 male, Public health practitioner)

“No matter how much you know it's not about judging you personally, when you first start to come that

is how it feels and there are still times that you would sit there or a colleague would say “I don’t want to

present this one I'm not happy with it,” and but, you just get on, your grit your teeth, and actually when

that's happened to me — I felt supported at the end of it”(ID19 TB nurse specialist)

"We are all a bit more relaxed in presenting our cases” (ID5 TB nurse specialist)

"The more you go the less threatening it becomes" (ID21 TB nurse specialist)

Page 9 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




10


When discussing whether

participants felt they had buy in to

TBCA from colleagues

“I’ve suggested my junior trainees and registrars come, this could help in their career progression.” (ID27

Consultant physician)

If you're going on your own and you've got nobody else there with you, supporting you, it's like; you

[consultant physicians] don’t really care what we do” (ID6 TB nurse specialist)

"“Our Consultant says that TB comprises of about 5% of his total workload, so in the scheme of things it's

not a huge priority, you know he’s sort of balancing it with obviously his cancer patients and

bronchoscopy lists, everything else, so I don’t really feel he intends to come” (ID23 nurse specialist)

“I think they do need to have quite a good input into public health, because obviously TB you know it has

implications on public health and especially if there's been sort of an outbreak situation"(ID12 TB nurse

specialist)

Changes

attributed to

NW TBCA

Personal benefits and costs to

individuals of attending TBCA

related to communication

community and learning

“It makes me think about what I am doing, the care I am giving, it makes me sure I tick those boxes but I

also know why I am ticking them boxes and why it is important“(ID5 TB nurse specialist)

"It does make people a bit more aware of the extent of the difficulty of doing our work “(ID8 TB nurse

specialist)

"It's good to talk about your ideas with some of the Consultants that you don’t work with directly" (ID14

TB nurse specialist)

“You think your patients are all doing well then you go to a TB cohort review and [see that] actually 25%

of patients with TB in this area died, and you think ‘ah … I didn’t … really appreciate that, I've seen a

couple die, but I didn’t know … the big picture” (ID34 Consultant physician)

"Now it's my own patients it's much more interesting, and actually getting feedback on the things that I

should have done or shouldn't have done, is even more helpful. I love it, they are very interesting" (ID32


Individuals perceived a range of

benefits and costs of TBCA to

service/footprint. Some felt

empowered to use the TBCA

outcomes and data to make service

changes. TBCA was seen to reduce

“It's been good to help push the Trust in the way that TB patients should be cared for - and how the

service should be managed, I've been able to use it as leverage to say 'this is what's needed … because

you're being watched now,'” (ID21 male TB nurse specialist)

“If something’s presented at cohort which is not meeting an adequate standard then intervention will

occur. It got picked up because of audit, it got highlighted because of audit, and action took place

Page 10 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




11


risk to patients and practitioners,

act as a source of support and

advice when cases are complicated

(especially in low incidence areas

and for lone workers)

because of audit” (ID19 female TB nurse specialist)

“You can raise issues and challenge, in a positive way, management of patients in different areas. The

only problem is that the people who, really need to be listening are not coming”(ID34 Consultant

physician)

“The worst thing in the world is for there to be a disconnect between policy-makers, strategists, public

health and clinical services, that's disastrous” (ID13 Public health practitioner)

“The way that funding is obtained for TB control now is, has to be kind of negotiated locally now, so we

need this information to feedback to Commissioners so that they understand the burden of disease and

the particular issues the need for perhaps additional workforce” (ID26 Public health practitioner)

As mentioned in previous findings,

participants described an overall

picture of a new community of

practice which developed through

attendance at TBCA

“It's sort of built this idea of collegiate working, you know that you want to work together, that you are

colleagues and you can help each other out” (ID19 TB nurse specialist)

“It just builds bridges really, it's a lot easier free-flowing information and they’ll help us, and we’ll help

them”.(ID10 TB nurse specialist)

“I think it’s developed into much more than just data collection, it’s ensuring that the patients are getting

what the patient deserves, getting the treatment that is the right treatment, in a timely manner, with the

best outcomes.” (ID1 TB nurse specialist)

Individuals listed numerous

changes of practice they attributed

to attendance at TBCA, from their

individual practice to service

changes, including a renewed

sense of co-working to improve

outcomes and an appreciation of

the bigger picture and complexity

of TB care and control in the region

“It's also about reminding people for the best investigations, for example thoracoscopy for pleural TB

rather than just pleural aspirations so some of the improvement is documented and some of it

isn't.”(ID32 Consultant physician)

“For the patients it means that their treatment has been gone through a recognised panel of people or a

cohort of a panel which is quality assurance really” (ID3 Consultant physician)

“It’s sort of a reflective learning exercise for us and the TBNSs to see what could have been done better

or what could have been done differently” (ID7 Consultant physician)

“There's a collective sort of ownership that, we as a group of people involved in TB control, public health,

TB services (agree targets) and so they're meeting their own targets that we've all set, they're not

meeting something that I, from outside have imposed on them, or even that their bosses have imposed

on them” (ID13 Public health practitioner)

Page 11 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




12


Looking Ahead When they were asked how they

would feel if TBCA did not

continue, participants uniformly

did not want to see that happen

and felt it could be a risk to

patients, service delivery and TB

care in the NW

“TB is a condition that can't just be looked at locally, it has to be looked at on a bigger picture, regionally,

nationally and internationally, and they all feed into each other, and they're all interdependent of each

other, and so to go back to just being in that one little pot you lose so much, we can't put a fence around

[our area] and say ‘that's us done, on your way’ “(ID19 TB nurse specialist)

“[How would you feel if TBCA stopped?] “Gutted really” (ID5 TB nurse specialist)

“I feel like it's a safety net” (ID25 TB nurse specialist)

I think if the cohort review wasn't there, there is the possibility that it would slip and other things take

over and patients slip through the net, 'cause it's human nature, it will happen; I think cohort review

keeps us on track and I think it really has a direct impact on patient safety (ID10 TB nurse specialist)

“I think it would be a disaster” (ID7 Consultant physician)

“The consequences of getting TB care wrong are so high - even in costs terms alone - not to mention the

impact on the patient of course, but the cost of treating someone for MDR TB for example are so much

higher than a case of standard TB that we just can't afford not to do things properly, and if the cohort

review is what it takes then I'm sure that's a highly cost effective way of preventing even a single case of

MDR TB in a year, and that, you know that would more than pay for the costs of the meeting and the

administration and everything” (ID32 Consultant physician )

“ If cohort review becomes part and parcel and owned by, if you like, the local health economy, that

ownership I think makes it possibly more likely that it will feed into commissioning” (ID13 Public health

practitioner)

Key Informants Key informants had an in-depth

understanding of the inception and

function of TBCA in the NW

“You’re saving lives, you can really see that you've influenced practice; it's incredible to see. I just think

it's really powerful, it's really rare in public health to see such improvement so quickly” (ID31 Key

informant)

There have been specific instances where it's made a radical change to the way a patient’s been treated.

And then there's been a more collective changes, [for example] if you look at treatment completion rates

“(ID24 key informant)

“The biggest failing is that we haven't been able to do the reporting structure ;” (ID31 key informant)

Page 12 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




13

Preconceptions

There were a number of preconceptions about TBCA ranging from concerns about time for

form-filling and anxiety about scrutiny to optimism about its potential.

Engagement with TBCA

The TB nurse specialists interviewed had attended all or most of the audits (this is expected

as it is TB nurses that present cases). By contrast, half of the consultant physicians had

attended half of the audits and half had attended one audit only Public health practitioners’

attendance varied, with consultants in disease control attending most or all audits in their

region and epidemiologists/analysts attending fewer audits.


Part time TB nurse specialists had more problems finding time for both preparation and actual attendance. Some TB nurse specialists felt that managers did not understand the importance of TBCA. Consultants cited time as an issue in their attendance more often than nurse specialists and emphasised the importance of knowing dates in advance. Public health practitioners had the fewest problems in attending as their diaries were less constrained by clinical commitments. Changes in perspective on TBCA after attendance




before attendance felt it was a useful process.

Presenting cases











about public health participation in meetings, with some expressing ambivalence about the

clinical focus.







Page 13 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



14

Changes due to TBCA



This, in turn, has increased motivation to improve outcomes. TBCA, was described as

providing support, reassurance and a place to ask questions. This was especially important

for new members of staff, particularly TB nurse specialists working on their own (some TB

nurse specialists working in the community did not regularly meet with consultant

physicians). TB nurse specialists identified opportunities for reflective practice and regular

ring-fenced time together with peers as particular benefits.






picture’.







epidemiology.

