Frontline Providers' and Patients' Perspectives on Improving Diagnostic Safety in the Emergency Department: A Qualitative Study.

BACKGROUND: Few studies have described the insights of frontline health care providers and patients on how the diagnostic process can be improved in the emergency department (ED), a setting at high risk for diagnostic errors. The authors aimed to identify the perspectives of providers and patients on the diagnostic process and identify potential interventions to improve diagnostic safety. METHODS: Semistructured interviews were conducted with 10 ED physicians, 15 ED nurses, and 9 patients/caregivers at two separate health systems. Interview questions were guided by the ED-Adapted National Academies of Sciences, Engineering, and Medicine Diagnostic Process Framework and explored participant perspectives on the ED diagnostic process, identified vulnerabilities, and solicited interventions to improve diagnostic safety. The authors performed qualitative thematic analysis on transcribed interviews. RESULTS: The research team categorized vulnerabilities in the diagnostic process and intervention opportunities based on the ED-Adapted Framework into five domains: (1) team dynamics and communication (for example, suboptimal communication between referring physicians and the ED team); (2) information gathering related to patient presentation (for example, obtaining the history from the patients or their caregivers; (3) ED organization, system, and processes (for example, staff schedules and handoffs); (4) patient education and self-management (for example, patient education at discharge from the ED); and (5) electronic health record and patient portal use (for example, automatic release of test results into the patient portal). The authors identified 33 potential interventions, of which 17 were provider focused and 16 were patient focused. CONCLUSION: Frontline providers and patients identified several vulnerabilities and potential interventions to improve ED diagnostic safety. Refining, implementing, and evaluating the efficacy of these interventions are required.

Examining the differences of perceptions and experience with online health information accessibility between deaf and hearing individuals: A qualitative study.

OBJECTIVE: Describe and compare the experiences and preferences of Deaf and hearing individuals with different levels of health literacy in accessing, interpreting, and acting upon online health information. METHODS: We conducted semi-structured interviews with 17 Deaf and 10 hearing participants with high and low health literacy from three healthcare sites. We conducted thematic analysis of the transcripts to explore information navigation experiences, information sources and dissemination preferences. RESULTS: We found thematic differences between Deaf and hearing participants with high and low health literacy in terms of information needs, information search experiences, information search perceptions, and preferred information dissemination approaches. Relative to hearing counterparts, Deaf participants were more likely to encounter challenges in accessing and understanding online information. Deaf participants with low health literacy were more likely to rely on visual graphics to support their understanding of the information than those with high health literacy. Deaf participants advocated for tailored approaches to disseminate health information to Deaf communities. CONCLUSION: Our findings suggest that differences in online health information navigation experiences and accessibility may inform disparities in health literacy outcomes between Deaf and hearing individuals. PRACTICE IMPLICATIONS: Online health information should be presented in a manner accessible to Deaf community members.

Validation of the Measurement Approaches to Partnership Success (MAPS) Questionnaire.

Conceptualizing and testing factors that contribute to the success of community-academic partnerships are critical to understanding their contributions to the health and well-being of communities. Most measures to date focus on factors that contribute to the development of new partnerships, and only a few have been adequately tested and validated. Methods. The Measurement Approaches to Partnership Success (MAPS) study followed a community-based participatory research (CBPR) approach and a multiphase process that included the construction and pilot testing of a questionnaire, and a national survey to validate the psychometric properties of the questionnaire in long-standing CBPR partnerships (existing ≥ six years). All members within partnerships were recruited to complete the survey (55 partnerships with 563 partners). We used confirmatory factor analysis (CFA), Cronbach's alpha statistics, and a pairwise correlations approach to assess discriminant and convergent validity, and assessed internal consistency, and test-retest reliability. Results. All MAPS Questionnaire dimensions demonstrated strong validity and reliability and demonstrated agreement over time. Conclusion. The MAPS Questionnaire includes seven dimensions and 81 items related to the MAPS conceptual model and provides a scientific, in-depth measurement tool that allows long-standing CBPR partnerships to evaluate their work toward achieving health equity.

Cultivating an ecosystem: A qualitative exploration of sustainability in long-standing community-based participatory research (CBPR) partnerships.

