To create learning initiatives that improve healthcare outcomes, we need to focus on what is going on now, and what the ideal state could be. It is easy to make assumptions about both the current and future states, but as we have learned from lean initiatives, the best bet is to always ‘go to the Gemba’ (go to the real place where work is done). Focus groups are an efficient way of getting the voice of the customer and may help you to develop creative solutions that may have otherwise been missed.

The concept of a focus group is not new and is frequently used in qualitative and marketing research. Within education, focus groups may feel a bit more like debriefing, but the principles are the same:

1. Gather a group of similar participants that are directly connected to the problem to be solved. Ideally, you should take a 360 approach, and have separate groups around the work, such as frontline staff, management, and educators to provide different perspectives.
2. Set a safe environment for the focus group (Learning Card 4). ‘Vegas Rules’ of what happens here, stays here, works, with the key being that facts/findings will be shared, not WHO participated or said any particular comment.
3. Guide the group through three questions about the problem:
   • What is working?
   • What could be better?
   • If you were CEO (or other appropriate ‘boss’) what would you do?
4. Collect all ideas and provide a summary report (both to participants and stakeholders).

Figure 1: Focus Group Format – Learning Card 12

Choosing the correct individuals to be in your focus group can be difficult, and may require multiple attempts. When in doubt, you should err on the side of adding another focus group, even if you are not sure what they can add. Educators often make the wrong assumption that the students do not know what they are missing so they cannot provide useful feedback (in other words, the educator ‘knows better’ than the student). In actuality, it is rather remarkable how much students may know what they are missing and what would help. For example, to improve nursing orientation in a hospital, focus groups were completed with current orientees (or had just completed orientation), preceptors, managers and educators:

Figure 2, Sample focus groups findings for Nursing Orientiaton (Zigmont et al, 2015)

Creating a safe environment for focus groups may be difficult, if they are a ‘new’ concept to the group, and if the topic is ‘tough’ (see Learning Card 4 for more about setting a psychologically safe environment). Most commonly, participants will worry that what they say will get back to their boss (or the like) and will negatively impact their work or grades. Participants will need to trust the facilitator and will only take back facts (not who said them), and sometimes it will take a few focus groups before people feel comfortable. The facilitator will also need to be someone outside of the participants ‘chain of command’ (watch out for power differentials), and the participants will need to feel that the facilitator truly is curious (rather than trying to point the finger at someone/something). You may not be able to complete focus groups with your students or staff and may need help from others to make it a safe environment. Additionally, each focus group, and individuals within, need to be safe and is best done within a group of peers. Try to set up separate focus groups for staff and management (or students and teachers).

The three questions (what worked, what could be better and if ceo…) are not prescriptive, but reflect a good starting point for most problems. Participants will often not have a problem answering what works or what could be better, but may struggle with what to do if they were CEO (or another boss, Dean, etc…). The intent of the ‘if CEO’ question is to get participants out of their habit of having a ‘gripe session’ and focus on how to improve. Skilled facilitators will need to help the group fill all three sections equally (or as close as possible) and not focus on one or another. It is common for participants in a focus group to spend more of their time on the negative, but if they say everything is perfect (and you are there to do a problem identification step) double check to make sure the environment is safe for sharing or if there is a reason everything is perfect (as nothing truly is).

When having participants answer the three questions, the two most common methods for conducting these sessions are open and closed brainstorming. Open brainstorming, or sharing, is familiar to most and looks like a facilitator (or scribe) writing down ideas thrown at them verbally from the group. Open discussion can be useful, but keep an eye out for the quiet ones and ensuring all perspectives are gathered. Closed brainstorming may help get more perspectives and create an environment for sharing. The first step is to have each participant put all of their answers to the three questions on a post-it note (one idea per note, and have them designate if it is positive, negative or CEO) and then placing them on a whiteboard under each category. The facilitator (or participants) can then sort them into related ideas, and have a discussion about why some things are more common than others. The closed brainstorming format allows for quantifying ideas (i.e. 6 out of 7 participants stated) and is fascinating when multiple people in a group have the same idea of how to improve (or what they would do as CEO), as it provides credibility to an idea.

Reporting focus group data varies by the audience that will be receiving the report. If you have done closed brainstorming it is often impactful to share a photograph of everyone’s ideas. The goal is to let the data provide the ‘why’ behind the problem you are solving. In the example above, the ‘what’ showed a 40% increase in orientation budget year over year, and the focus groups showed it was because of a series of factors in each the individual (or learner), experience and the environment. Most focus groups lead to some surprising ‘ah-ha’ moments, and simple solutions that can be tried. Your report of the focus group should provide context, and ideally verbatim statements, that illustrate the why (and support your solution recommendation). It is good practice to share these reports with participants of the focus groups as it builds buy-in and credibility.

When reporting the data, you may be pressured by the receiver on who said what. Hence the reason for anonymity, (such as with post-it notes) and adherence to the Vegas rules. Receiving focus group data can be challenging, and it is common for the stakeholder to try to reason out the data and blame certain individuals or groups. Be strong, and don’t give in as it will hurt both you personally, and the ability to use focus groups in the future. You will need to redirect the receiver to the overall themes, and help them not to try to figure out who said what.

Application Experience:

Time to complete: 30 minutes

Participants: 6-10 (for this exercise it does not matter who)

Directions:

The best way to work with focus groups is to do one. You can either complete this exercise with a problem you are currently trying to solve, or use the topic of: “How to improve compliance with hand washing.”

• Ask 1 participant to ‘sit out’ the focus group and provide feedback to you on the process and your facilitation of the group. Have them focus on how you set a safe environment and if you stayed curious throughout (i.e. asked effective questions rather than making statements or guiding the group to an answer). Don’t be afraid to ask the group how to make the environment safe.
• Hand out post-it notes to all participants and have them do closed brainstorming for each of the three questions.
• Post the answers in a column for each. (Start grouping post-it notes as you post them.)
• Facilitate a discussion with the group about the responses they gave.
• Close the session by highlighting the key findings you would share with a stakeholder from the focus group and what other interested parties you would want to invite to future focus groups.

References

Zigmont, J.J., Wade, A., Edwards, T., Hayes, K., Mitchell, J., Oocumma, N., (2015) Utilization of Learning Outcomes Model Reduces RN Orientation by >35%, Clinical Simulation in Nursing Vol. 11, No 2, pp.79-94

This part of a series called “Learning That Works” by Jason Zigmont, Ph.D.,  (jay.zigmont@gmail.com ). For a video on this topic and more information, visit http://L12.LearningInHealthcare.com . The principles above are part of the core content (Learning Card 12) of the Foundations of Experiential Learning Manual (http://FEL.learninginhealthcare.com). To view the video directly, scan this QR Code: