Table 1.

Emergence of the Study Design

YearIntended Study Design for the YearEvents Within the Year Requiring Design Change
PCG = Primary Care Groups; PCT = Primary Care Trust.
First year (2000)Comparative case studies of clinical governance programs of 4 PCGsLocal facilitators never started in-practice work and withdrew from the project
Intervention PCGs used local multidisciplinary teams to facilitate change within practicesUnexpected announcement of fast progress toward PCT status altered priorities of clinical governance groups
Amalgamated near-clinical indicators from practice computers would contribute to comparative dataNear-clinical indicators impossible to gather from practice computers
Second year (2001)Comparative aspects of the study abandoned
 At request of intervention sites, facilitators refocused away from the clinical governance programs to support reflection and action inside the clinical governance subcommittees themselves. Doing so focused on effective meeting behavior and how to carry into the PCT their most valuable work
 Studies of nurses and financial directors took place hereEmerging enthusiasm among stakeholders that ideas about learning organizations and participatory action research help to understand learning and change in the health care system
 Recognition among the stakeholders that facilitation of learning and innovation had less to do with formal structures and more to do with facilitative processes that free up conversations and reflections throughout the system, helping local people to make “top down” models relevant within their specific context
Third year (2002)Refocus away from structures and roles within PCGs toward analysis of what things help and hinder people to do things for themselvesThe start of PCTs and a realization among participants that their size and complexity requires rethinking about the meaning of leadership in primary care