Hi Katheryn



Your project sounds really interesting. In terms of your CMOs, I would suggest thinking of the mechanism in terms of the reasoning or response of the team members and thinking through what it is about the context that would lead them to respond in that way. For example, I would see 'reduction in variability in terminology' as an intermediate outcome, rather than a mechanism. To work out the contexts, I would think about what is necessary for the introduction of the resource to be successful. For example, what is necessary for instant feedback of case status (resource) to lead to learning and debriefing? Is it that staff actually have to perceive the value of this (context) and so respond to the blast messages as an opportunity for reflection and learning? 



Best wishes



Rebecca 



Dr Rebecca Randell

Lecturer

School of Healthcare

Baines Wing (room G.16a – please note change of room)

University of Leeds

Leeds LS2 9UT

Tel: +44 (0) 113 343 1337

Email: [log in to unmask]









-----Original Message-----

From: Realist and Meta-narrative Evidence Synthesis: Evolving Standards [mailto:[log in to unmask]] On Behalf Of Katheryn Courville

Sent: 11 September 2015 19:47

To: [log in to unmask]

Subject: Contingency CMO configurations



For my dissertation I am proposing a realist evaluation (RE) of a mobile application used by healthcare workers to improve team-based care (TBC) for a patient experiencing a ST-elevated myocardial infarction (STEMI).  I am currently writing my proposal and need feedback on whether or not I am on the right track...or if I have derailed....or if I'm still at the station.  I am open to comments.



Background (briefly)

The American Heart Association offers guidelines and protocols for the care of a patient experiencing an acute STEMI (a type of heart attack requiring immediate reperfusion interventions such as stent placement).  In accredited healthcare facilities, STEMI care teams are established.  Team members include pre-hospital personnel (paramedics), emergency department nurses and physicians, cardiac catheterization lab team members (nurses, technicians, and cardiologist), and hospital rapid response teams or house supervisors. Also included are non-clinician roles such as unit clerks and a STEMI care coordinator (usually a nurse) who oversees the STEMI program and collects/disseminates reportable statistics to accreditation agencies.  All personnel are considered part of the team and have responsibilities upon the activation of a STEMI (activation = the first notification of a patient experiencing signs & symptoms of STEMI).  

	Using “old” (ha!) technology, the process of activation included paramedics faxing electrocardiograms (ECG) from the field to the emergency physician for verification of the STEMI, faxing the same ECG to a cardiologist, paging physicians (and waiting for call backs), paging cath  lab team members to set up for a case, paging rapid response team members (or house supervisors) notifying them of a STEMI coming in. A unit clerk usually does the paging and records times of activation and activity.  

	The technology to be evaluated is called StopSTEMI© a mobile application downloaded onto all team members (or departmental) mobile devices (smart phones or tablets).  This technology offers resources to improve upon team-based care thus leading to reduced patient times and thus improving patient outcomes. When a team member (typically paramedic in the field) activates the STEMI application, all team members receive instant notification that a possible STEMI is afoot.  The ECG is transmitted (securely) to all team members at once.  Blast communication among team members is used instead of one individual (unit clerk) paging various team members and waiting for call backs.  The application has been used in many hospitals in the U.S. including the hospital for which I work as an emergency nurse. I have seen the app in use, and this helped me create my CMOs.



Devising contingency CMO configurations 

	In order to come up with initial/contingency CMO configurations, I started with the developer’s website (www.pulsara.com)  and viewed the marketing material to determine the resources/features offered by the app.  In the table below, I list the resources in the left-hand column.  From these resources, I created CMO configurations. I was aided by a model for team-based care (Mitchell et al., 2012), the principles of which are: shared goals, clear roles, mutual trust, effective communication, and measureable processes & outcomes).  These principles (as well as a cursory review of lit and my own experience working in the emergency dept) guided me in creating CMOs.  As you can see below, for some resources, the result of the resource (real-time communication (R5) results in instant feedback) created a new resource with a new CMO.  This began to blow my mind, so I stopped after 6 (of 12) identified resources.  







(my table didn't paste over nicely)  I have labeled my resources (R1, R2...)



Standardized communication (R1)	Standardized communication (R1) will reduce the variability in terminology (M1) in TBC* (C1) leading to improved interprofessional communication (O1)



Universal clock (R2)	A universal clock (R2) syncs the entire case (M2) no matter which team member is entering data into the record (C2) leading to a more accurate record of patient times** (O2)



One-step (“tap”) entering of information (R3)	One-step ("tap") entering of information (R3) allows for quick and easy logging of information (M3) for team members who are busy (C3) leading to reduced patient times (O3a)



One-step ("tap") entering of information (R3) allows for quick and easy logging of information (M3) for team members who are busy (C3) leading to user satisfaction (O3b)



Administrator dashboard (R5)	The administrator dashboard (R4) collects pertinent case information in one location (M4a) in TBC (C4) leading to accountability and transparency of job-specific benchmarks (O4a) 



The administrator dashboard (R4) allows the care coordinator to view all relevant case data in one location (M4b) in TBC (C4) leading to user satisfaction (O4b)



Real-time communication (to all team members) (R5)	Real-time communication with all team-members via blast messages (R5) provides timely uniform information dissemination (M5a) in TBC (C5) allowing for better utilization of resources (O5a), reduced patient times (O5b) and user satisfaction (O5c)



Real-time communication with all team-members via blast messages (R5) provides instant feedback of case status (what happened to patient?) (M5b) in TBC where members are located in different departments and facilities (EMS/emergency dept/cardiac cath lab) (C5b) provides opportunities for learning and debriefing by all members (O5d)



Instant feedback (R5b/R6?) - [this is a result of real-time communication (R5)] provides opportunities for learning and debriefing by all members (M5c?) in TBC where members are located in different depts and facilities (C5b) leading to improved patient times (O5e)



Abbreviations/Definitions:

*TBC = team-based care in time-sensitive disease process (such as STEMI)

**patient times = the reportable times such as “door-to-balloon” time (the time the patient enters the emergency room “door” to the time when reperfusion occurs (a balloon is inflated in the occluded coronary artery thus allowing for reperfusion of the tissue)