BMC Health Services Research
Involving end-users in the design of an audit and feedback intervention in the emergency department setting – a mixed methods study
Welmoed K. van Deen ORCID: orcid.org/0000-0002-4836-98491,2,
Edward S. Cho3,
Kathryn Pustolski4,
Dennis Wixon4,
Shona Lamb3,
Thomas W. Valente5 &
Michael Menchine6
BMC Health Services Research volume 19, Article number: 270 (2019) Cite this article
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.
Emergency Departments (EDs) often face problems related to overcrowding and long waiting times [1] which leads to reduced quality and efficiency, as patients may decompensate or leave before being seen [2]. Long length of stay (LOS) in the ED is associated with higher seven-day mortality rates, more unnecessary hospital admissions [2, 3], and less patient-centered care [4]. Many factors likely contribute to long LOS, including patient volume and acuity, ED space and staffing [1, 2], and the number of diagnostic tests (e.g. lab and imaging tests) ordered [1, 5]. While many of these LOS factors are influenced by circumstances out of physicians’ control, the number of diagnostic tests ordered is directly influenced by the behavior of ED physicians. This is especially important as the number of lab and imaging tests ordered varies substantially across physicians and overutilization is a common quality concern [6,7,8,9], which delays the care delivery process and can cause harm to patients [10].
A variety of implementation strategies are used to change physicians’ practice patterns, ranging from educational methods to financial incentives and regulations [11]. Audit and feedback, the process of showing physicians performance feedback dashboards that compare their performance to their peers’, is a strategy that generally achieves small to moderate behavioral changes in healthcare settings [12]. Audit and feedback interventions work better when feedback is more intensive, [12] the reported outcomes are actionable [13, 14], and there is trust in the accuracy of the data [13]. Additionally, the perceived importance of the goal is important in achieving behavior change [15]. However, many questions remain about the most effective ways to deliver an audit and feedback intervention [16, 17].
The involvement of end-users in the design of the intervention is likely to improve its effectiveness, though this has yet to be formally evaluated in the ED setting [14]. Involvement of end-users mitigates the risk of creating an ineffective system that does not adequately meet users’ needs. This concept has long been understood in the field of human-centered design. Human-centered design is an approach that systematically incorporates end-user feedback throughout the design process [18]. This process helps to ensure that the design is functional, supports the end-user’s goals, and fits the organizational context [19]. Additionally, it ensures ease-of-use and usefulness of the technology, thereby engendering more positive attitudes towards the technology [20].
The implementation setting in which an audit and feedback intervention takes place also affects the desired behavior changes [12]. Organizational culture is thought to be a motivational force that shapes practitioners’ behaviors, attitudes, and thought-processes [21]. The underlying social networks, in turn, have been shown to impact culture and beliefs [22, 23]. Social networks also influence human behavior, as illustrated by evidence in the use of contraception [24] or attitudes towards smoking [25, 26]. The social network within the workplace has been shown to influence physician behavior as well [27, 28]. Additionally, the social network is integral to innovation diffusion, which demonstrates the role of interpersonal connections in the adoption of new technology [22, 29].
Here, we describe the development and exploratory evaluation of a performance feedback dashboard in the ED setting with the goal to reduce LOS. We employ a human-centered design approach to identify the most suitable measures to include on the dashboard and to ensure essential design requirements are met. We hypothesize that the systematic involvement of end-users in the design process will lead to a more appropriate intervention design and superior usability. This would improve physicians’ likelihood of using the performance feedback dashboard and increase their motivation to change practice patterns. Additionally, we hypothesize that both adoption and motivation are affected by the underlying culture and social network of the department.
This mixed methods study took place in the Los Angeles County + University of Southern California (LAC+USC) Medical Center ED. LAC+USC is a large public hospital owned and operated by the LAC Department of Health Services and is a major teaching hospital. The University of Southern California (USC) provides most of the attending services at the hospital. The ED is staffed by approximately 60 attending physicians and 70 ED residents. With over 100,000 patient visits per year, this ED is one of the largest in the country and serves predominantly uninsured and underinsured populations. The median LOS in 2016 was approximately 9 h for admitted patients and 6 h for discharged patients, which is well above the LOS observed in other EDs serving un- and underinsured populations [30]. Additionally, there was substantial variation between providers in LOS and utilization metrics; for example, the interquartile range (IQR) of the median LOS per provider was 6–9 h and the IQR of the % patients with a CT scan was 10–30%.
Human-centered design approach
We employed a human-centered design approach to inform the development of a performance feedback dashboard for attending physicians. The goal of the performance dashboard was to reduce overall LOS by changing attending physicians’ practice patterns. Before developing the initial design, we performed a series of 60-min semi-structured interviews with ED leadership and ED attending physicians. Leadership interviews were performed to understand the strategic goals of the department and how a dashboard with specific performance measures could help attain those goals. Attending physician interviews were conducted to obtain end-user input on the measures to include and the design and functionality of the dashboard as well as to identify barriers to its implementation. The interview guides were developed specifically for this study (Additional file 1).
In total, two leadership and six attending physician interviews were performed to inform the initial design. The ED leaders were ED physicians whose primary responsibility was leadership but who also worked as attending physicians in this ED. We used a purposive sampling strategy to ensure a diverse representation of ED physicians. We included both male and female physicians with various levels of experience and different responsibilities (e.g. clinical, educational, academic, and administrative). Physicians employed by both USC and by the LA County Department of Health Services were included because incentive structures are different in the two settings. All participants were required to have worked in this ED for a minimum of 2 years to ensure they had a thorough understanding of the ED workflow. Twelve attending physicians were invited to participate, of which six completed interviews. Interviews were recorded and transcribed before analysis. Interviewees received a $25 gift card for their participation.
