Table 3.

Catalyst team members experience with each phase of the Collaborative Reflexive Deliberative Approach

CRDA phase	Catalyst team experience with CRDA phase
Refining original published studies (Circle A in Figure 1)	In August 2010, we converged on the picturesque colonial era town of Lambertville, New Jersey on the Delaware River, each of us equipped with publications and reports generated through large-scale projects in which we had participated from our particular context. We each optimistically hoped our own work would contribute to a comprehensive understanding of primary health care reform, and in retrospect, had the simplistic idea that we would ‘compare and contrast’ and ‘cut and paste’ our results into common themes that would generate a comprehensive cross-contextual approach to primary healthcare reform. However, it soon became clear that we needed to understand the real story behind each of the ‘published stories’ in order to transcend contexts. To find the ‘gems’ that cut across stories, we were compelled to capture core concepts from each study on yellow cards and placed these on a huge storyboard (the floor). Everyone stood around contemplating and some eventually began ‘pile sorting’, physically moving cards back and forth—all the time negotiating meaning and intent, much like a distant image coming in and out of focus until finally commonalities of perspective and meaning emerged. Diversity of players was important to this process, but so was having an outside facilitator to keep the discussions moving with some coherence. While some took a big picture perspective and pulled diverse threads together, others listened and extracted concrete commonalities. It was amazingly generative, frustrating, stimulating, productive and fun. These were not words we had commonly used to describe our research, but it was definitely an experience that renewed our faith in the power of research to contribute to change.
Organizing broader study material (Circle B in Figure 1)	We left Lambertville with enthusiasm and a lot of great ideas, but also knowing we would need another face-to- face meeting before our next major gathering. Fortunately, most of our collaborative team was planning to attend an upcoming NAPCRG conference, so we reserved a conference room for the afternoon of the final day of the conference. Early in this 5 h intense sprint one of the participants led off with, ‘I went back this morning to the Pawson realist synthesis paper and it’s not clear what the difference is between mechanism and context’. That’s all it took to get us on a prolonged rant on definitions and strategies for completing matrices. In fact, a whole host of challenges to completing the matrices had emerged over the previous 2 months as investigators attempted to fill in cells from their studies. This meeting became critical for hashing out differences in definitions and coming up with clearer and shared understanding for what went into each cell. Having the same facilitator from our initial retreat was critical; although this time she was present only via Skype and clearly had challenges in keeping things on track. By the end of the meeting, we fully realized that for our next retreat to be successful, we would need to have a smaller group really focus on completing the matrices.
Interpreting collaborative knowledge (Circle C in Figure 1)	Coming off our brief second face-to-face meeting at NAPCRG, a smaller analysis group was formed and met monthly to prepare for what was to be our defining meeting at Sorrento, Victoria, Australia in February 2011. The initial meeting of this smaller group began by summarizing decisions made by the larger group at NAPCRG and expanding on the analysis from that meeting. We paid particular attention to changes in the research questions and clarification of how we were using the three matrices (context, mechanisms and findings), being explicit about how we defined the rows and columns that populated each matrix. We quickly acknowledged the difficulty of ‘analysing from a distance’. Our second meeting focused specifically on the mechanisms matrix. There was some difficulty for the group in coming up with a shared definition of ‘mechanisms’ for this study and it was sometimes conflated with ‘findings’. One member said we needed to be ‘nose-to-nose’ to clarify the meanings we were making of the analytic matrix and data analysis. We decided to focus on the findings matrix and use this, along with the context matrix, to prepare for the next face-to-face meeting and discussed how we could make our short time together most productive. It was decided that one member would start a cross-case analysis, present these interim findings to the larger group at the next face-to-face meeting and that would springboard the discussion into further analysis. As the face-to-face Sorrento retreat neared, the analysis group reflected on the logistics of organizing the meeting, all the while keeping in mind that the Sorrento retreat needed to develop a conceptual framework, plan the writing of publications, and identify options for future studies to enable the group to keep working together and further develop our findings.
Integrating experiential reflections (Circle D in Figure 1)	After 8 months of really getting to know each other by iterating ideas and painstakingly completing data matrices, the collaborative Catalyst team reconvened for its final multi-day retreat at the Hotel Sorrento overlooking Port Phillips Bay in Victoria, Australia. We had done a lot of work to this point, but we were far from agreement and really needed this 2½ day retreat to solidify our thinking. With flip-chart stands in each corner for jotting ideas, a large white board, and a computer projecting onto a large screen for taking notes, we were ready for what we hoped was the final push. To get us started, Will Miller summarized five initial conditions and eleven findings that came from the summary. Almost immediately there was a lot of bantering back and forth, but there appeared to be partial agreement on most of these. By lunch of the first full day, we had a couple of model diagrams on the white board and by the end of the day we had made a lot of progress on a general outline and some key propositions that would drive a manuscript summarizing the deliberative synthesis. Nevertheless, we were still struggling with the terminology and found words were easily muddled. At one point, Mark suggested that changing concepts to verbs might help, using words like connect, communicate, coordinate, cooperate, collaborate and integrate. The group, especially the physicians, was really struggling with the discovery that physician autonomy and dominance was potentially the most potent barrier to team formation. Thankfully the work was interspersed with walks along the shoreline, regular breaks and congenial chats over meals.