Integrating clinical pharmacists and industrial engineers' perspectives to develop a codebook to characterize structure at anticoagulation clinics

Purpose: Health care quality is inferred from three constructs: structure, process, and outcomes. The literature on quality in anticoagulation clinics (ACCs) is focused on processes and care outcomes. Our interdisciplinary research aims to better understand the structural dimension of health care delivery in an ACC. The purpose of this study was to integrate clinical and industrial engineering perspectives to create a codebook that guides analysis of qualitative data to identify components of ACC structure that affect quality

Methods: Members from six ACCs within the Veterans Health Administration System (VHA) were interviewed to assess the quality of anticoagulation care delivery. A research team of two clinical pharmacists, three industrial engineers, and one physician was assembled to develop a codebook based on the interview data. Codes emerged from existing theory, raw data, and from our research goals and questions. Three coders (one industrial engineer and two clinical pharmacists) qualitatively analyzed interviews by inductive analysis and creative synthesis. Coders and other team members met regularly to discuss existing codes, develop new ones, clarify definitions, and share examples. Consensus was reached on all codes over a six month period through a multi-step sense-making process, beginning from the separate codes developed by each coder.

Results: The codebook contains 46 codes describing components of the ACC structure and organized into nine categories: Organizational Factors, Technology, ACC Processes, Staff Related Issues, VHA Context, ACC Outcomes, Interactions with Other Clinics, Interaction with Patient, and Patient Related Factors. The codebook is an intermediate product of qualitative inquiry and also serves as a detailed description of important components related to ACC structure. 

Conclusion: Clinical pharmacists and industrial engineers provided complementary perspectives for understanding the ACC structure. Such multidisciplinary collaborations can lead to unique insights with practical and theoretical implications for improving anticoagulation care.