All transcripts were analyzed for comments related to relevant peer-comparison metrics, desired functionality, and perceived barriers. Based on the interview results, a guide was developed that specified design requirements for the performance dashboard. A team with experience in human-centered design developed (DW and KP) a front-end prototype in Axure RP PRO 8 (Axure Software Solutions, Inc., San Diego, CA). The design-team (DW, KP, ESC, WKvD) met on a bi-weekly basis to review the design and discuss appropriate solutions for design challenges. After the front-end prototype was developed using insights from the initial round of interviews, additional feedback was sought in a second round of 45-min interviews with five attending physicians, during which iterative improvements were made to the design.
We conducted pre- and post-surveys (Additional file 2) 6 weeks apart to test whether the performance feedback dashboard (1) increases physicians’ motivation to make faster decisions about the patients’ management and (2) decreases physicians’ likelihood to order tests in a specific scenario; two outcomes that could lead to reductions in ED LOS. Screenshots of the prototype dashboard developed during the human-centered design process were displayed prior to the post-survey. Questions related to the culture and social network in the ED were included in the pre-survey, and feedback on the usability of the dashboard was obtained in the post-survey. Both surveys were hosted in Qualtrics (Provo, UT) and were electronically distributed to the 56 attending physicians that were active in the ED at the time the pre-survey was sent out. The pre-survey was sent out on January 1, 2018, with three reminders in the following month. The post-survey was sent out on March 13, 2018, with two reminders in the following month. Two OpenTable gift cards with $150 value were raffled among participants as an incentive to complete the pre-survey. In the post-survey, a $5 Starbucks gift card was offered to each participant as an incentive.
The primary outcome was the effect of the performance feedback dashboard on physicians’ motivation to make a quick disposition decision (i.e. the moment the physician decides whether the patients will be admitted to the hospital or discharged from the ED). To measure motivation, we used a set of measures derived from Self-Determination Theory which posits that perceived value/usefulness, competence, and autonomy support are important factors for motivation [15]. We used the Value/Usefulness and Competence subscales of the Intrinsic Motivation Inventory and the six-question version of the Work Climate Questionnaire for Perceived Autonomy Support [31], which have been used and validated in a variety of settings including educational settings, sports psychology, and the workplace environment [32, 33]. All questions were rated on a seven-point Likert scale ranging from “Not at all true” to “Very true”. These questions were included in both the pre- and post-survey.
To estimate changes in physicians’ practice patterns, we focused on test-ordering, which is a known predictor of LOS and is directly influenced by physicians’ decisions [1, 5]. To assess physicians’ likelihood of ordering diagnostics tests, we included a vignette adapted from Kool et al. [34] in which the need for imaging is purposefully ambiguous. After reviewing the vignette, physicians were asked whether they would order diagnostic imaging, and if so, what type of diagnostic order. The vignette was included in both the pre- and post-survey.
To evaluate the design of the prototype performance dashboard in the post-survey, we assessed the perceived usefulness and ease of use based on the Technology Acceptance Model [20]. The Technology Acceptance Model has been used extensively to evaluate physician acceptance of health technology [35, 36]. Questions such as “I believe that the performance feedback tool is flexible to interact with” were scored on a seven-point Likert-scale ranging from “Disagree strongly” and “Agree strongly”. We also assessed physicians’ perception of the importance of the metrics included in the dashboard and physicians’ perceptions of their ability to affect these measures on the same seven-point Likert-scale. Lastly, we asked physicians a Net Promotor Score question, which is widely used in various industries to understand the quality of the product or service: “How likely are you to recommend this performance feedback tool to your colleagues and peers to visualize and improve their performance as ED physicians?” with an eleven-point response scale ranging from “Not likely at all” to “Extremely likely.” We also asked for suggestions to improve the tool and inquired about additional physician comments.
To assess the ED culture, we asked physicians about their perceptions of the social, technical, and environmental aspects of their workplace in the pre-survey. We used the first thirteen questions of the Safety Attitudes and Safety Climate Questionnaire, which has been extensively psychometrically validated [21, 37]. These thirteen questions specifically address the teamwork and safety climate. All questions were scored on a five-point Likert scale ranging from “Disagree strongly” to “Agree strongly”, with an N/A option for each question. To describe the underlying social network, we included the question “Who do you discuss problems with at work?” which returns social network data indicating specifically who communicates with whom in the organization [38]. Understanding this network is important if there are cultural barriers that limit the adoption of an intervention [39]. Up to seven names could be selected from a pre-specified list of ED provider-names, including those in leadership roles. See Additional file 2 for the complete surveys.
To assess the importance of end-user involvement in the development process, respondents were categorized as (1) directly involved in the dashboard development (interviewees, co-author MM), (2) not directly involved in the development but ≥30% of their network was involved, or (3) not directly involved and < 30% of their network was involved. The social network question was used to create a model that assessed the level of exposure that each participant had to people who were involved in the development of the dashboard. Exposure was defined as the percentage of nominated people who were involved in the development [23].
Centrality measures for the social network analysis (in-degree, out-degree, closeness, and betweenness) were calculated using the igraph library [40]. Out-degree is the number of people someone selected in the network question; in-degree is the number of times a person was selected by someone else; closeness measures the average distance someone has to everyone else in the network; and betweenness is a measure of how often each person lies on the shortest paths connecting others [41]. People with high betweenness scores are thought to be key in the early adoption of innovation, people with a high in-degree are ‘popular’ figures in the network that are important for the innovation to spread to the early majority, and people with a high closeness score are thought to be important for an innovation to spread to a large amount of people [41].