Perceived benefits and costs of TB audit to service delivery





Community



roles. Individuals felt more able to ask for help or to collaborate between catchment areas to

ensure better patient care. Public health practitioners explained that previous attempts to

link public health with TB teams had not been successful.

Changes in Practice






Page 14 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



15













Looking ahead

All groups of participants expressed a desire for TBCA to continue and felt heavily invested

in the process.






established. Although too soon to evaluate the difference it was making, it was considered

that loss of TBCA would be detrimental to the North West and may result in more mistakes

being made.

Public health practitioners thought that more evaluation was needed to be done before the


that there needed to be a mechanism to feed data into wider service improvement and public

health processes.

Key Informants

Themes emerging from the eight interviews with key informants were compared with the

results from the three main respondent groups as a method of validation. The key informants










Page 15 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



16












result.

Community of Practice

Running through the participant narratives were recurring themes which describe the

inception of a ‘community of practice’. This concept was constructed from depictions of a

renewed engagement as a collective to collaborate and engage in regional TB control. The

mainly negative preconceptions of TBCA were unsubstantiated and attendance at TBCA

built confidence and trust in the process. Participants gained personal benefit from attending

TBCA which was due to a sense of support, learning, communication and coming together.

Engagement with the process and perceived benefits and costs varied by professional

group. Each group also had differing reasons for attendance or non-attendance and

suggestions for improvements to the process.

Participants were unanimous that if TBCA ceased to function, this would be a loss to them

and would damage TB care in the NW.

DISCUSSION



implementation of TBCA over a large geographic area in the UK.

As demonstrated by the results the key finding was a description of collaborative working

and the development of a community of practice with a common purpose.[30] Tuberculosis

services across the UK have reported weaknesses in communication between sectors with

fewer than half of TB services having local arrangements to work with local authorities and

social care services.[31] Lack of communication and collaboration in healthcare teams has

negative effects on patient outcomes with failure of communication being the primary cause

for the majority of errors[32] and outbreaks of TB have been shown to frequently originate

from clinical mistakes in diagnosing and treating TB.[33] Reducing the burden of TB in the

UK requires the co-ordinated action of many partners, working together across local

authority and NHS boundaries.[5]



Page 16 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



17

in this area by interacting on an ongoing basis'.[34] They have been found to break down




across the patient pathway and span organisational boundaries.[35] Therefore, the



TB nurse specialists in this study had a wide variety of working patterns and many were

practicing on their own in low incidence rural areas. Nonetheless, they described how they

felt increased acknowledgement of their practice, and they experienced support and

reassurance which improved their morale. TBCA was felt to be especially important for those

nurses who did not work in a TB team, both to raise morale and improve standards.

Empowerment as a result of closer linkage to colleagues both across footprints and between

disciplines was described in this study and has previously been shown to improve job

satisfaction and patient outcomes.[36] Since the completion of this analysis, TB nurse

specialists have been paired with clinical chairs and this is likely to lead to enhanced

leadership skills which can contribute to a reduction in power differentials and improve inter-

professional collaboration.[37]



speak out often enough and that this can be rectified.[38]



practice). This may have led to some disengagement.[39] Successful involvement of multiple


this will require more contribution from the public health perspective.[41]




Interviews with key informants detailed meticulous planning by the steering group which





whose importance has been cited elsewhere.[43]The emphasis by TBCA leaders (Chairs


‘psychological safety’ of participants in cross-disciplinary engagement.[44]





has since been published.[17] The delay in producing a report was due to lack of


Page 17 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



18


and structure to facilitate and embed improved integration of services.[45]


methods analysing clinical outcomes of TB treatment, no studies have assessed contextual

factors in the successful implementation (defined as being made workable and integrated in

everyday health care practice[46]) of TBCA or evaluated participant experience. The use of

in depth one-to-one interviews allowed us to explore a complex process by examining the

perceptions and shared experiences of TBCA.[47]

Our dataset included a large and extensive number of stakeholders from the three main

cadres who participate in TBCA, across four geographic footprints, purposely sampled to

attain a wide range of disciplines and working practices. Data analysis found recurrent

themes that indicated saturation[48], especially within the TB nurse specialist profession.




implementation of the NW TBCA. The themes evolving from framework analysis of the data

were further validated[49] by the use of two researchers to double code the transcripts and

discussion with a further author on emergent themes.




Information on participant preconceptions of TBCA were only collected after participants had

experienced cohort review which could introduce recall bias.




(NCL) TB Service TBCA in 2010 from an online questionnaire.[11] In agreement with our




Earlier studies suggest that unidisciplinary communities of practice retard the spread of

innovation[50] it may be that the TBCA differs by allowing knowledge transport to be

facilitated between professions by the use of chairs as ‘brokers’.[51]

TBCA provides a mechanism for staff to speak up about unsafe practice and organisational

issues that affect care. TBCA has provided a level playing field between historically unequal

professions to make self-directed culture change possible.[52]

Page 18 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



19




TBCA can be an important means of quality improvement in similar contexts.[53] PHE’s new

TB Strategy[5] promotes a coordinated approach to TB, involving NHS commissioners,

providers, local government and PHE through TB Control Boards. The model of TBCA

described here provides an important coordination mechanism through which the ‘soft data’

of process and learning can be an explicit part of the TB Strategy. The benefits of

communities of practice tend to accrue over time and a follow up, qualitative process

evaluation could be valuable in the future.[54] In such an evaluation it will be important to

include individuals who choose not to attend TBCA in order to gain insights into the barriers

to attendance.

Conclusion

The Northwest TBCA model has enabled cross-sectoral collaboration and the establishment

of a community of practice which has facilitated a culture of shared experience, open

communication and respect. This community of practice is vital as a tool for continued quality

improvement in TB control. Further qualitative study of practitioners who are resistant to

attending TBCA may provide a better understanding of how to facilitate attendance.

The paper demonstrates the operational perspectives which underpin development of a

powerful and robust multi-disciplinary community of practice across a wide geographical

area. It will inform the establishment of effective TB cohort audits across the new TB Control

Board footprints (as established by PHE’s new TB Strategy).

Acknowledgements



Abbreviations



PHE Public Health England

TB Tuberculosis







Page 19 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



20

Funding statement




England or LSTM.



of the study: MW, PC, KD, SF, PMcM, CW, JW, DS, SBS. They contributed to the study

design and the writing of the paper. However the interviewing and data analysis were the

sole responsibility of SW and KJ who were independent of all Cohort Audit processes.

Otherwise we have no conflicts of interest to declare.

Data sharing statement

No additional data available.

REFERENCES





5. England PH. Collaborative tuberculosis strategy for England: 2015–20. 2015 6. Van Hest N, Aldridge R, De Vries G, et al. Tuberculosis control in big cities and urban risk

groups in the European Union: a consensus statement. 2014 7. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services

research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4(1):50

8. Organization WH. Implementing the WHO Stop TB Strategy: a handbook for national TB control programmes: World Health Organization, 2008.






14. England PH. Tuberculosis in England: 2015 report. 2015

Page 20 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



21

15. Hoppe LE, Kettle R, Eisenhut M, et al. Tuberculosis—diagnosis, management, prevention, and control: summary of updated NICE guidance. BMJ 2016;352:h6747

16. Summit TT. North West TB Regional Audit - Cohort Review Handbook. 2013 17. Group NWTCAS. North West TB Cohort Audit 2014 Report, 2014. 18. MacPherson PS, Stephen Bertel MD BChir, MD, FRCP; Cleary, Paul; Davies, Stefanie;

Wake, Carolyn; Dee, Katie; Walker, Jenny; Farrow, Stacey; McMaster, Paddy; Woodhead, Mark; Sloan, Derek James. Equitable tuberculosis care in the North West of England: analysis of TB cohort review data. The International Journal of Tuberculosis and Lung Disease 2016

19. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. Bmj 2000;321(7262):694-96

20. Green J, Thorogood N. Qualitative methods for health research: Sage, 2013. 21. King N, Horrocks C. Interviews in qualitative research: Sage, 2010. 22. Bryman A. Social research methods: Oxford university press, 2012. 23. Guion LA, Diehl DC, McDonald D. Triangulation: Establishing the validity of qualitative

studies. 2011 24. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research

(COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 2007;19(6):349-57

25. Patton MQ. Qualitative analysis and interpretation. Qualitative research and evaluation methods 2002;3:431-539

26. Jefferson L, Bloor K, Maynard A. Women in medicine: historical perspectives and recent trends. British medical bulletin 2015

27. Sofaer S. Qualitative research methods. International Journal for Quality in Health Care 2002;14(4):329-36

28. Gale NK, Heath G, Cameron E, et al. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology 2013;13(1):117


30. The Meaning of a Healthcare Community of Practice. Nursing forum; 2015. Wiley Online Library.




34. Wenger E, McDermott RA, Snyder W. Cultivating communities of practice: A guide to managing knowledge: Harvard Business Press, 2002.

