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Table 1 Summary of ethnographic methods used to study the implementation of an evidence-based primary care intervention in CHCs

From: Ethnographic process evaluation in primary care: explaining the complexity of implementation

  Method Previous research Innovation Detail
Used to discover key themes and patterns Site Coordinators (SCs) - Hired from outside the organization - Hired from within the organization Nurses and quality improvement specialists, 2.5 FTE between 4 SCs; training in interview methodology + ongoing informal methods training
- Assist with implementation (practice facilitation) - Play an essential role in data collection, analysis/interpretation (as well as practice facilitation)
Diary entries completed by SCs - Structured format with set open-ended questions - Unstructured format, no set questions Submitted weekly; email reminders; qualitative lead collates each month’s entries by site, inserts questions & comments & returns to SC for clarification; relevant practices and ideas shared with team
- Rolled out with no training - Training that emphasizes rich description and the value of the diarists’ own knowledge and insight
- One way flow of information from diarist to researcher - Feedback loops between diarist and researcher regarding diary content
ECCO (Episodic Communication Channels in Organization) surveys - Measure spread of multiple messages to capture communication channels in a given organization - Snapshot of success of communication strategies by role related to a single intervention Anonymous 2-page paper survey conducted 1 year post-implementation at 5 clinics; completed by 64 individuals (15 PCPs*, 12 RNs**, 17 MAs***, 20 other (pharmacy, panel managers, etc.)
Document review - Collect relevant clinic documents to gain insight into organizational culture and context - Same; also collect relevant email communications to document team interactions within and across organizations SCs forward clinic documents to qualitative team, with explanations placing them in context. As of study year 4, have 191 such documents.
Observation - Observation of clinical workflow - Same; also view team meetings as ethnographic encounters worthy of study Informal observation in clinics and at team meetings throughout study; formal half day shadowing of 1–2 clinicians per clinic. Study year 3 & 4.
Used to challenge or corroborate findings; fill in detail Group Discussion - Scheduled as stand-alone discussions with pre-selected participants - Integrated into regular clinic meetings 1-2 group discussions per clinic, with PCPs, RNs, MAs and panel managers (divided by role); Discussions last 0.5-1 hr; Recorded & transcribed. Study years 3–5.
   - Emphasis on confidentiality; no clinic leadership present - Usually co-conducted with clinic leadership  
   - Principal method of data collection - Used to fill in knowledge gaps and test researcher understandings  
  Interviews - Conducted by single outside researcher - Co-conducted by outside researcher and site coordinator 4-6 interviews per clinic
     (2–3 PCPs, 0–1 RNs, 0-2 management) Recorded & transcribed. Study years 3–5.
   - 0.5-1 hr in length - 20 mins in length (1 patient encounter)  
   - Principal method of data collection - Used to fill in knowledge gaps and test researcher understandings  
Human subjects protection Informed consent - Signed - Verbal Ethics board considered the process evaluation low risk.
  1. *Primary care provider; **Registered nurse; ***Medical assistant.