Background: While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence ≥ 6 years) CBPR partnerships. Objectives: The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships. Methods: This qualitative analysis is part of Measurement Approaches to Partnership Success (MAPS), a participatory mixed methods validity study that examined "success" and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semi-structured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships. Results: The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership's work and of ongoing relationships among partners. Conclusions: Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

Cultivating an Ecosystem: A Qualitative Exploration of Sustainability in Long-Standing Community-Based Participatory Research Partnerships.

BACKGROUND: While sustainability is crucial to the success of community-based participatory research (CBPR) partnerships, there is a lack of conceptual clarity on what defines sustainability and what characterizes sustainability-promoting practices in long-standing (in existence 6 years or longer) CBPR partnerships. OBJECTIVES: The aim of this article is to explore the definition of sustainability, as well as practices that influence sustainability from the perspectives of academic and community experts in long-standing CBPR partnerships. METHODS: This qualitative analysis is part of Measurement Approaches to Partnership Success, a participatory mixed methods validity study that examined "success" and its contributing factors in long-standing CBPR partnerships. Thematic analysis of 21 semistructured interviews was conducted, including 10 academic and 11 community experts of long-standing CBPR partnerships. RESULTS: The key defining components of sustainability we identified include: distinguishing between sustaining the work of the partnership and ongoing relationships among partners; working towards a common goal over time; and enduring changes that impact the partnership. We further identified strengthening and capacity building practices at multiple levels of the partnership that served to promote the sustainability of the partnership's work and of ongoing relationships among partners. CONCLUSIONS: Sustainability can be understood as supporting an ecosystem that surrounds the beneficial relationships between academic and community partners. Ongoing evaluation and application of practices that promote the sustainability of partnership activities and relationships may strengthen the long-term effectiveness of CBPR partnerships in advancing health equity.

The Measurement Approaches to Partnership Success (MAPS) Questionnaire and Facilitation Guide: A Validated Measure of CBPR Partnership Success.

Partnerships that effectively engage in certain key structural and process functions are more likely to meet their research goals and contribute to longer-term health equity outcomes. Ongoing evaluation of partnerships' level of achievement of these key functions, along with their fidelity to the guiding principles of community-based participatory research (CBPR), is therefore essential to understand how they can achieve desired partnership outcomes. This article describes the validated Measurement Approaches to Partnership Success (MAPS) Questionnaire and the use of an accompanying Facilitation Guide in helping members of CBPR partnerships evaluate their partnership's state of development and interpret findings to improve its structure, processes, and outcomes. We describe the conceptual framework guiding the development of the MAPS Questionnaire and its 81-item across seven key outcome dimensions, along with 28 items measuring precursor characteristics of CBPR partnership outcomes. The Facilitation Guide provides general guidelines for sharing, interpreting, and applying results within partnerships using a participatory process, definitions and items for each dimension, an example of presenting summary means, and dimension-specific reflective questions for discussion. We offer recommendations for practical uses of the MAPS Questionnaire and Facilitation Guide. Whether used as a comprehensive tool or by dimension, the MAPS Questionnaire is conceptually sound and empirically validated for evaluating how CBPR partnerships can achieve long-standing success. CBPR partnerships at any stage of development will find the MAPS Questionnaire and Facilitation Guide useful in measuring and interpreting indicators of partnership success, sharing results, and improving their ability to contribute to achieving health equity goals.

Patient-reported outcomes in clinical HIV care: protocol for a single-centre, multistage, mixed-methods study in Denmark.