35. Woodard F, Weller G. An action research study of clinical leadership, engagement and team effectiveness in working across NHS boundaries. Work Based Learning e-Journal 2011;1(2):80-119


37. Bell AV, Michalec B, Arenson C. The (stalled) progress of interprofessional collaboration: the role of gender. Journal of interprofessional care 2014;28(2):98-102



Page 21 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



22






45. Nasir L, Robert G, Fischer MD, et al. Facilitating knowledge exchange between health-care sectors, organisations and professions: A longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality. Health Service Delivery Research 2013;1(7)

46. May C, Finch T, Mair F, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Services Research 2007;7(1):148





50. Ferlie E, Fitzgerald L, Wood M, et al. The nonspread of innovations: the mediating role of professionals. Academy of management journal 2005;48(1):117-34

51. Tasselli S. Social Networks and Inter-professional Knowledge Transfer: The Case of Healthcare Professionals. Organization Studies 2015:0170840614556917

52. Davies HTO, Mannion R. Will prescriptions for cultural change improve the NHS? BMJ 2013;346


54. Wenger E, Trayner B, de Laat M. Promoting and assessing value creation in communities and networks: A conceptual framework. The Netherlands: Ruud de Moor Centrum 2011

Page 22 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



Informant Role Footprint 5.1 Why is audit not working 5.2 Attendance 5.3 Changes to audit structure

1 Male

10 Yrs

Nurse CL at the beginning many of my colleagues felt threatened by

it and there was some commentary from them about that,

it didn’t occur to me that it was looking at an individuals

practice to be critical of them so that was never a problem

I had and I think now that people have been to them that is

pretty much gone. I know that some of my colleagues in

the past have felt that they were doing the presentation

when the clinicians should have been doing it, it wasn’t

there decision and they had difficulty responding

they think we have got a tb lead

and they are attending

I think every case presentation needs to

be there to collect the data the form is

limited in the info it captures so it’s

quite repetitive

4 Female

11 Yrs

Nurse CM it doesn’t improve the length that the time of the patient is

diagnosedall they are doing is charting when it gets 1st

referred to other Tb services and to when the Tb nurse

does it . but the timing isn’t there and that is what NICE

guidelines introduced have always introduced a certain

time of getting the contact so again it is not even

measuring that it is just measuring they just pulled out a

figure out of the sky didn’t they. If all it is going to do is just

to say that everybody gets and HIV test and they never use

to have it that is extremely extravagant because that’s the

clear thing that people have improved upon, they cant just

suddenly cancel a clinic

You wont get standardisation of

treatment if consultants dont

turn up. trainee Drs or registrars

could attend. I am asking my

manager to come with me next

time she is coming cos she wants

to see it so she is coming next

time

they could cycle days surely . Nurses

chairing would allow you to see other

areas and what they do.I would think if

they got to a stagnant level of

improving the number of the outcomes

and there weren’t being improved I

think just presenting every two cases

every two minutes continuing to do

that may not have any benefit cos once

you have presented an x number of

cases they are all the same aren’t they

5 Female

15 Yrs

Nurse NM what we do need though is moving forward is the dates

well in advance , if the Drs are on the ward or if they are in

clinic they need to cancel them clinics well in advance they

don’t allow you to cancel a clinic no at 3 or 4 weeks notice,

we need the 12 month dates

I think its hard for them to

commit to giving their time and I

don’t think Tb is all they do it is a

small part of what most of the

consultants do so it isn’t

something that they are focused

on day in day out where as it is

for the Tb nurses we do it day in

day out so it is all of what we do,

so I mean that way they probably

I don’t think there was written

guidance it was all done initially not to

make it scary for the nurses, it was

done to be relaxing mm take your time

go through your forms nobody is going

to question you in a negative way it is

all supportive, maybe as people get

familiar to them they need a guidance

sheet that says this is the minimum we

need presenting. maybe co-charing

Page 23 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960





stand to get more out of it than

we could if they (attended).

Paediatric cases could all be

presented in one go.

Microbiologists should attend

would be nice but i do think the nurses

like having the sort of somebody that

they feel is expert and can answer all

those questions that we sometimes

cant . Could increase to full day to fit

everything in or add more in, you are

conscious that if it is not a cohort

review that it is another day that

people have got to take out of clinical

practice

6 Female

8 Yrs

Nurse NM when you're trying to fill that cohort review you can't alter

it once it's on, you know when it's all been pulled from ETS

you can't change it. Difficult to go back and fill in results

and treatment outcomes.

I think we should get some GPs

from different areas. it would be

nice, you know for us all really

that we get other input from

other places. Maybe you know

even from immunology or

somewhere like that, that we do

all the IGRA testing from, you

know someone come and giving

us a chat on that and explaining it

a little bit more in-depth. We do

these tests and you know

although we know why we're

doing them we don’t understand

them fully or the values and you

know ratios they use

I think we picked up last time that we

were going to try and invite, maybe

invite guest speakers to make the day a

little bit interesting so it doesn't get

monotonous, to break the day up. And

also maybe present a couple of cases,

so if we've got interesting cases for

instance, or we've got a child, maybe

look at their x-ray and see you know

different things in a bit more detail, a

bit more discussion around, monitor

the cases. And also to, you know get

more medical input to see how they

would deal with things, and do things

differently

Page 24 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357

No. Item

Guide questions/description Reported on Page #

Domain 1: Research team and reflexivity

Personal Characteristics

1. Inter viewer/facilitator Which author/s conducted the inter view or focus group?

Methods, p. 6

2. Credentials What were the researcher’s credentials? E.g. PhD, MD

MPH

3. Occupation What was their occupation at the time of the study?

Methods, p. 6

4. Gender Was the researcher male or female? Female

5. Experience and training What experience or training did the researcher have?

Methods, p. 6

Relationship with participants

6. Relationship established Was a relationship established prior to study commencement?

No

7. Participant knowledge of the interviewer

What did the participants know about the researcher? e.g. personal goals, reasons for doing the research

All attendees at TBCA were informed at cohort meetings that an evaluation would be taking place by a researcher independent to the TBCA process. This was reiterated during the interview.

8. Interviewer characteristics

What characteristics were reported about the inter viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic

Methods, p. 6

Domain 2: study design

Theoretical framework

9. Methodological orientation and Theory

What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis

Methods, p.6-7

Page 25 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



Participant selection

10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, snowball

Methods, p.6

11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email

Methods, p. 7

12. Sample size How many participants were in the study? Methods, p. 7

13. Non-participation How many people refused to participate or dropped out? Reasons?

Methods, p.7

Setting

14. Setting of data collection

Where was the data collected? e.g. home, clinic, workplace

Methods, p. 7

15. Presence of non-participants

Was anyone else present besides the participants and researchers?

Methods, p. 7

16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date

Results, p.7

Data collection

17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested?

Methods, p. 6.

18. Repeat interviews Were repeat inter views carried out? If yes, how many?

N/A

19. Audio/visual recording Did the research use audio or visual recording to collect the data?

Methods, p.7

20. Field notes Were field notes made during and/or after the interview or focus group?

Methods. p.7

21. Duration What was the duration of the inter views or focus group?

Methods, p.7

22. Data saturation Was data saturation discussed? Discussion p.17

23. Transcripts returned Were transcripts returned to participants for comment and/or correction?

Ethics, p. 7

Domain 3: analysis and findings

Data analysis

24. Number of data coders How many data coders coded the data? Methods, p. 7

25. Description of the coding tree

Did authors provide a description of the coding tree?

N/A

26. Derivation of themes Were themes identified in advance or derived from the data?

Methods, p. 7

27. Software What software, if applicable, was used to manage the data?

N/A

28. Participant checking Did participants provide feedback on the findings?

Participants were sent their transcripts to check for accuracy so could have commented on their own testimony, but not the findings of the full paper

Page 26 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



(although this has been presented at the NW TB conference which was attended by many of the participants)

Reporting

29. Quotations presented Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number

Results Table 2

30. Data and findings consistent

Was there consistency between the data presented and the findings?

Relationship to existing knowledge

31. Clarity of major themes Were major themes clearly presented in the findings?

Results

32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?

Discussion p16.