Descriptive statistics were used to describe the sample and survey results. Pre- and post-survey data were compared using a Wilcoxon Ranked Sum test for continuous measures and the McNemar’s Test for categorical variables. The Kruskal-Wallis Test was used to compare change-scores between groups. A Spearman correlation coefficient was used to describe relations between continuous data. Rho correlations coefficients of > 0.7 were considered strong correlations, coefficients between 0.5–0.7 were considered moderate, and coefficients between 0.3 and 0.5 were considered weak. A p-value of < 0.05 was considered significant. Analyses were performed in SAS 9.4 (Cary, NC).
Human-centered design approach - interviews
A total of eight semi-structured interviews were performed to guide the initial design of the performance feedback dashboard between May and August 2017 (Additional file 3: Table S1). Half of the interviewees were male, their median time since starting residency was 12 years (range 9–45), and their median length of employment in the current ED was 8 years (range 2–31). Two of the interviewees had primarily leadership roles, three primarily clinical responsibilities, and three primarily academic responsibilities. Two were employed by the LA County Department of Health and six by USC. The median duration of the interviews was 57 min (range 35–77). Thematic saturation was achieved after seven interviews; no new themes emerged in the eighth interview.
Dashboard content – metrics
Numerous metrics were discussed in the interviews, including the number of patients, their discharge disposition, and a variety of length of stay, utilization, and outcomes measures (Additional file 3: Table S2). Overall, the time between the moment a physician first sees the patient until the moment a disposition decision is made (i.e. decision to admit a patient to the hospital or discharge from the ED), was perceived to be the most relevant LOS metric. “Provider to decision time. Yeah, I think that’s an important metric, I think that there’s probably some wiggle room in there. In general, I think that’s an important part of our job is to have a disposition decision within whatever time frame we deem to be appropriate.” (Interview 7).
Additionally, test utilization, including CT scans, MR scans, and labs, was thought to be of interest, especially if compared to peer utilization. “I think the number of yes [sic], I order 500 CT-scans in a year, and somebody else orders three, would be interesting. It would be interesting to know the false positives and the false [negatives].” (Interview 5). Interviewees also expressed an interest to know the outcomes of their decisions, or what happened to patients after they left the ED: “Bounce backs, maybe? Stuff that’s, like, more subjective, like, you know, your decisions on the patient. [ …] you admit someone to the floor and they die. Should they have gone to the ICU? Or you discharge them and they die. [ …] That’d be nice to know.” (Interview 2).
Dashboard content – comparisons
Interviewees expressed the importance of comparing their data to others and of including historic trends. “So ideally [the data] would be where you are, where you were the previous month, or the previous time last year. And then where the department is.” (Interview 8). Ideally data would have to be aggregated on a weekly or monthly basis, as a day would not provide useful information because shifts vary day to day, while a year would be too long to remember. “[ …] if you wait too long then it doesn’t make any sense to you because you’re like, ‘That happened in September of last year. I don’t care. I don’t know what happened then.’ If you do it every day, then they’re kind of like, ‘Well, how am I supposed to know what I’m supposed to change?’” (Interview 2). Interviewees wanted to receive their data compared to their peers in a blinded fashion. Some expressed discomfort with others seeing their data: “I’m personally um, scared you know, scared to be compared with others.” (Interview 3). Others didn’t think it would be necessary to share the data openly to achieve change: “We serve as our sort of biggest critics already and that for us to see it is enough to be like a blow to an ego where you can say, ‘Oh wow, I’m that slow compared to my colleagues?’ ” (Interview 7).
Dashboard functionality
Three key themes emerged in the discussions about desired functionality of the performance feedback dashboard. First, participants emphasized the need for the dashboard to be easily accessible to increase the likelihood that people would actually use the dashboard. “If it’s like one more thing to do, I might not do it. It would have, it would have to be something that was like every time you logged in it popped up or something, or I would not look at it. Yeah. I’m not gonna go seek out that information.” (Interview 4). On the other hand, physicians did want to be able to drill down the data further to know what happened during specific shifts or with specific patients. “Ideally for people that have unscheduled returns, I would like to see why ... I would like their name, their medical record number so I could look them up and also then what happened to them on the return visit.” (Interview 8). Lastly, interviewees expressed that they would like to see a certain level of customization to define metrics of interest for them: “a good dashboard should give you the ability to, um, customize it, customize the view and the parameters that you look at for your, for your position at that time. Um, and you should be able to change that on the fly.” (Interview 1).
Barriers and unintended consequences
A variety of concerns were brought up during the interviews. A performance dashboard might increase physician stress levels, dehumanize the patient experience, and potentially negatively affect the quality and safety of care: “Yeah, if I’m seeing four patients an hour and I need to have a dispo [disposition decision] on each of them within an hour and a half or two hours or whatever the ED group tells you is the right metric then probably I’m cutting a lot of corners not having substance of conversations with the patient, not providing great patient care.” (Interview 7). Additional concerns were related to physicians’ responsibility to teach the many residents in the ED, which could be negatively affected. “A lot of times we give the residents a lot of leeway to think things through. And part of that is that we haven’t had to move on a very like super-fast time process. [ …] if you’re having time in the ED as something you’re thinking about more than necessarily clinical accuracy, it’s ... it is gonna change the way we practice with supervision.” (Interview 4).
Data accuracy was a concern as well, given that electronic medical record (EMR) data might not always be accurate. “All of your metrics are only as good as the people putting them in, and that’s always gonna be, you know, um, an issue with accuracy [ …]. ” (Interview 1). Interviewees also expressed the need to correct for the acuity of patients seen and the shift. “Oh, if you work more night shifts you’re gonna see more of them [more challenging cases]. Probably have to control for shift in some way.” (Interview 4). Additionally, concerns were expressed regarding gaming of the system and problems with attribution of patients to the right physician, especially in a teaching hospital with many residents. “When they’re finally put in to a room, they very well may see a different resident and attending at that point. So, there may be three different [physicians involved]. And that’s not even counting change of shift.” (Interview 8).
Human centered design – initial design and iterative improvement
Based on the interviews, we designed an initial version of the performance feedback dashboard between August and November 2017, which was then iteratively improved in two additional design cycles based on additional end-user feedback from five physicians in November and December 2017 (Additional file 3: Table S1). The first major iteration was developed after three additional interviews; the second and last major iteration was developed after another two interviews that revealed only minor required changes (Table 1), after which the design process was finalized.
Table 1 Design decisions made during human-centered design
The design incorporates a monthly summary email that includes a few selected measures to ensure the data is easy to access (Additional file 3: Figure S1). A link would be provided to an interactive performance dashboard with a variety of measures that can be accessed on demand (Additional file 3: Figure S2), to give physicians the opportunity to dive deeper into the data if desired. The interactive dashboard includes three pages: a “Personal” page showing a physician’s individual performance compared to their peers, an “Emergency Department” page showing the performance of the ED overall as a reference, and a “My Favorites” page that displays measures selected by individual physicians (Fig. 1). During the iterative interviews, tabs were added to the pages to allow physicians to drill down by the timing of shift and the area of care within the ED as this reflects the severity of the cases, thereby providing an opportunity to adjust for case-mix. Table 1 gives a complete overview of the design considerations in the human-centered design process and the iterative improvements made.
Top section of performance feedback dashboard. The top section of the designed prototype performance feedback dashboard. The name Jane Doe is a false name
The selection of measures for the dashboard was informed by audit and feedback best practices [12,13,14] and on information obtained during interviews in accordance with a human-centered design approach [18]. We specifically ensured a selection of measures that are actionable to physicians as this is a known requirement for effective audit and feedback interventions [13, 14]. The primary goal of the dashboard was to reduce overall patient LOS. However, to increase actionability of the measure, we focused on the time that can be influenced directly by physicians. In initial versions, this was the time from first physician to the time the physician makes the disposition decision (i.e. decision to admit to hospital, observation, or discharge). After additional interviews, we modified this to the time from when the patient is roomed until the disposition decision is made, as this more accurately represents the period directly influenced by the attending physician.
Test utilization data, including the percentage of patients with a CT scan, MR scan, ultrasound, and lab test, were included because they affect LOS and are directly controlled by the physician. The number of requested consultations was not included as the data were not readily available in the EMR. Outcome data were included to address concerns about unintended consequences related to the quality of care if the focus was merely on LOS and test utilization. Initially, we included 72-h return rates and number of deaths. However, deaths were excluded from later versions in response to concerns about the reliability of EMR-derived death-data. Hospital LOS after admission was included as a proxy measure of appropriateness of admission, with the assumption that a short LOS might indicate that the patient did not need to be admitted. The total number of patients with the breakdown by timing of shift, area of care, and discharge disposition was included to provide more context about the patient population seen. During iterative rounds of improvements, we added detailed definitions of the measures used and clarified section headers to improve comprehension and trust in the dashboard.
It was decided to report data by monthly intervals to minimize the effect of day-to-day random variation, but to also ensure physicians still remember what happened during a given period. Comparison data were provided on the “Emergency Department” page showing summary measures for the entire ED. On initial designs, comparison data was shown on the “Personal” page as a ranking that included blinded peer data to provide physicians with achievable goals for improvement. However, further feedback made it clear that a ranking was not perceived as appropriate because the highest or lowest score does not necessarily indicate the best or the worst performance. Instead, it was decided to show the interquartile range of all physicians.
In total, 19 attending physicians (34%) responded to both pre- and post-surveys. Forty-two physicians (75%) responded to the pre-survey which included the clinical vignette and measures for value/interest, perceived competence, autonomy support, teamwork climate, and safety climate. Twenty-one physicians (37.5%) responded to the post-survey which included a mockup of the performance feedback dashboard, the clinical vignette, measures for value/interest, perceived competence, autonomy support, and the perceived usefulness of the dashboard and the perceived ease of use (Additional file 3: Table S3). Of the 19 physicians that responded to both surveys, 5 had been involved in the development of the dashboard, 7 physicians had more than 30% of their direct network involved in the development, 5 physicians had less than 30% of their direct network involved, and 2 did not answer the network question. Physicians with less exposure to those involved in the development process tended to have less experience and physicians who were directly involved in the development tended to have a more central position in the ED social network. Although all groups selected a roughly equal number of people to ask for advice (out-degree), physicians who were involved in the development were selected more frequently by others (in-degree), and had numerically higher betweenness scores. Closeness scores were similar between groups (Table 2).
Table 2 Characteristics of survey respondents
When comparing pre- and post-survey responses to the clinical vignette, we did not observe any differences in the percentage of physicians who would order imaging after seeing the prototype dashboard (12/19 pre and 14/19 post; p = 0.69). There were also no significant changes in the self-determination theory-based motivation measures; median pre- and post-values for value/usefulness were 4.4 (IQR 4.2–5.2) and 5.0 (IQR 4.0–5.8), respectively (p = 0.21); the perceived competence values were 5.5 (IQR 4.3–6.0) and 5.0 (IQR 4.0–6.3), respectively (p = 0.88); and the autonomy support values were 5.0 (IQR 2.8–5.7) and 4.0 (IQR 3.0–6.0), respectively (p = 0.83). We then assessed changes in sub-groups based on the level of exposure to people involved in the development process as determined by the social network analysis. We found that higher exposure was significantly associated with changes in the perceived value/usefulness of making quick disposition decisions (p = 0.048) after seeing the dashboard. The perceived value/usefulness-score of physicians who were directly involved in the development rose by a median of 0.6 points, while the score of physicians with low exposure (< 30% of network was involved) decreased by a median of 0.4 points. Similarly, physicians’ perceived competence in making quick disposition decisions increased in those physicians who were actively involved, and decreased in those with low exposure (NS, p = 0.059). No differences between groups were observed in change-scores for autonomy support by ED leadership (Fig. 2). No correlation was observed between the physicians’ perception of the culture in the ED and change scores (Table 3).
The effects of the performance feedback dashboard on motivation. The effect of the prototype performance feedback dashboard on perceived value/usefulness of making quick disposition decisions, perceived competence in making quick disposition decisions, and perceived autonomy support from emergency department leadership in physicians who were involved in the development (Inv, n = 5), those of which ≥ 30% of their network was involved in the development (≥30%, n = 7, high exposure), and those with < 30% (< 30%, n = 4, low exposure). Horizontal bars represent the group average. Each dot represents a unique observation
Table 3 Correlation between climate and outcome measures
While the importance of the metrics on the dashboard was generally rated highly (median 6 out of 7, IQR 4–6) and physicians reported they could affect the measures (median 6 out of 7, IQR 5–6), the perceived usefulness of the overall dashboard was only rated a median of 4 out of 7 (IQR 3–4.5). The median ease of use rating was 5 out of 7 (IQR 4.3–5.5) and physicians rated the likelihood they would recommend the dashboard to their peers as 6 out of 10 (IQR 5–7). When looking at specific subgroups, we found that physicians with little exposure to those involved in the development process rated the importance of the metrics significantly lower than others (p = 0.02, Table 4). A trend towards lower scores for perceived usefulness, ease of use, and likelihood to recommend the dashboard was found in these physicians as well (Table 4). Additionally, moderate correlations between the perceived safety climate and positive evaluations of the dashboard were observed. No correlation was observed between perceived teamwork climate and positive evaluations of the dashboard, except for the ability to affect measures (Table 3).
Table 4 Quantitative assessment of the performance feedback dashboard
Physicians’ comments in the survey were analyzed qualitatively. Several physicians commented that the ability to have measures available would be a “step up”, would “provide an incentive”, or would be “interesting”. The visual design of the performance dashboard was described with words such as “clear”, “easy to understand”, “pleasant to look at”, and “user friendly”, though one physician commented it was “big brother controlling”. Other concerns were related to data accuracy, negative consequences on patient care or work culture, and the effect on the teaching environment. Lastly, while benchmarks were visualized on the dashboard using an interquartile range, several physicians commented that a benchmark would be needed in the dashboard for it to be useful, implying that a more intuitive design to display this information needs to be considered.
This study described the development of a front-end prototype performance feedback dashboard to deliver feedback to attending physicians about their performance with the goal of reducing patient LOS in the ED. We employed a human-centered design approach to ensure we developed a dashboard that fits the end-users needs. This approach guided the selection of measures, development of functionality, and visualization of data. During the eleven interviews performed as part of the human-centered design process, a variety of barriers were identified that we attempted to address in the design. Additionally, we found preliminary evidence that the social network in which the intervention is developed and implemented is likely to be of key importance to the adoption of the intervention and the achievement of the intended changes in physicians’ practice patterns.
The involvement of end-users in the design of the dashboard allowed us to select relevant measures. Particularly, it helped us select measures that were perceived as actionable and under control of the physician. It also helped identify appropriate comparisons and clear visualizations. The multiple interviews before and during development provided insights about the importance of having drilldown functionality, both to increase trust in the data as well as to correct for confounding variables such as patient acuity. While we were able to address a variety of concerns that came up during the design process, other issues were not sufficiently addressed according to post-survey results. Interviewees expressed concerns about the application of a performance-feedback tool in an educational setting, in which they also have the responsibility to teach residents. This is consistent with prior findings that clear goals need to be aligned with audit and feedback interventions [14]. Another recurring barrier was the lack of trust in EMR data. This too is consistent with prior studies, and a variety of strategies are available to improve the accuracy of, and trust in, EMR data for quality improvement purposes [42, 43].
We showed preliminary evidence that the ED/workplace culture may be important for the adoption of technology. Physicians who reported higher scores on questions about safety climate based on questions such as “I would feel safe being treated here as a patient” and “The culture in this clinical area makes it easy to learn from the errors of others,” also reported higher scores for acceptability of the dashboard. This suggests that nurturing a culture that supports learning from errors is important for acceptance of performance feedback. Additionally, we showed data that suggests that the involvement of end-users in the design can lead to higher acceptability and increased motivation to change. Not only were those involved in the design more likely to report higher acceptance scores, this effect also appeared to be disseminated through their social network; conversely, physicians with little exposure to those involved in the design of the dashboard reported lower acceptance of the dashboard compared to those who had higher levels of exposure. Similarly, the dashboard had a positive effect on motivation of those involved in the design and a negative effect on those with little exposure. These findings are consistent with other studies showing that social networks have important roles in dissemination of innovation and behavior change [22, 27,28,29]. This implies that it might be important to strategically select the people involved in the design process based on their position in the social network.
While these preliminary findings offer useful insights, the sample size is small and with only 19 of 56 participants responding to both surveys, there is likely a selection bias. Therefore, these results should not be interpreted as a proof of concept, but rather as preliminary evidence that needs to be further explored in future studies. Additionally, physicians who were included in the design process had more experience than those who were not involved and had a more central position in the ED social network. This is likely due to our purposive sample selection strategy along with the selection bias introduced by the participation of only about half of the physicians that were invited. We purposefully excluded physicians with less than 2 years of experience in this ED because we expected those to have less insight regarding the needs and workflows of the ED. Moreover, our study only included attending physicians at a single site, limiting generalizability to other settings and other healthcare providers such as nurse practitioners. Furthermore, while we were able to test the effect of this prototype dashboard on physicians’ motivation to make faster disposition decisions, the prototype did not include real, personalized data which likely decreased the observed impact.
Lastly, we would like to acknowledge that caution should be exercised when attempting to implement a performance dashboard such as the one developed in this study. Both intended and unintended consequences should be monitored closely, for example through the inclusion of balancing measures. This is especially important when appropriateness measures are not readily available for metrics such as test utilization and LOS in the ED; reductions in test ordering may not always be appropriate and reductions in LOS might not always improve quality of care even if they may increase patient satisfaction. While we included 72-h return rates as a balancing measure on the dashboard, several other potential unintended consequences were identified in the interview process, including physician stress levels, dehumanization of the patient experience, effects on teaching, and effects on quality and safety of care.
In summary, this small pilot study in a single ED showed the feasibility of designing a performance feedback dashboard using a human-centered design approach over the course of 8 months. Additionally, we showed preliminary evidence suggesting that both the culture and social network can be leveraged to facilitate the adoption and enhance the effect of such an intervention. A social network analysis prior to the initiation of the human-centered design process could help identify the right stakeholders to involve in this process and increase the likelihood of successful implementation. This evidence, along with the observation that data quality and unclear goals are barriers to acceptance, shows that implementation of an audit and feedback intervention cannot happen in a vacuum; this type of intervention requires close collaboration of senior leadership, designers, researchers, IT, and end-users.
EMR:
LAC+USC:
Los Angeles County + University of Southern California
USC:
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Hartzler AL, Chaudhuri S, Fey BC, Flum DR, Lavallee D. Integrating patient-reported outcomes into spine surgical care through visual dashboards: lessons learned from human-centered design. EGEMS (Wash DC). 2015;3(2):1133.
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Valente TW. Models and methods for innovation diffusion. Models and methods in social network analysis; 2005. p. 98–116.
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Valente TW, Palinkas LA, Czaja S, Chu KH, Brown CH. Social network analysis for program implementation. PLoS One. 2015;10(6):e0131712.
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Valente TW. Measures, Centrality. Social networks and health: models, methods, and applications, Chapter 5. New York: Oxford University Press; 2010.
van der Bij S, Khan N, Ten Veen P, de Bakker DH, Verheij RA. Improving the quality of EHR recording in primary care: a data quality feedback tool. J Am Med Inform Assoc. 2017;24(1):81–7.
Benin AL, Fenick A, Herrin J, Vitkauskas G, Chen J, Brandt C. How good are the data? Feasible approach to validation of metrics of quality derived from an outpatient electronic health record. Am J Med Qual. 2011;26(6):441–51.
We would like to thank Dr. Donna Spruijt-Metz, Dr. Gil Shlamovitz, and Dr. Song-Hee Kim for their thoughtful comments throughout this project. We would also like to thank the ED physicians who participated in the interviews and surveys.
This project was supported by the University of Southern California Gehr Family Center for Health Systems Science and by the SC CTSI (NIH//NCATS) through Grant UL1TR001855. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The funding sources had no role in the study design, data collection, data analysis, interpretation of data or in writing the manuscript.
The datasets used and/or analyzed in this study are available from the corresponding author on reasonable request. As the data contains potentially identifiable elements, we will de-identify the data upon request in accordance with the needs of the requesting party.
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
Welmoed K. van Deen
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
Edward S. Cho
& Shona Lamb
Interactive Media & Games Division, School of Cinematic Arts, University of Southern California, 900 West 34th Street, Los Angeles, CA, 90089, USA
Kathryn Pustolski
& Dennis Wixon
Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N Soto Street, Los Angeles, CA, 90032, USA
Thomas W. Valente
Department of Emergency Medicine, Keck School of Medicine, University of Southern California, 1200 N State Street, Room 1011, Los Angeles, CA, 90033, USA
Michael Menchine
Search for Welmoed K. van Deen in:
Search for Edward S. Cho in:
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WKvD conceived and designed the study, performed the interviews, oversaw data collection and interpretation, and wrote the manuscript. ESC designed the data collection strategy, collected, analyzed, and interpreted survey data, and reviewed the manuscript for important intellectual content. KP analyzed and interpreted interview data, designed the dashboard, and reviewed the manuscript for important intellectual content. DW designed the interview strategy, analyzed and interpreted interview data, and reviewed the manuscript for important intellectual content. SL did the quantitative data analysis and reviewed the manuscript for important intellectual content. TWV designed the social network analysis strategy, analyzed and interpreted the network analysis, and reviewed the manuscript for important intellectual content. MM conceived and designed the study and reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript.
Correspondence to Welmoed K. van Deen.
Written study information sheets were provided to interview participants and verbal consent was obtained. Survey participants were provided with a study information sheet prior to starting the online survey with the option to discontinue. No verbal consent was obtained from survey participants as the survey was administered online. No signed consent forms were required per the Institutional Review Board (IRB) as this was deemed a minimal risk study. All study procedures as well as the consent processes were approved by the University of Southern California Health Sciences IRB under protocol number HS-17-00293.
Participants verbally consented the use of non-identifiable quotes in publications and presentations and were provided the opportunity to review and comment on the presented results prior to finalization of the paper.
MM works in the LAC+USC ED. The authors declare that they have no competing interests.
Interview Guides. The interview guides used in the human-centered design process. Three interview guides are included; the interview guide used for leadership interviews, the interview guide for attending physician interviews for the first round of interviews, and the interview guide used during the iterative improvement process. (DOCX 32 kb)
Pre- and Post Surveys. The complete pre- and post-surveys used in this study. The surveys were administered online. (DOCX 62 kb)
Supplemental Tables and Figures. The supplemental tables and figures references throughout the paper. (DOCX 272 kb)
van Deen, W.K., Cho, E.S., Pustolski, K. et al. Involving end-users in the design of an audit and feedback intervention in the emergency department setting – a mixed methods study. BMC Health Serv Res 19, 270 (2019) doi:10.1186/s12913-019-4084-3
Performance feedback
Audit and feedback
Quality, performance, safety and outcomes


Greg Hughes
HomeGreg Hughes
Greg has been drawing for as long as he can remember but he’s been a painter for eleven years. He got his first set of watercolours for his thirteenth birthday and completed his first picture in about fifteen minutes. The earliest experience of art he can remember was making a sculpture at school in New Zealand at age six. A green apple with toothpicks in it called “The Incredible Hulk”. Greg’s painting paints in acrylic, and gouache with pen and ink. He sold his first picture at 19, when he entered a competition with the theme Brisbane’s Environmental Heritage with a painting of the City Botanic Gardens. Greg paints landscapes using photographic references. Sometimes the landscapes are of real places, other times they’re just made up. He has also tried portraiture. Greg’s work is held in private collections in Mexico, Wales, England and Belgium. Greg has also created a a series of “futuristic” scenes and is inspired by the detailed work of fantasy artists such as Chris Moore, Tim White, Jim Burns, Bob Eggleton and Fred Gambino. In late 1998, Greg had an exhibition of “fantasy art” at the Sugar ‘n Spice cafe. Since leaving school he has studied graphic design part-time at Morningside TAFE. He is currently studying Fine Art full-time at the Queensland College of Art and has a passion to work as a graphic designer or illustrator.


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April 30 : Presbyterian Missionaries Freed
30 April, 2012 in April 2012 by davidtmyers | No comments
This Day in Presbyterian History:
Misperception of Ministry Hard to Overcome
Partial information and misperceptions about one’s ministry are hard to overcome, especially when it involves an action which has taken place in the past.
Think either back to the years of World War Two, or remember in your history this calamitous time in our nation’s history. The Axis powers of Germany and Japan had suddenly captured large areas in foreign lands, or in the case of Japan, delivered devastating blows to the Western world, as in the case of Pearl Harbor, Hawaii. Many foreigners were caught in what had been friendly territory, but now were enemy countries. These included diplomats and their families, tourists, and missionaries of the cross.
Enter the Geneva Convention. It specified that treatment of non-combatants would be carried out with kindness and care. Further, plans would be made to extradite such individuals back to their home via neutral nations.
In the United States during these War Years, the State Department operated a small number of internment facilities, many of them being resorts and hotels in isolated parts of the country. Some of them were the Homestead Hotel (White Sulphur Springs, Virginia), Greenbriar Hotel (White Sulphur Springs, Virginia), a hotel in Asheville, Virginia, and other Virginia sites in Staunton, Hot Springs, New Market, and Bedford Springs, Pennsylvania.
The sole North Carolina retreat and conference center was at Montreat Assembly Inn. This was a Presbyterian retreat center, run by the Presbyterian Church in the United States. From October 29, 1942 to April 30, 1943, it held 133 Japanese and 131 German diplomats and their families.
It was an interesting opportunity to witness to these Axis diplomats. Into each of the hotel rooms had been placed New Testaments in both the German language and the Japanese languages. Further, church groups visited at Christmas and handed out presents to all the children. Christmas carols were sung at the retreat center, with many joining in the familiar carols. One simply doesn’t know what seeds of the gospel were being planted by the Holy Spirit during this time.
When the time of exchange came with our diplomats, business people, and missionaries, it soon became clear that their experience in German and Japan held internments was not as plush as their counterparts in American areas.
Agents of the Federal Bureau of Investigation and the Border Patrol escorted the foreign diplomats and their families to trains which took them to ships from neutral countries. Usually they were marked clearly so enemy submarines would not torpedo them on their way back to their home countries.
Words to Live By: Consider with gratitude the amazing exchange program in the gospel. Our sins were imputed or laid to the account of Christ, and His righteousness is imputed or laid to our account. We who were enemies of God became His friends. Thank God for this great exchange today.
Through the Scriptures: Psalms 58 – 60
Through the Standards: The liberties and privileges of adoption
WCF 12:1
“All those that are justified, God vouchsafes, in and for His only Son Jesus Christ, to make partakers of the grace of adoption, by which they are taken into the number, and enjoy the liberties and privileges of the children of God, have His name put upon them, receive the spirit of adoption, have access to the throne of grace with boldness, are enabled to cry Abba, Father, are pitied, protected, provided for, and chastened by Him as by a Father: yet never cast off, but sealed to the day of redemption; and inherit the promises, as heirs of everlasting salvation.”
Tags: Geneva Convention, Japan, United States, World War Two
April 29 : WSC Q. 26 – Christ’s Office of King
Do You Know King Jesus?
We have looked at the two offices of prophet and priest which Jesus executes. Now we come, in the absence of anything Presbyterian, to Jesus executing the office of king. Number 25 of the Shorter Catechism reminds us that “Christ executes the office of a king, in subduing us to himself, in ruling and defending us, and in restraining and conquering all his and our enemies.”