INTRODUCTION: People with HIV-1 (PWH) have worse health-related quality of life (HRQoL) compared with the general population. Using patient-reported outcomes (PROs) may help reorient the focus of HIV care towards improving HRQoL. This study aims to develop, implement and evaluate the use of PROs in HIV care. METHODS AND ANALYSIS: This is a Danish single-centre, multistage mixed-methods study consisting of four substudies (studies I-IV). Study I is a qualitative focus group interview study aiming to identify relevant PRO domains, and barriers and benefits to PRO use. Participants are 5-10 PWH and 5-10 HIV healthcare providers (HCPs). Data are thematically analysed. Results will guide the design of a PRO measure (PROM). Study II is a quantitative study aiming to assess PWH's willingness and ability to engage with PRO. All PWH are consecutively invited to complete the PROMs before their next consultations. Demographic data are collected at enrolment. Differences between PWH who do/do not complete the PROMs are assessed. Study III is a quantitative before-and-after study aiming to assess the impact of PRO use on HCP awareness. Participants are all who complete the PROMs in Study II. In contrast to study II, HCPs are notified of the PROM results. The number of problems documented by the HCP in patients' medical records during studies II and III are compared using χ2 tests. Multiple regression models are used to identify factors associated with HCP awareness. Study IV is a qualitative study aiming to explore PWH and HCP experiences of using PROs. Participants are 15-20 PWH and 10-15 HCP. Data are collected from participant observation of PRO consultations and individual interviews. Data are analysed thematically. ETHICS AND DISSEMINATION: This study is approved by the Danish Data Protection Agency. Participants will provide written consent prior to participation. Results will be published in peer-reviewed journals.

Expanding Our Methodological Toolbox to Improve Quality: The Role of Mixed-Methods Evaluations.

The care delivered to patients with cardiovascular disease involves coordination among a multitude of clinical team members spanning diverse inpatient and outpatient settings. The majority of quality improvement interventions in cardiovascular care have been developed based on quantitative evidence, which neither fully accounts for multilevel determinants (eg, patient, clinician, and institution) nor contextualization from key informants. The rigor and effectiveness of these interventions would be enhanced by mixed-methods studies whose strengths include (1) the use of qualitative research methodologies (eg, eliciting patient or clinician perspectives on barriers and facilitators of best practices) and (2) integrating qualitative and quantitative data and analyses to understand more fully effective strategies for achieving optimal care and outcomes for these patients across diverse settings. This article illustrates the application of a complex mixed-methods design to advance an evidence-based, customizable infection prevention toolkit for durable left ventricular assist device therapy. The study (1) uses quantitative clinical data merged with Medicare claims to evaluate interhospital variability in the incidence of infection; (2) uses qualitative methods to understand local practice patterns across low- and high-performing centers; and (3) integrates both data sources to gain a comprehensive understanding of the overall findings.

Incidence of Newborn Drug Testing and Variations by Birthing Parent Race and Ethnicity Before and After Recreational Cannabis Legalization.

Importance: Thirty-seven US states and the District of Columbia mandate reporting newborns with suspected prenatal substance exposure to the state, and punitive policies that link prenatal substance exposure to newborn drug testing (NDT) may lead to disproportionate reporting of Black parents to Child Protective Services. The impact of recreational cannabis legalization on racial disproportionality in NDT is unknown. Objectives: To examine variations in the incidence and results of NDT by birthing parent race and ethnicity, variables associated with variation, and changes after statewide legalization of recreational cannabis. Design, Setting, and Participants: This retrospective cohort study was conducted from 2014 to 2020 with 26 366 live births to 21 648 birthing people who received prenatal care at an academic medical center in the Midwestern United States. Data were analyzed from June 2021 to August 2022. Exposures: Variables included birthing parent age, race, ethnicity, marital status, zip code, insurance type, prenatal and newborn diagnoses codes, and prenatal urine drug test orders and results. Main Outcome and Measures: The primary outcome was an NDT order. Secondary outcomes were substances detected. Results: Among 26 366 newborns of 21 648 birthing people (mean [SD] age at delivery, 30.5 [5.2] years), most birthing parents were White (15 338 [71.6%]), were non-Hispanic (20 125 [93.1%]), and had private insurance coverage (16 159 [74.8%]). The incidence of NDT ordering was 4.7% overall (1237 newborns). Clinicians ordered more NDTs for Black compared with White newborns (207 of 2870 [7.3%] vs 335 of 17 564 [1.9%]; P < .001) when the birthing parent had no prenatal urine drug test, a presumably low-risk group. Overall, 471 of 1090 NDTs (43.3%) were positive for only tetrahydrocannabinol (THC). NDTs were more likely to be positive for opioids in White compared with Black newborns (153 of 693 [22.2%] vs 29 of 308 [9.4%]; P < .001) and more likely to be positive for THC in Black compared with White newborns (207 of 308 [67.2%] vs 359 of 693 [51.8%]; P < .001). Differences remained consistent after state recreational cannabis legalization in 2018. Newborn drug tests were more likely to be positive for THC after legalization vs before legalization (248 of 360 [68.9%] vs 366 of 728 [50.3%]; P < .001) with no significant interaction with race and ethnicity groups. Conclusions and Relevance: In this study, clinicians ordered NDTs more frequently for Black newborns when no drug testing was done during pregnancy. These findings call for further exploration of how structural and institutional racism contribute to disproportionate testing and subsequent Child Protective Services investigation, surveillance, and criminalization of Black parents.

