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BMC Health Serv Res. 2019 Apr 29;19(1):270. doi: 10.1186/s12913-019-4084-3.

Involving end-users in the design of an audit and feedback intervention in the emergency department setting - a mixed methods study.

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Gehr Family Center for Health Systems Science, Department of Medicine, Keck School of Medicine, University of Southern California, 2020 Zonal Ave, IRD 318, Los Angeles, CA, 90033, USA.
Cedars-Sinai Center for Outcomes Research and Education, Department of Medicine, Division for Health Services Research, Cedars-Sinai Medical Center, 116 N. Robertson Boulevard, PACT 801, Los Angeles, CA, 90048, USA.
Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA.
Interactive Media & Games Division, School of Cinematic Arts, University of Southern California, 900 West 34th Street, Los Angeles, CA, 90089, USA.
Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N Soto Street, Los Angeles, CA, 90032, USA.
Department of Emergency Medicine, Keck School of Medicine, University of Southern California, 1200 N State Street, Room 1011, Los Angeles, CA, 90033, USA.



Long length of stays (LOS) in emergency departments (ED) negatively affect quality of care. Ordering of inappropriate diagnostic tests contributes to long LOS and reduces quality of care. One strategy to change practice patterns is to use performance feedback dashboards for physicians. While this strategy has proven to be successful in multiple settings, the most effective ways to deliver such interventions remain unknown. Involving end-users in the process is likely important for a successful design and implementation of a performance dashboard within a specific workplace culture. This mixed methods study aimed to develop design requirements for an ED performance dashboard and to understand the role of culture and social networks in the adoption process.


We performed 13 semi-structured interviews with attending physicians in different roles within a single public ED in the U.S. to get an in-depth understanding of physicians' needs and concerns. Principles of human-centered design were used to translate these interviews into design requirements and to iteratively develop a front-end performance feedback dashboard. Pre- and post- surveys were used to evaluate the effect of the dashboard on physicians' motivation and to measure their perception of the usefulness of the dashboard. Data on the ED culture and underlying social network were collected. Outcomes were compared between physicians involved in the human-centered design process, those with exposure to the design process through the ED social network, and those with limited exposure.


Key design requirements obtained from the interviews were ease of access, drilldown functionality, customization, and a visual data display including monthly time-trends and blinded peer-comparisons. Identified barriers included concerns about unintended consequences and the veracity of underlying data. The surveys revealed that the ED culture and social network are associated with reported usefulness of the dashboard. Additionally, physicians' motivation was differentially affected by the dashboard based on their position in the social network.


This study demonstrates the feasibility of designing a performance feedback dashboard using a human-centered design approach in the ED setting. Additionally, we show preliminary evidence that the culture and underlying social network are of key importance for successful adoption of a dashboard.


Audit and feedback; Culture; Dashboard; Emergency Department; Human centered design; Performance feedback; Social network

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