Page 27 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from




Journal: BMJ Open

Manuscript ID bmjopen-2015-010536.R2


Date Submitted by the Author: 16-Feb-2016


Wake, Carolyn; Public Health England Walker, Jenny; NHS Liverpool Community Health Sloan, Derek; Liverpool school of tropical medicine, International health; Liverpool Heart and Chest Hospital NHS Trust Squire, Bertie; Liverpool school of tropical medicine, Centre for Applied Health Research and Delivery & Department of Clinical Sciences; Royal Liverpool Hospital, Respiratory Medicine




Keywords:

Clinical audit < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES, HEALTH SERVICES ADMINISTRATION & MANAGEMENT, PUBLIC HEALTH, QUALITATIVE RESEARCH, THORACIC MEDICINE


BMJ Open on F


http://bmjopen.bm

j.com/

BM


jopen-2015-010536 on 16 March 2016. D

ownloaded from



1




Dr Paul Cleary Consultant Epidemiologist Field Epidemiology Service Public Health England 5th Floor Rail House Lord Nelson Street Liverpool L1 1JF Katie Dee, Deputy Director, Public Health England, Cheshire and Merseyside Centre 5th Floor Rail House Lord Nelson Street Liverpool L1 1JF Stacey Farrow TB Nurse Specialist

NHS Bolton Dr Paddy McMaster Consultant in Paediatric Infectious Diseases North Manchester General Hospital Limbert House Manchester M8 5RB Carolyn Wake NW TB Coordinator Public Health England Greater Manchester Jenny Walker TB Specialist Nurse NHS Liverpool Community Health Abercromby Health Centre Grove Street Liverpool L7 7HG Dr Derek Sloan Senior Lecturer and Consultant Physician Department of Clinical Sciences, Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA UK Prof S B Squire Centre for Applied Health Research and Delivery & Department of Clinical Sciences, Liverpool School of Tropical Medicine Pembroke Place Liverpool L3 5QA UK

Key words: Tuberculosis, Cohort audit, Community of practice Word Count: 5192 No of Tables: 2 Number of references: 54

Page 1 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



2




Wake 4, J Walker7, D. Sloan1,8, S.B. Squire1,9





4. Public Health England

5. Bolton NHS Trust


7. Liverpool Community Health Trust 8. Liverpool Heart and Chest Hospital

9. Royal Liverpool University Hospital

ABSTRACT

Objectives Tuberculosis cohort audit (TBCA), was introduced across the North West (NW)

of England in 2012 as an on-going, multidisciplinary, systematic case review process,

designed to improve clinical and public health practice. TBCA has not previously been

introduced across such a large and socio-economically diverse area in England, nor has it


experiences of the process after 1,515 cases had been reviewed.

Design Qualitative study using semi-structured interviews. Respondents were purposively

sampled from three groups involved in the NW TBCA: (a) TB nurse specialists; (b)

consultant physicians, and (c) public health practitioners. Data from the 26 respondents were


through observation of TBCA meetings.







from public health professionals, nurses and clinicians; all groups want it to continue. TBCA

is regarded as a tool for quality improvement that improves patient safety.

Conclusions TBCA provides peer support and learning for management of a relatively rare,

but important infectious disease through discussion in a no-blame atmosphere. It is seen as

an effective quality improvement strategy which enhances TB care, control, and patient

safety. Continuing success will require increased engagement of consultant physicians and

public health practitioners, a secure and on-going funding stream and establishment of clear

reporting mechanisms within the public health system.

Page 2 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



3

ARTICLE SUMMARY


• This study is the first to formally evaluate the perceptions of participants at TB cohort audit (TBCA)

• Our qualitative dataset included a large and extensive number of stakeholders from three main cadres that participate in TBCA.

• The unique geographic configuration and implementation of the NW TBCA may mean that the findings are not easily transferred to other areas without careful adaptation.

INTRODUCTION

Growing pressure on the National Health Service (NHS) to provide safe effective healthcare

within a limited budget [1] has focussed attention on ways to promote efficient working of

diverse multidisciplinary groups.

Where infectious diseases such as tuberculosis are rare,[2] issues can arise where public


knowledge of current treatment options.[3] Countries with a low incidence of TB need to

ensure they have continuing and adequate vigilance systems to detect and treat TB cases

and thereby prevent transmission.[4]



prevention.[4]


North West of the UK in 2012. TBCA has not previously been introduced across such a large

and socio-economically diverse area in the UK, nor has it undergone formal, qualitative



improving staff morale.[5 6]

In order for health services to be effective and translate into meaningful patient care

outcomes it is necessary to evaluate not only summative but also formative outcomes to

assess if, how and why implementation is effective in a specific setting. Individual beliefs

govern behaviour change and ultimately determine whether there is engagement with

change initiatives.[7]

This paper aims to build a greater understanding of how TBCA in the NW was perceived by

groups of differing health professionals, across a wide-geographic area, dealing with a low

incidence but high consequence disease. Our findings will be of relevance to those

interested in establishing and supporting effective TBCA and in understanding some of the

factors that contribute to successful communities of practice in health care.

BACKGROUND

TBCA was first developed in Tanzania in the 1990’s and rapidly became an integral part of

the international tuberculosis control effort.[8]It was subsequently adapted for use in New

Page 3 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



4

York during the 1990s, where it contributed to an increase in completion rates and a

reduction in TB and multi-drug-resistant (MDR) TB cases.[9] TBCA was first implemented in

the UK in North Central London (NCL) in 2010, and has been recommended in NICE

guidance since 2012.[10] Evaluation of the London model of TBCA, where each area has a

separate process, found improvements in case management, contact tracing and

identification of service issues, but suggested that TBCA should be monitored after

implementation.[11]


particularly high rates in metropolitan areas and linked to deprivation.[12 13] In the year of

this study (2014), London PHE Centre and West Midlands PHE Centre reported the highest

TB notification rates in the UK (30.1 per 100,000 and 13.7 per 100,000), [14]. Both cities run

focussed, urban, TBCA processes. The average rate across the North West was low at 9.1

per 100,000 but urban Manchester’s notification rate was 31.3 per 100,000 (three year

average annual rate 2012-2014).[14]

Due to these pockets of high incidence of TB in the NW, TBCA was implemented (in line

with international and national best practice[8 10 15]) in 2012 as a single, co-ordinated

process across the whole range of rural, urban and socio-economic contexts of the

region.[16] Objectives of the NW TBCA relate to case management and TB control but also

include provision of ongoing training and education for staff and provision of a forum for

open discussion.[17]

STUDY DESIGN

Context of the health care system

Tuberculosis care in the UK is co-ordinated by lead TB consultant physicians who work

within secondary care hospital and community trusts which are part of the NHS. This is a

system of universal free health care funded through taxation. Once TB is confirmed, TB

treatment is initiated either in the community or in hospital, depending on the clinical severity

or complexity of each case. Once stabilised, patients are supported in the community by TB

nurse specialists. Each case undergoes a standardised risk assessment and direct

observation of therapy is reserved for the most complex cases.

TBCA process and costs


(nurses, doctors and public health staff). The budget lines of TBCA in the model described

here have been identified, but not yet formally costed. They include the salary of an 80%

FTE co-ordinator, the hire of meeting venues, the purchase of refreshments and the travel

costs of TBCA Chairs (see below). There are also travel costs for the meetings of the TBCA

Steering Group which established, and continues to monitor and develop the system of

quarterly multi-disciplinary meetings in four operational footprints: Cheshire & Merseyside,

Cumbria & Lancashire, North Manchester and South Manchester, each covering both urban

and rural contexts and a number of NHS Trusts. The time devoted to preparation of cases

and participants’ time in meetings are regarded as part of service delivery and quality

assurance.

Page 4 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



5

Cases are identified by the TBCA Co-ordinator from Enhanced Tuberculosis Surveillance

(ETS) notifications during a three month period ending six months before each TBCA

meeting. TB nurse specialists complete a bespoke, anonymised electronic data collection

form for each case and present the completed forms at each meeting.

TBCA meetings are chaired by clinicians (some now co-chaired by TB nurse specialists)

from outside the footprint represented in a given meeting. The chairperson opens the

meeting with introductory slides outlining results of programme performance from all four

operational footprints against 10 pre-specified outcome measures.[18] TB nurses then

present the cases. During and after each case key data are checked and corrected.

Challenges in case management, service strengths, weaknesses and staff training needs

emerge from the discussion that surrounds each case and are flagged for action through the

steering group by the Chair. Data are collated live by Public Health England staff and results

on outcome measures are fed back at the end of each meeting.[14] Thus TBCA differs from

conventional multi-disciplinary case conferences in that all cases are discussed

retrospectively with a public health focus on a pre-specified set of outcome measures rather

than a focus on solving individual case management problems for selected, difficult cases.