Mortality following durable left ventricular assist device implantation by timing and type of first infection.

OBJECTIVE: Although infections are common after left ventricular assist device implantation, the relationship between timing and type of first infection with regard to mortality is less well understood. METHODS: The Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support patients receiving a primary left ventricular assist device from April 2012 to May 2017 were included. The primary exposure was defined 3 ways: any infection, timing of first infection (early: ≤90 days; intermediate: 91-180 days; late: >180 days), and type (ventricular assist device specific, ventricular assist device related, non-ventricular assist device). The association between first infection and all-cause mortality was estimated using Cox regression. RESULTS: The cohort included 12,957 patients at 166 centers (destination therapy: 47.4%, bridge-to-transplant: 41.2%). First infections were most often non-ventricular assist device (54.2%). Rates of first infection were highest in the early interval (10.7/100 person-months). Patients with any infection had a significantly higher adjusted hazard of death (hazard ratio, 2.63; 2.46-2.86). First infection in the intermediate interval was associated with the largest increase in adjusted hazard of death (hazard ratio, 3.26; 2.82-3.78), followed by late (hazard ratio, 3.13; 2.77-3.53) and early intervals (hazard ratio, 2.37; 2.16-2.60). Ventricular assist device-related infections were associated with the largest increase in hazard of death (hazard ratio, 3.02; 2.69-3.40), followed by ventricular assist device specific (hazard ratio, 2.92; 2.57-3.32) and non-ventricular assist device (hazard ratio, 2.42; 2.20-2.65). CONCLUSIONS: Relative to those without infection, patients with any postimplantation infection had an increased risk of death. Ventricular assist device-related infections and infections occurring in the intermediate interval were associated with the largest increase in risk of death. After left ventricular assist device implantation, infection prevention strategies should target non-ventricular assist device infections in the first 90 days, then shift to surveillance/prevention of driveline infections after 90 days.

Examining the influence of group diversity on the functioning of community-based participatory research partnerships: A mixed methods study.

Public health has endorsed the use of community-based participatory research (CBPR) to address health inequities involving diverse and marginalized communities. However, few studies have examined how group diversity among members of CBPR partnerships influenced how well the partnerships achieve their goals of addressing health inequities through equitable collaboration. We conducted secondary, convergent, mixed methods analysis to (1) evaluate the association between group diversity and participatory decision-making within CBPR partnerships, and (2) identify the perceived characteristics, benefits, and challenges of group diversity within CBPR partnerships. Using data from a cross-site study of federally funded CBPR partnerships, we analyzed and integrated data from surveys of 163 partnerships (n = 448 partners) and seven in-depth case study interviews (n = 55 partners). Quantitatively, none of the measured characteristics of group diversity was associated with participatory decision-making within the partnerships. Qualitatively, we found that partnerships mainly benefited from membership differences in functional characteristics (e.g., skillset) but faced challenges from membership differences in sociocultural characteristics (e.g., gender and race). The integrated findings suggest the need to further understand how emergent group characteristics and how practices that engage in group diversity contribute to collective functioning of the partnerships. Attention to this area can help promote health equity achievements of CBPR partnerships.

Care fragmentation predicts 90-day durable ventricular assist device outcomes.

