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Table 1 Co-Development Research Process

From: Implementation science for ambulatory care safety: a novel method to develop context-sensitive interventions to reduce quality gaps in monitoring high-risk patients

Key Questions Based on NAM Improving Diagnosis Framework

PROBLEM: What vulnerabilities exist in monitoring outpatients for high risk conditions (e.g., cancer)?

SOLUTION: What elements of work systems and the diagnostic process are important to produce robust monitoring & thereby reduce diagnostic errors?

Stage 1: Identify 5 High-risk Populations and Clinical Informants

• Review literature

• Corroborate with local clinicians taking care of these patients

• Determine with clinical leadership who to interview, based on responsibility for patient monitoring (2-3 clinicians/clinic; 11 total)

Stage 2: Develop Journey Maps

• Identify key participants to learn about workflows for each high-risk population

• Elicit with semi-structured interview a description of the patient and data flow from worker’s vantage

• Visualize this information into swim lanes or “clusters” of activities

• Show swim lanes to participants and revise (as needed)

• Visit clinic sites to observe critical parts of process (as needed)

Stage 3: Generate Vulnerability List

• Abstract vulnerabilities from interview notes and journey maps

• Return to clinic participants to validate the list (one or more clinic has indeed experienced vulnerability)

• Map validated list of items to theory domains from applicable patient safety frameworks [1, 60]

Stage 4: Analyze Journey Maps for Commonalities

• Categorize types of activities in the journey using human factors method of process tracing (novel extension to derive tracings from journey maps)

• Generate process trace sequences for each clinic’s workflow [61]

• Look for patterns of workflow that are similar and variable across the 5 populations

Stage 5: Develop Design Seeds for Interventions and Link to Implementation Theory

• State what a solution would need to do to address vulnerabilities identified from previous stage

• Reduce the list to solution attributes (design seeds) that address common problems and needs across clinics

• Aim for design seeds that meet the generic needs of robust monitoring and that enable evaluation

• Hypothesize which contexts are likely to affect the effectiveness of the implementation of the interventions emanating from the design seeds using Taylor et al’s contextual domains and features (see Additional file 3) [39]

Stage 6: Seek Reactions from Clinics on Design Seeds

• Assess anticipated impact (improved monitoring of patients, reduced time spent by clinic team) and relative priority of each design seed (see Additional files 1 and 2 for script and data collection instrument used in each clinic)