TB nurse specialists are key to the process; across the NW they have a wide variety of

employers and contract types ranging from full-time to part-time. For some, only a small

percentage of the workload is devoted to TB.


TBCA is considered a complex intervention and it is recognised that evaluations of this type

of initiative should include qualitative design to enable in-depth exploration of participants’

experiences from their own perspectives.[19] The aim of this study was therefore to

qualitatively explore and understand perceptions and experiences of TBCA with three main

stakeholder groups: TB nurse specialists, consultant physicians and public health

practitioners. The epistemology underpinning the study is interpretivist, understanding

knowledge as subjective and prioritising the individual meanings participants assign to their

own experiences, knowledge that is inaccessible through experimental methods.[20 21]

Face-to-face, semi-structured interviews were considered the most suitable primary data

collection tool to access this knowledge and to enable flexible, in-depth exploration of the

issues.[22] Interviews were conducted by SW, a public health researcher trained in

qualitative research, independent of TBCA. These interviews were supplemented with

additional key informant interviews with members of the NW TBCA Steering Group.

Interviews for this study took place in Jan-Mar 2014 (approx. two years after TBCA was

implemented in the region and after 1,515 TB cases had been reviewed). Topic guides were

developed for the interviews, based on discussion with the cohort audit co-ordinator, steering

group and a review of the existing literature. These were piloted and refined in an iterative

process throughout the study. Interviews were further triangulated by observation

undertaken by SW during TBCA meetings.[23]

The study is presented in line with the Consolidated Criteria for Reporting Qualitative

Research (COREQ)[24] (see online supplement file A).


Page 5 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



6

Maximum variation purposive sampling was used to select potential staff participants and

gain perspectives from a broad range of representative healthcare professionals.[25]

Sampling was intended to include: gender balance; professionals working in high and low

incidence areas; mix of professional roles and working patterns; mix of regular and less

regular attendance at cohort. On the contact list for the TBCA there are approximately 125

clinicians (92M/33F) , 49 nurses (3M/46F), 43 other – PHE leads, Epidemiologists, LA leads,

PH leads, Admin, other TB leads (12M/31F).

The larger share of female nurses and male consultants in the sample reflects national

recruitment patterns to these professions nationally.[26] Twenty-eight participants were

originally selected from the three groups across the four geographic ‘footprints’ and

contacted by the researcher by email. Twenty-six individuals were interviewed (one

participant declined to take part and one was unable to schedule time to be interviewed) in

private rooms chosen by the participants. Numbers of participants interviewed within the

professional groups represented the proportions in which they attend TBCA. Duration of the

interviews were approximately one hour, audio recorded and supplemented with notes taken

by the researcher.

Key informants were individuals with a strategic in-depth knowledge of TBCA[27] who were

instrumental in running of TBCA – (Chairs, epidemiologists/ PHE TB leads, steering group

members) and were purposively sampled from across the four geographic sub-footprints.

Eight participants were selected, two from each footprint.

Ethical procedure

Approval was obtained from the LSTM Research Ethics Committee (ref no 13.37). No risks

to interviewees were anticipated from participation in the study. We obtained informed

consent prior to the start of the interviews, explaining the purpose of the interview and

interview process to participants, emphasising voluntary participation and confidentiality.

Interviews were transcribed and saved in password protected files, with transcripts sent to

interviewees to affirm them as true records.

Analysis

As the aim was to explore and understand perceptions and experiences of TBCA from a

wide range of stakeholders, thematic qualitative analysis was considered the most

appropriate means by which to identify areas of commonality and difference across the data.

In particular, the Framework approach to thematic analysis–a systematic, matrix-based

method to classify and organise qualitative data–was chosen as the specific thematic

approach.[28] The transparency of Framework’s analytical method and its step-by-step

approach was considered most suitable to an interdisciplinary team and to a policy-oriented

study hoping to inform practice. Two researchers (SW and KJ) double coded six initial

transcripts. Data were analysed noting experiences participants underwent, processes they

described, understandings and perceptions they held, motivations they expressed. SW and

KJ discussed initial coded sections, proposing their own interpretations and potential

categories which would inform the research question. Categories of these common

experiences were developed to build an analytical framework (coding index), against which

the remaining transcripts were coded. Each main category was then charted within a matrix

of rows (individual cases) and columns (codes) with ‘cells’ of summarised data providing a

Page 6 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



7

structure into which the data were systematically reduced. From reading the matrices, SW,

KJ and SBS discussed emergent concepts and critically explored interviewee responses,

comparing their own interpretations. This process was informed throughout by the overall

research aim and shaped inductively by ideas that emerged from the data, and deductively

from literature reviewed. During this process, the researchers moved from description to

interpretation and more explanatory analysis enabling final themes (e.g. ‘Looking Ahead’,

concerning participants’ feelings concerning the future of TBCA) to be agreed. An example

of the analysis process is provided in the appendix.

RESULTS




respondents


ratio

North

Manchester

South

Manchester

Cumbria &

Lancashire

Cheshire &

Merseyside

M:F

a TB Nurse

Specialists

4 4 3 4 15 2:13

b Consultant

Physicians

2 2 1 2 7 6:1

c Public Health

Practitioners

1 1 1 1 4 4:0

d Key

Informants

2 2 2 2 8 6:2


Changes attributed to NW TBCA and looking ahead. Illustrative quotes for the key themes

are presented in Table 2.

Page 7 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



8

Table 2: Key themes, findings interpreted and illustrative quotes


Preconceptions Views varied widely. Negative

views were mainly concerns about

time and scrutiny of practice

(relating to individuals)

“Whenever you hear about things like that, you think 'Oh for goodness sake,' you know 'what more do

they want us to do?' (ID8 TB nurse specialist)

“My concern was getting Trusts to accept it as a valuable or valid part of our work” (ID21 TB nurse

specialist)

“I couldn't imagine how that's going to be useful or have an impact until I attended” (ID7 Consultant

physician)

Positive views expressed optimism

about the potential to improve

practice and outcomes

“[I thought] it was a perfect change agent for us” (ID10 TB nurse specialist)

“I was very pleased to see that there [would be a] multi-disciplinary forum” (ID25 Public health

practitioner)

Engagement

with TBCA

Participants listed a number of

reasons for their attendance/non-

attendance at TBCA. Participants

found that attendance brought

them a sense of community and

enlarged their sphere of influence

and support

“It’s just become part of practice now, and I do appreciate it very much, what it offers” (ID9 TB nurse

specialist)

“It wasn’t a witch hunt [the audit process]; it's about trying to get the outcome at the end of it” (ID6 TB

nurse specialist)

“People say "Well, I did this," or "I did that,” and so you think, 'Oh, I might try that next time'.” (ID29 TB

nurse specialist)

"Sometimes you feel a little bit isolated and I think this helps with the isolation” (ID25 TB nurse

specialist)

“You have to make your job pay [...] that's the difficult choice of whether you go to cohort review, which

earns nothing — nothing [of] monetary value — but a heck of a lot in other ways.”

(ID21 TB nurse specialist)

Page 8 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




9


There were changes in participants

perspective on TBCA after

attendance, mainly due to a

reassessment of the value of

attendance; many expressed that

their fears prior to attendance were

unjustified

“I have always thought they were beneficial and I still think they are beneficial; perhaps at the beginning I

didn’t appreciate from a learning point of view how much.” (ID5 TB nurse specialist)

"I was looking forward to the next one from a point of view of you know professional practice, it's very

stimulating” (ID11 Public health practitioner)

Participants conveyed a range of

experiences of attending audit and

presenting cases. Over time people

became more confident and

relaxed. Consultants felt engaged

when their patients were

presented

“It was refreshing just to go through patients from all over the region and see the TB nurses presenting

their patients, how much work they put in to achieving good outcomes”

(ID34 male, Consultant physician)

"Sometimes it becomes a little bit tiring and stressful when you don't have anything to highlight during

them" (ID7 Consultant physician)

“When they are going through the case you get more of an appreciation of what is actually going on and

all these things obviously help when it comes to our outbreak support”

(ID2 male, Public health practitioner)

“No matter how much you know it's not about judging you personally, when you first start to come that

is how it feels and there are still times that you would sit there or a colleague would say “I don’t want to

present this one I'm not happy with it,” and but, you just get on, your grit your teeth, and actually when

that's happened to me — I felt supported at the end of it”(ID19 TB nurse specialist)