OBJECTIVES: To examine whether fragmentation of care is associated with worse in-hospital and 90-day outcomes following durable ventricular assist device (VAD) implant. STUDY DESIGN: Cohort study. METHODS: This study was conducted using Medicare claims linked to the Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) among patients undergoing VAD implant between July 2009 and April 2017. Medicare data were used to measure fragmentation of the multidisciplinary care delivery network for the treating hospital, based on providers' history of shared patients within the previous year. STS Intermacs data were used for risk adjustment and outcomes ascertainment. Hospitals were sorted into terciles based on the degree of network fragmentation, measured as the mean number of links separating providers in the network. Multivariable regression was used to associate network fragmentation with 90-day death or infection risk. RESULTS: The cohort included 5159 patients who underwent VAD implant, with 11.2% dying and 27.6% experiencing an infection within 90 days after implant. After adjustment, a 1-unit increase in network fragmentation was associated with an increase of 0.179 in the probability of in-hospital infection and an increase of 0.183 in the probability of 90-day infection (both P < .05). Similar results were observed in models of the numbers of in-hospital and 90-day infections. Network fragmentation was predictive of the probability of 90-day mortality, although this relationship was not significant after adjustment. CONCLUSIONS: Care delivery network fragmentation is associated with higher in-hospital and 90-day infection rates following durable VAD implant. These networks may serve as novel targets for enhancing outcomes for patients undergoing VAD implant.

Mixed methods research: A primer for the vascular surgeon.

Mixed methods research is an approach that intentionally integrates both quantitative and qualitative research methods to answer a research question. The hallmark of mixed methods research is a focus on designing studies that integrate both quantitative and qualitative data, yielding greater results than either method could yield on its own. There are a number of fundamental concepts that are essential to conducting mixed methods research. These include a methodological approach that employs one of the three core study designs, involvement of a multidisciplinary team that includes both methodological and subject matter experts, and meticulous planning to ensure that the data collected can ultimately be integrated to yield findings that answer the original research question to the investigators' (and funders') satisfaction. In this article, we will discuss mixed methods research designs, data sources typically used in mixed methods research, and common data analysis and integration strategies. We will also provide examples of mixed methods research projects that have been used in vascular surgery. The intent of this article was to provide an overview of the field of mixed methods research, enabling the reader to critically assess mixed methods research studies in the literature and consider how this methodology might benefit their own research endeavors.

Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset.

BACKGROUND: Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS: Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS: The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (ß=16032.5, p=0.008). CONCLUSIONS: Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.

Incompleteness of health-related quality of life assessments before left ventricular assist device implant: A novel quality metric.

BACKGROUND: Improved health-related quality of life (HRQOL) is an important outcome following durable left ventricular assist device (LVAD) implant. However, half of pre-implant HRQOL data are incomplete in The Society of Thoracic Surgeons' Intermacs registry. Pre-implant HRQOL incompleteness may reflect patient status or hospital resources to capture HRQOL data. We hypothesized that pre-implant HRQOL incompleteness predicts 90 day outcomes and serves as a novel quality metric. METHODS: Risk factors for pre-implant HRQOL (EQ-5D-5L visual analog scale; 12-item Kansas City Cardiomyopathy Questionnaire "KCCQ") incompleteness were examined by stepwise logistic modeling. Direct standardization method was used to calculate adjusted incompleteness rates using a mixed effects logistic model. Hospitals were dichotomized as low or high based on median adjusted incompleteness rates. Andersen-Gill models were used to associate pre-implant HRQOL adjusted incompleteness rate with adverse events within 90 day post-implant. RESULTS: The study cohort included 14,063 patients receiving a primary LVAD (4/2012-8/2017). HRQOL incompleteness at high-rate hospitals was more often due to administrative reasons (risk difference, EQ-5D: 10.1%; KCCQ-12: 11.6%) and less likely due to patient reasons (risk difference, EQ-5D: -8.9%; KCCQ-12: -11.4%). A 10% increase in the adjusted pre-implant EQ-5D incompleteness rate was significantly associated with higher risk of infection-related mortality (HR: 1.09), infection (HR: 1.05), and renal dysfunction (HR: 1.03). A 10% increase in the adjusted pre-implant KCCQ-12 incompleteness rate was significantly associated with higher risk of infection (HR: 1.04). CONCLUSIONS: Hospital adjusted pre-implant HRQOL incompleteness was predictive of 90-day post-implant outcomes and may serve as a novel quality metric.

Correction: Understanding and Addressing Variation in Health Care-Associated Infections After Durable Ventricular Assist Device Therapy: Protocol for a Mixed Methods Study.

