In qualitative research,
theory is used in three ways. First used as a basis for understanding
variables, constructs and to propose hypothesis as in the case of Ethnographic
studies. Secondly used a theoretical lens or perspective forming the overall
orientation for the data collection and research process. Third, the theory is
used at the end, where from the data broad themes are constructed and based on
which generalized model or theory is proposed. (Cresswell, 2007).  In case study, the generalizations
are done in ways, Propositional generalization which is researchers summary of
interpretations and naturalistic generalization based on researcher’s personal
experience (Stake, 1995, p. 86). Pattern theory as opposite to the causal
theory, does not require causal relationship between the interconnected
concepts or relationships. They form a sequence of stages or contributes
towards one single concept. (Neuman, 2000, p.38).

In the present study,
theory is used as an advocacy lens and as an end point. The theoretical
proposition based on the quality management and implementation literature,
quality guru’s ideologies, the different model, frameworks and expert opinions
is created, and it act as the Skelton for the case study protocol. The
theoretical proposition becomes the overall orienting lens at every stage of
the research. Secondly, the themes created from the data is analyzed based on
the proposed theories and attempts are made to identify broad patterns,
generalizations and theories.

Case Selection

The research is done with special reference to healthcare
sector in Kerala. Selecting Kerala for the study is apt as it is a state well
known for Advanced and sophisticated hospitals of International standards. Both Primary and Secondary data are used for the study.
Sampling for primary data collection is done at three levels; first for
choosing districts in Kerala for detailed study, second for selecting hospitals
from the districts and third for choosing respondents from the hospitals, for
qualitative and quantitative studies. The healthcare sector in Kerala is
subjected to a detailed analysis, from different dimensions. In the first stage, the Districts were divided into two
strata on the basis of indicators such as literacy rate, bed population ratio
(Private and Government) and the number of hospitals with quality
certifications. One District was selected at random from each of the strata and
the two districts namely Ernakulam and Idukki are selected for the study.
Ernakulam is one of the most developed districts in Kerala with the highest
number of hospitals with quality certifications like NABH, ISO, JCI etc. On the
other hand, Idukki is a high range district, with lesser number of townships
and lowest number of quality certified hospitals.

The case selection was done based on five main criteria – hospitals which
practices Allopathic medicine system, hospitals which has all the major medical
departments, hospitals with more than 250 bed capacity, started before 2010 and
has begun some quality management initiative. Only hospitals practicing Allopothic medicines with all the major
departments are taken for study to ensure common grounds for comparison. The third
and fourth criteria of 250 bed capacity and starting before 2010 are set under
the assumption that, these parameters of bigger magnitude hospitals will ensure
that the selected hospitals will have a researchable organisational structure
and scope for a detailed research.  The
hospitals which has a quality certification or began with the certification
process or those which had a quality certification at some point is included as
per the last criteria.

The hospitals in both
the districts meeting the set criteria was selected as the cases for the study
based on information from different sources like ‘ Panjayat level statistics,
2011 – Ernakulam District’, ‘Panjayath Level Statistics, 2011 – Idukki
District’, the listing of hospitals in quality certification bodies like NABH,
ISO, JCI etc and researcher’s personal meeting with the hospital authorities.
Under the required criteria, Ernakulam district and Idukki districts has a
total of 11 hospitals and 3 hospitals respectively. From both the districts, the medical colleges and research
centers are exempted as the systems and functioning of such institutions are different.
Hospitals which are part of a network of institutions are also not taken as
case sites, as the decision making is decentralized, and the administrative
activities are spread across it different segments. Hence, total number 10
hospitals were solicited to participate in the study. One hospital was
eliminated as the management was reluctant in taking part in the research.