"We are all a bit more relaxed in presenting our cases” (ID5 TB nurse specialist)

"The more you go the less threatening it becomes" (ID21 TB nurse specialist)

Page 9 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




10


When discussing whether

participants felt they had buy in to

TBCA from colleagues

“I’ve suggested my junior trainees and registrars come, this could help in their career progression.” (ID27


If you're going on your own and you've got nobody else there with you, supporting you, it's like; you

[consultant physicians] don’t really care what we do” (ID6 TB nurse specialist)

"“Our Consultant says that TB comprises of about 5% of his total workload, so in the scheme of things it's

not a huge priority, you know he’s sort of balancing it with obviously his cancer patients and

bronchoscopy lists, everything else, so I don’t really feel he intends to come” (ID23 nurse specialist)

“I think they do need to have quite a good input into public health, because obviously TB you know it has

implications on public health and especially if there's been sort of an outbreak situation"(ID12 TB nurse

specialist)

Changes

attributed to

NW TBCA

Personal benefits and costs to

individuals of attending TBCA

related to communication

community and learning

“It makes me think about what I am doing, the care I am giving, it makes me sure I tick those boxes but I

also know why I am ticking them boxes and why it is important“(ID5 TB nurse specialist)

"It does make people a bit more aware of the extent of the difficulty of doing our work “(ID8 TB nurse

specialist)

"It's good to talk about your ideas with some of the Consultants that you don’t work with directly" (ID14

TB nurse specialist)

“You think your patients are all doing well then you go to a TB cohort review and [see that] actually 25%

of patients with TB in this area died, and you think ‘ah … I didn’t … really appreciate that, I've seen a

couple die, but I didn’t know … the big picture” (ID34 Consultant physician)

"Now it's my own patients it's much more interesting, and actually getting feedback on the things that I

should have done or shouldn't have done, is even more helpful. I love it, they are very interesting" (ID32


Individuals perceived a range of

benefits and costs of TBCA to

service/footprint. Some felt

empowered to use the TBCA

outcomes and data to make service

changes. TBCA was seen to reduce

“It's been good to help push the Trust in the way that TB patients should be cared for - and how the

service should be managed, I've been able to use it as leverage to say 'this is what's needed … because

you're being watched now,'” (ID21 male TB nurse specialist)

“If something’s presented at cohort which is not meeting an adequate standard then intervention will

occur. It got picked up because of audit, it got highlighted because of audit, and action took place

Page 10 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




11


risk to patients and practitioners,

act as a source of support and

advice when cases are complicated

(especially in low incidence areas

and for lone workers)

because of audit” (ID19 female TB nurse specialist)

“You can raise issues and challenge, in a positive way, management of patients in different areas. The

only problem is that the people who, really need to be listening are not coming”(ID34 Consultant

physician)

“The worst thing in the world is for there to be a disconnect between policy-makers, strategists, public

health and clinical services, that's disastrous” (ID13 Public health practitioner)

“The way that funding is obtained for TB control now is, has to be kind of negotiated locally now, so we

need this information to feedback to Commissioners so that they understand the burden of disease and

the particular issues the need for perhaps additional workforce” (ID26 Public health practitioner)

As mentioned in previous findings,

participants described an overall

picture of a new community of

practice which developed through

attendance at TBCA

“It's sort of built this idea of collegiate working, you know that you want to work together, that you are

colleagues and you can help each other out” (ID19 TB nurse specialist)

“It just builds bridges really, it's a lot easier free-flowing information and they’ll help us, and we’ll help

them”.(ID10 TB nurse specialist)

“I think it’s developed into much more than just data collection, it’s ensuring that the patients are getting

what the patient deserves, getting the treatment that is the right treatment, in a timely manner, with the

best outcomes.” (ID1 TB nurse specialist)

Individuals listed numerous

changes of practice they attributed

to attendance at TBCA, from their

individual practice to service

changes, including a renewed

sense of co-working to improve

outcomes and an appreciation of

the bigger picture and complexity

of TB care and control in the region

“It's also about reminding people for the best investigations, for example thoracoscopy for pleural TB

rather than just pleural aspirations so some of the improvement is documented and some of it

isn't.”(ID32 Consultant physician)

“For the patients it means that their treatment has been gone through a recognised panel of people or a

cohort of a panel which is quality assurance really” (ID3 Consultant physician)

“It’s sort of a reflective learning exercise for us and the TBNSs to see what could have been done better

or what could have been done differently” (ID7 Consultant physician)

“There's a collective sort of ownership that, we as a group of people involved in TB control, public health,

TB services (agree targets) and so they're meeting their own targets that we've all set, they're not

meeting something that I, from outside have imposed on them, or even that their bosses have imposed

on them” (ID13 Public health practitioner)

Page 11 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




12


Looking Ahead When they were asked how they

would feel if TBCA did not

continue, participants uniformly

did not want to see that happen

and felt it could be a risk to

patients, service delivery and TB

care in the NW

“TB is a condition that can't just be looked at locally, it has to be looked at on a bigger picture, regionally,

nationally and internationally, and they all feed into each other, and they're all interdependent of each

other, and so to go back to just being in that one little pot you lose so much, we can't put a fence around

[our area] and say ‘that's us done, on your way’ “(ID19 TB nurse specialist)

“[How would you feel if TBCA stopped?] “Gutted really” (ID5 TB nurse specialist)

“I feel like it's a safety net” (ID25 TB nurse specialist)

I think if the cohort review wasn't there, there is the possibility that it would slip and other things take

over and patients slip through the net, 'cause it's human nature, it will happen; I think cohort review

keeps us on track and I think it really has a direct impact on patient safety (ID10 TB nurse specialist)

“I think it would be a disaster” (ID7 Consultant physician)

“The consequences of getting TB care wrong are so high - even in costs terms alone - not to mention the

impact on the patient of course, but the cost of treating someone for MDR TB for example are so much

higher than a case of standard TB that we just can't afford not to do things properly, and if the cohort

review is what it takes then I'm sure that's a highly cost effective way of preventing even a single case of

MDR TB in a year, and that, you know that would more than pay for the costs of the meeting and the

administration and everything” (ID32 Consultant physician )

“ If cohort review becomes part and parcel and owned by, if you like, the local health economy, that

ownership I think makes it possibly more likely that it will feed into commissioning” (ID13 Public health

practitioner)

Key Informants Key informants had an in-depth

understanding of the inception and

function of TBCA in the NW

“You’re saving lives, you can really see that you've influenced practice; it's incredible to see. I just think

it's really powerful, it's really rare in public health to see such improvement so quickly” (ID31 Key

informant)

There have been specific instances where it's made a radical change to the way a patient’s been treated.

And then there's been a more collective changes, [for example] if you look at treatment completion rates

“(ID24 key informant)

“The biggest failing is that we haven't been able to do the reporting structure ;” (ID31 key informant)

Page 12 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




13

Preconceptions

There were a number of preconceptions about TBCA ranging from concerns about time for

form-filling and anxiety about scrutiny to optimism about its potential.

Engagement with TBCA

The TB nurse specialists interviewed had attended all or most of the audits (this is expected

as it is TB nurses that present cases). By contrast, half of the consultant physicians had

attended half of the audits and half had attended one audit only Public health practitioners’

attendance varied, with consultants in disease control attending most or all audits in their

region and epidemiologists/analysts attending fewer audits.


Part time TB nurse specialists had more problems finding time for both preparation and actual attendance. Some TB nurse specialists felt that managers did not understand the importance of TBCA. Consultants cited time as an issue in their attendance more often than nurse specialists and emphasised the importance of knowing dates in advance. Public health practitioners had the fewest problems in attending as their diaries were less constrained by clinical commitments. Changes in perspective on TBCA after attendance




before attendance felt it was a useful process.

Presenting cases











about public health participation in meetings, with some expressing ambivalence about the

clinical focus.







Page 13 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



14

Changes attributed to NW TBCA Perception of personal benefits and costs of attending

TBCA


This, in turn, has increased motivation to improve outcomes. TBCA, was described as

providing support, reassurance and a place to ask questions. This was especially important

for new members of staff, particularly TB nurse specialists working on their own (some TB

nurse specialists working in the community did not regularly meet with consultant

physicians). TB nurse specialists identified opportunities for reflective practice and regular

ring-fenced time together with peers as particular benefits.






picture’.







epidemiology.

Perceived benefits and costs of TB audit to service delivery





Community



roles. Individuals felt more able to ask for help or to collaborate between catchment areas to

ensure better patient care. Public health practitioners explained that previous attempts to

link public health with TB teams had not been successful.

Changes in Practice






Page 14 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



15













Looking ahead

All groups of participants expressed a desire for TBCA to continue and felt heavily invested

in the process.






established. Although too soon to evaluate the difference it was making, it was considered

that loss of TBCA would be detrimental to the North West and may result in more mistakes

being made.

Public health practitioners thought that more evaluation was needed to be done before the


that there needed to be a mechanism to feed data into wider service improvement and public

health processes.

Key Informants

Themes emerging from the eight interviews with key informants were compared with the

results from the three main respondent groups as a method of validation. The key informants










Page 15 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



16












result.

Community of Practice

Running through the participant narratives were recurring themes which describe the

inception of a ‘community of practice’. This concept was constructed from depictions of a

renewed engagement as a collective to collaborate and engage in regional TB control. The

mainly negative preconceptions of TBCA were unsubstantiated and attendance at TBCA

built confidence and trust in the process. Participants gained personal benefit from attending

TBCA which was due to a sense of support, learning, communication and coming together.

Engagement with the process and perceived benefits and costs varied by professional

group. Each group also had differing reasons for attendance or non-attendance and

suggestions for improvements to the process.

Participants were unanimous that if TBCA ceased to function, this would be a loss to them

and would damage TB care in the NW.

DISCUSSION



implementation of TBCA over a large geographic area in the UK.

As demonstrated by the results, the key finding was a description of collaborative working

and the development of a community of practice with a common purpose.[30] Tuberculosis

services across the UK have reported weaknesses in communication between sectors with

fewer than half of TB services having local arrangements to work with local authorities and

social care services.[31] Lack of communication and collaboration in healthcare teams has

negative effects on patient outcomes with failure of communication being the primary cause

for the majority of errors[32] and outbreaks of TB have been shown to frequently originate

from clinical mistakes in diagnosing and treating TB.[33] Reducing the burden of TB in the

UK requires the co-ordinated action of many partners, working together across local

authority and NHS boundaries.[5]



Page 16 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



17

in this area by interacting on an ongoing basis'.[34] They have been found to break down




across the patient pathway and span organisational boundaries.[35] Therefore, the



TB nurse specialists in this study had a wide variety of working patterns and many were

practicing on their own in low incidence rural areas. Nonetheless, they described how they

felt increased acknowledgement of their practice, and they experienced support and

reassurance which improved their morale. TBCA was felt to be especially important for those

nurses who did not work in a TB team, both to raise morale and improve standards.

Empowerment as a result of closer linkage to colleagues both across footprints and between

disciplines was described in this study and has previously been shown to improve job

satisfaction and patient outcomes.[36] Since the completion of this analysis, TB nurse

specialists have been paired with clinical chairs and this is likely to lead to enhanced

leadership skills which can contribute to a reduction in power differentials and improve inter-

professional collaboration.[37]



speak out often enough and that this can be rectified.[38]



practice). This may have led to some disengagement.[39] Successful involvement of multiple


this will require more contribution from the public health perspective.[41]




Interviews with key informants described meticulous planning by the steering group which





whose importance has been cited elsewhere.[43]The emphasis by TBCA leaders (Chairs


‘psychological safety’ of participants in cross-disciplinary engagement.[44]





has since been published.[17] The delay in producing a report was due to lack of


Page 17 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



18


and structure to facilitate and embed improved integration of services.[45]


methods analysing clinical outcomes of TB treatment, no studies have assessed contextual

factors in the successful implementation (defined as being made workable and integrated in

everyday health care practice[46]) of TBCA or evaluated participant experience. The use of

in depth one-to-one interviews allowed us to explore a complex process by examining the

perceptions and shared experiences of TBCA.[47]

Our dataset included a large number of stakeholders from the three main cadres who

participate in TBCA, across four geographic footprints, purposely sampled to attain a wide

range of disciplines and working practices. Data analysis found recurrent themes that

indicated saturation[48], especially within the TB nurse specialist profession.




implementation of the NW TBCA. The themes evolving from framework analysis of the data

were further validated[49] by the use of two researchers to double code the transcripts and

discussion with a further author on emergent themes.




Information on participant preconceptions of TBCA were only collected after participants had

experienced cohort review which could introduce recall bias.




(NCL) TB Service TBCA in 2010 from an online questionnaire.[11] In agreement with our




Earlier studies suggest that unidisciplinary communities of practice retard the spread of

innovation[50] it may be that the TBCA differs by allowing knowledge transport to be

facilitated between professions by the use of chairs as ‘brokers’.[51]

TBCA appears to provide a mechanism for staff to speak up about unsafe practice and

organisational issues that affect care. Further, it appears that TBCA contributes to more

interaction between historically unequal professions which could make self-directed culture

change possible.[52]

Page 18 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



19




TBCA can be an important means of quality improvement in similar contexts.[53] PHE’s new

TB Strategy[5] promotes a coordinated approach to TB, involving NHS commissioners,

providers, local government and PHE through TB Control Boards. The model of TBCA

described here provides an important coordination mechanism through which the ‘soft data’

of process and learning can be an explicit part of the TB Strategy. The benefits of

communities of practice tend to accrue over time. The results of this study will be valuable

to the TBCA Steering Committee for reflection on how to further strengthen the community of

practice and a follow up, qualitative process evaluation could be valuable in the future.[54]

In such an evaluation it will be important to include individuals who choose not to attend

TBCA in order to gain insights into the barriers to attendance.

Conclusion

The Northwest TBCA model has enabled cross-professional collaboration and the

establishment of a community of practice which is facilitating a culture of shared experience,

open communication and respect. This community of practice is vital as a tool, which should

be sustained and further improved for continued quality improvement in TB control. Further

qualitative study of practitioners who are resistant to attending TBCA may provide a better

understanding of how to facilitate attendance.

The paper demonstrates the operational perspectives which underpin development of a

powerful and robust multi-disciplinary community of practice across a wide geographical

area. It will inform the establishment of effective TB cohort audits across the new TB Control

Board footprints (as established by PHE’s new TB Strategy).

Acknowledgements



Abbreviations



PHE Public Health England

TB Tuberculosis







Page 19 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



20

Funding statement




England or LSTM.



of the study: MW, PC, KD, SF, PMcM, CW, JW, DS, SBS. They contributed to the study

design and the writing of the paper. However the interviewing and data analysis were the

sole responsibility of SW and KJ who were independent of all Cohort Audit processes.

Otherwise we have no conflicts of interest to declare.

Data sharing

No additional data available.

REFERENCES





5. England PH. Collaborative tuberculosis strategy for England: 2015–20. 2015 6. Van Hest N, Aldridge R, De Vries G, et al. Tuberculosis control in big cities and urban risk

groups in the European Union: a consensus statement. 2014 7. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services

research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009;4(1):50

8. Organization WH. Implementing the WHO Stop TB Strategy: a handbook for national TB control programmes: World Health Organization, 2008.






14. England PH. Tuberculosis in England: 2015 report. 2015

Page 20 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



21

15. Hoppe LE, Kettle R, Eisenhut M, et al. Tuberculosis—diagnosis, management, prevention, and control: summary of updated NICE guidance. BMJ 2016;352:h6747

16. Summit TT. North West TB Regional Audit - Cohort Review Handbook. 2013 17. Group NWTCAS. North West TB Cohort Audit 2014 Report, 2014. 18. MacPherson PS, Stephen Bertel MD BChir, MD, FRCP; Cleary, Paul; Davies, Stefanie;

Wake, Carolyn; Dee, Katie; Walker, Jenny; Farrow, Stacey; McMaster, Paddy; Woodhead, Mark; Sloan, Derek James. Equitable tuberculosis care in the North West of England: analysis of TB cohort review data. The International Journal of Tuberculosis and Lung Disease 2016

19. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. Bmj 2000;321(7262):694-96

20. Green J, Thorogood N. Qualitative methods for health research: Sage, 2013. 21. King N, Horrocks C. Interviews in qualitative research: Sage, 2010. 22. Bryman A. Social research methods: Oxford university press, 2012. 23. Guion LA, Diehl DC, McDonald D. Triangulation: Establishing the validity of qualitative

studies. 2011 24. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research

(COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 2007;19(6):349-57

25. Patton MQ. Qualitative analysis and interpretation. Qualitative research and evaluation methods 2002;3:431-539

26. Jefferson L, Bloor K, Maynard A. Women in medicine: historical perspectives and recent trends. British medical bulletin 2015

27. Sofaer S. Qualitative research methods. International Journal for Quality in Health Care 2002;14(4):329-36

28. Gale NK, Heath G, Cameron E, et al. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology 2013;13(1):117


30. The Meaning of a Healthcare Community of Practice. Nursing forum; 2015. Wiley Online Library.




34. Wenger E, McDermott RA, Snyder W. Cultivating communities of practice: A guide to managing knowledge: Harvard Business Press, 2002.