[This corrects the article DOI: 10.2196/14701.].

A CBPR-Enhanced Delphi Method: The Measurement Approaches to Partnership Success Case Study.

As part of a 5-year study to develop and validate an instrument for measuring success in long-standing community-based participatory research (CBPR) partnerships, we utilized the Delphi method with a panel of 16 community and academic CBPR experts to assess face and content validity of the instrument's broad concepts of success and measurement items. In addition to incorporating quantitative and qualitative feedback from two online surveys, we included a 2-day face-to-face meeting with the Expert Panel to invite open discussion and diversity of opinion in line with the CBPR principles framing and guiding the study. The face-to-face meeting allowed experts to review the survey data (with maintained anonymity), convey their perspectives, and offer interpretations that were untapped in the online surveys. Using a CBPR approach facilitated a synergistic process that moved above and beyond the consensus achieved in the initial Delphi rounds, to enhance the Delphi technique and the development of items in the instrument.

Understanding diagnostic processes in emergency departments: a mixed methods case study protocol.

INTRODUCTION: Diagnostic processes in the emergency department (ED) involve multiple interactions among individuals who interface with information systems to access and record information. A better understanding of diagnostic processes is needed to mitigate errors. This paper describes a study protocol to map diagnostic processes in the ED as a foundation for developing future error mitigation strategies. METHODS AND ANALYSIS: This study of an adult and a paediatric academic ED uses a prospective mixed methods case study design informed by an ED-specific diagnostic decision-making model (the modified ED-National Academies of Sciences, Engineering and Medicine (NASEM) model) and two cognitive theories (dual process theory and distributed cognition). Data sources include audio recordings of patient and care team interactions, electronic health record data, observer field notes and stakeholder interviews. Multiple qualitative analysis methods will be used to explore diagnostic processes in situ, including systems information flow, human-human and human-system interactions and contextual factors influencing cognition. The study has three parts. Part 1 involves prospective field observations of patients with undifferentiated symptoms at high risk for diagnostic error, where each patient is followed throughout the entire care delivery process. Part 2 involves observing individual care team providers over a 4-hour window to capture their diagnostic workflow, team coordination and communication across multiple patients. Part 3 uses interviews with key stakeholders to understand different perspectives on the diagnostic process, as well as perceived strengths and vulnerabilities, in order to enrich the ED-NASEM diagnostic model. ETHICS AND DISSEMINATION: The University of Michigan Institutional Review Board approved this study, HUM00156261. This foundational work will help identify strengths and vulnerabilities in diagnostic processes. Further, it will inform the future development and testing of patient, provider and systems-level interventions for mitigating error and improving patient safety in these and other EDs. The work will be disseminated through journal publications and presentations at national and international meetings.

A Scoping Review of Decolonization in Indigenous-Focused Health Education and Behavior Research.

Public health remains acutely affected by the historical legacy and ongoing processes of colonization. Although scholars have advocated for decolonization of public health systems, the principles and processes of decolonization have not been explicitly elaborated nor applied broadly within the field. To map these concepts, we conducted a scoping review of decolonization of the Indigenous-focused health behavior and education literature. Following the JBI (formerly Joanna Briggs Institute) scoping review framework, we conducted searches in PubMed, PsycINFO, and Web of Science using key search terms: "health education," "health behavior," "health promotion," "health practice" AND "decolonization" or "decolonial." We also conducted targeted searches of key journals to ensure review completeness. For selected articles, we examined the article content, focal population, country context and health condition(s). We assessed for the definition of decolonization (if provided), descriptions of decolonial processes used (if stated), and the application of the decolonial processes (e.g., for research, intervention, or critique, etc.). Characteristics of decolonial processes were grouped by those that were similarly described leading to the generation of common themes of reflection, action, and planning. Our review suggests that no clear norms exist in conceptualizing the definitions and processes of decolonization in the reviewed literature. A small proportion of the articles articulate decolonial processes in manners that are consistent, cohesive and attentive to the goals of decolonization. We believe that this review will encourage public health practitioners to consider meaningful approaches to challenging colonizing structures and engage with community partners to advance the visions of social justice and health equity.