35. Woodard F, Weller G. An action research study of clinical leadership, engagement and team effectiveness in working across NHS boundaries. Work Based Learning e-Journal 2011;1(2):80-119


37. Bell AV, Michalec B, Arenson C. The (stalled) progress of interprofessional collaboration: the role of gender. Journal of interprofessional care 2014;28(2):98-102



Page 21 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



22






45. Nasir L, Robert G, Fischer MD, et al. Facilitating knowledge exchange between health-care sectors, organisations and professions: A longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality. Health Service Delivery Research 2013;1(7)

46. May C, Finch T, Mair F, et al. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Services Research 2007;7(1):148





50. Ferlie E, Fitzgerald L, Wood M, et al. The nonspread of innovations: the mediating role of professionals. Academy of management journal 2005;48(1):117-34

51. Tasselli S. Social Networks and Inter-professional Knowledge Transfer: The Case of Healthcare Professionals. Organization Studies 2015:0170840614556917

52. Davies HTO, Mannion R. Will prescriptions for cultural change improve the NHS? BMJ 2013;346


54. Wenger E, Trayner B, de Laat M. Promoting and assessing value creation in communities and networks: A conceptual framework. The Netherlands: Ruud de Moor Centrum 2011

Page 22 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from




1 Male

10 Yrs

Nurse CL at the beginning many of my colleagues felt threatened by

it and there was some commentary from them about that,

it didn’t occur to me that it was looking at an individuals

practice to be critical of them so that was never a problem

I had and I think now that people have been to them that is

pretty much gone. I know that some of my colleagues in

the past have felt that they were doing the presentation

when the clinicians should have been doing it, it wasn’t

there decision and they had difficulty responding

they think we have got a tb lead

and they are attending

I think every case presentation needs to

be there to collect the data the form is

limited in the info it captures so it’s

quite repetitive

4 Female

11 Yrs

Nurse CM it doesn’t improve the length that the time of the patient is

diagnosedall they are doing is charting when it gets 1st

referred to other Tb services and to when the Tb nurse

does it . but the timing isn’t there and that is what NICE

guidelines introduced have always introduced a certain

time of getting the contact so again it is not even

measuring that it is just measuring they just pulled out a

figure out of the sky didn’t they. If all it is going to do is just

to say that everybody gets and HIV test and they never use

to have it that is extremely extravagant because that’s the

clear thing that people have improved upon, they cant just

suddenly cancel a clinic

You wont get standardisation of

treatment if consultants dont

turn up. trainee Drs or registrars

could attend. I am asking my

manager to come with me next

time she is coming cos she wants

to see it so she is coming next

time

they could cycle days surely . Nurses

chairing would allow you to see other

areas and what they do.I would think if

they got to a stagnant level of

improving the number of the outcomes

and there weren’t being improved I

think just presenting every two cases

every two minutes continuing to do

that may not have any benefit cos once

you have presented an x number of

cases they are all the same aren’t they

5 Female

15 Yrs

Nurse NM what we do need though is moving forward is the dates

well in advance , if the Drs are on the ward or if they are in

clinic they need to cancel them clinics well in advance they

don’t allow you to cancel a clinic no at 3 or 4 weeks notice,

we need the 12 month dates

I think its hard for them to

commit to giving their time and I

don’t think Tb is all they do it is a

small part of what most of the

consultants do so it isn’t

something that they are focused

on day in day out where as it is

for the Tb nurses we do it day in

day out so it is all of what we do,

so I mean that way they probably

I don’t think there was written

guidance it was all done initially not to

make it scary for the nurses, it was

done to be relaxing mm take your time

go through your forms nobody is going

to question you in a negative way it is

all supportive, maybe as people get

familiar to them they need a guidance

sheet that says this is the minimum we

need presenting. maybe co-charing

Page 23 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960





stand to get more out of it than

we could if they (attended).

Paediatric cases could all be

presented in one go.

Microbiologists should attend

would be nice but i do think the nurses

like having the sort of somebody that

they feel is expert and can answer all

those questions that we sometimes

cant . Could increase to full day to fit

everything in or add more in, you are

conscious that if it is not a cohort

review that it is another day that

people have got to take out of clinical

practice

6 Female

8 Yrs

Nurse NM when you're trying to fill that cohort review you can't alter

it once it's on, you know when it's all been pulled from ETS

you can't change it. Difficult to go back and fill in results

and treatment outcomes.

I think we should get some GPs

from different areas. it would be

nice, you know for us all really

that we get other input from

other places. Maybe you know

even from immunology or

somewhere like that, that we do

all the IGRA testing from, you

know someone come and giving

us a chat on that and explaining it

a little bit more in-depth. We do

these tests and you know

although we know why we're

doing them we don’t understand

them fully or the values and you

know ratios they use

I think we picked up last time that we

were going to try and invite, maybe

invite guest speakers to make the day a

little bit interesting so it doesn't get

monotonous, to break the day up. And

also maybe present a couple of cases,

so if we've got interesting cases for

instance, or we've got a child, maybe

look at their x-ray and see you know

different things in a bit more detail, a

bit more discussion around, monitor

the cases. And also to, you know get

more medical input to see how they

would deal with things, and do things

differently

Page 24 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960




Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357

No. Item

Guide questions/description Reported on Page #

Domain 1: Research team and reflexivity

Personal Characteristics

1. Inter viewer/facilitator Which author/s conducted the inter view or focus group?

Methods, p. 6

2. Credentials What were the researcher’s credentials? E.g. PhD, MD

MPH

3. Occupation What was their occupation at the time of the study?

Methods, p. 6

4. Gender Was the researcher male or female? Female

5. Experience and training What experience or training did the researcher have?

Methods, p. 6

Relationship with participants

6. Relationship established Was a relationship established prior to study commencement?

No

7. Participant knowledge of the interviewer

What did the participants know about the researcher? e.g. personal goals, reasons for doing the research

All attendees at TBCA were informed at cohort meetings that an evaluation would be taking place by a researcher independent to the TBCA process. This was reiterated during the interview.

8. Interviewer characteristics

What characteristics were reported about the inter viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic

Methods, p. 6

Domain 2: study design

Theoretical framework

9. Methodological orientation and Theory

What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis

Methods, p.6-7

Page 25 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



Participant selection

10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, snowball

Methods, p.6

11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email

Methods, p. 7

12. Sample size How many participants were in the study? Methods, p. 7

13. Non-participation How many people refused to participate or dropped out? Reasons?

Methods, p.7

Setting

14. Setting of data collection

Where was the data collected? e.g. home, clinic, workplace

Methods, p. 7

15. Presence of non-participants

Was anyone else present besides the participants and researchers?

Methods, p. 7

16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date

Results, p.7

Data collection

17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested?

Methods, p. 6.

18. Repeat interviews Were repeat inter views carried out? If yes, how many?

N/A

19. Audio/visual recording Did the research use audio or visual recording to collect the data?

Methods, p.7

20. Field notes Were field notes made during and/or after the interview or focus group?

Methods. p.7

21. Duration What was the duration of the inter views or focus group?

Methods, p.7

22. Data saturation Was data saturation discussed? Discussion p.17

23. Transcripts returned Were transcripts returned to participants for comment and/or correction?

Ethics, p. 7

Domain 3: analysis and findings

Data analysis

24. Number of data coders How many data coders coded the data? Methods, p. 7

25. Description of the coding tree

Did authors provide a description of the coding tree?

N/A

26. Derivation of themes Were themes identified in advance or derived from the data?

Methods, p. 7

27. Software What software, if applicable, was used to manage the data?

N/A

28. Participant checking Did participants provide feedback on the findings?

Participants were sent their transcripts to check for accuracy so could have commented on their own testimony, but not the findings of the full paper

Page 26 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from



(although this has been presented at the NW TB conference which was attended by many of the participants)

Reporting

29. Quotations presented Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number

Results Table 2

30. Data and findings consistent

Was there consistency between the data presented and the findings?

Relationship to existing knowledge

31. Clarity of major themes Were major themes clearly presented in the findings?

Results

32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?

Discussion p16.

Page 27 of 27


BMJ Open

123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960



jopen.bmj.com

/B

MJ O


arch 2016. Dow

nloaded from


bmj open · analysis interview transcripts were analysed thematically using the framework approach....

Documents