Christ in the past is a king, is One now, and ever will be a king. His kingdom is a spiritual and invisible one. He Himself said in the midst of His arrest to Pilate that “My kingdom is not of this world. If it were, my servants would fight to prevent my arrest by the Jews. But now my kingdom is from another place.” (NIV – John 18:36). But it is in existence, and we as His people are kingdom-citizens of it. Paul tells us “he has rescued us from the dominion of darkness and brought us into the kingdom of the Son he loves.” (NIV – Colossians 1:13)
Jesus executes this office of kingdom by subduing us to Himself. “Thy people,” the Psalmist reminds us in Psalm 110:3 “shall be willing in the day of thy power.” (KJV) He further rules over us. “What? know ye not that your body is the temple of the Holy Ghost which is in you, which you have of God, and ye are not your own? For ye are bought with a price: therefore glorify God in your body, and in your spirit, which are God’s.” (KJV – 1 Corinthians 6:19, 20) He in addition as king defends us. When God delivered the Psalmist from the hands of his enemies, David broke out in psalm, singing Psalm 18:1, 2 “I love you, O LORD, my strength. The LORD is my rock, my fortress and my deliverer; my God is my rock, in whom I take refuge. He is my shield and the horn of my salvation, my stronghold.” (NIV) Last, He restrains and conquers all His and our enemies. In a text which has been quoted by His kingdom-citizens in harrowing days of old, to say nothing of the persecuted brothers and sisters all over this world, John the apostle reminds us that “he who is in you is greater than he who is in the world.” (ESV – 1 John 4:4b)
Words to Live By: As king, Christ’s mediatorial activity is performed in both directions — upward in intercession, and downward in applying the benefits of redemption and administering the affairs of His church. As king, Christ meets the problem of man’s weakness and dependence, supplying us with power and protection.
Through the Standards: The subject, sphere, and ground of adoption
WLC 74 — “What is adoption?
A. Adoption is an act of the free grace of God, in and for his only Son Jesus Christ, whereby all those that are justified are received into the number of his children, have his name put upon them, the Spirit of his Son given to them, are under his fatherly care and dispensations, admitted to all the liberties and privileges of the sons of God, made heirs of all the promises, and fellow-heirs with Christ in glory.”
Tags: Holy Ghost, Scriptures Psalms, Shorter Catechism, Son Jesus Christ
April 28 : What’s In A Name?: PCUSA sues over the name PCofA
28 April, 2012 in April 2012 by archivist | No comments
Goliath against David
Talk about Goliath against David. This was the case on this day April 28, 1937 when the Presbyterian Church in the United States of America went to court against the Presbyterian Church of America. They had been successful in winning the church properties of those ministers who had been suspended from their ranks. They had been successful in evicting them from the manse or parsonage. They had been successful in removing their life insurance policies. Now they wanted their name.
Their argument was simple. Plans had been under way for some time for a proposed union of the United Presbyterian Church of North America with the Presbyterian Church in the United States of America. And one of the names floated for that proposed union was the Presbyterian Church of America.
The principal witness for the Presbyterian Church, U.S.A., was the denomination’s Stated Clerk, Lewis Seymour Mudge. Key to the whole case was the question of similarity of names as the sole basis for the suit against the Presbyterian Church of America. Attempts by the latter group to show the doctrinal reasons for the new church were then met with objection after objection by the attorney for the Presbyterian Church, U.S.A.
Witnesses for the P.C. of A. were a “who’s who” of its early leaders. Ministers Paul Woolley, Edwin Rian, and Charles Woodbridge all testified on April 28 and April 29. Professor John Murray tried to bear witness about the doctrinal differences between the two denominations, but was hindered by objections to his presence on the stand. He left, without testifying.
It took several months before the decision was handed down. But as the historical devotional for February 9, 1939 showed, the decision was made against the Presbyterian Church of America. Moderator R.B. Kuiper called for an earlier than usual General Assembly in that month of February, 1939, and the new name of the Orthodox Presbyterian Church was chosen by the church.
When the union between the Presbyterian Church of the United States of America and the United Presbyterian Church of North America took place in 1958, their new name was the United Presbyterian Church in the United States of America (UPCUSA). In God’s providence, this gave the opportunity for the southern Presbyterians who left the Presbyterian Church in the United States in 1973 to choose the name, The Presbyterian Church in America, as their new name during their second General Assembly.
Presbyterian Guardian managing editor Thomas R. Birch remarked at the close of his report in the May 29th, 1937 issue, “And once more . . . Gideon’s band of true Christians, the Presbyterian Church of America, has publicly taken its unflinching stand on the side of historic Presbyterianism and the principles of religious liberty for which the fathers fought and died.” His entire article concerning the injunction can be read online in the May 29, 1937 issue of the Presbyterian Guardian. Yet through further legal appeal, it was not until March 15, 1939 that the denomination officially changed its name to The Orthodox Presbyterian Church. Mr. Birch wrote again at that time regarding the name change, “What’s In A Name?”, on page 47 of the March 1939 issue of The Presbyterian Guardian.
Words to Live By: Jesus promised His followers that they would be brought up before the courts for the sake of their profession as Christianity. This was one such example, and it will not be the last time in the history of the Christian church. Yet God’s Word is sure. Remain steadfast to the faith, and God’s reward will be ultimately yours in Christ.
Through the Standards: The nature of those justified who have been adopted
WSC 34 — “What is adoption?
A. Adoption is an act of God’s free grace, whereby we are received into the number, and have a right to all the privileges, of the sons of God.”
Image sources : 1. Photograph of Lewis S. Mudge, newsclipping from the Syracuse Herald, 28 May 1936, p. 3, as found in Scrapbook no. 2, p. 110, in the Henry G. Welbon Manuscript Collection.
2. Cover image of the Minutes of the Fourth General Assembly of the Presbyterian Church of America, meeting in Quarryville, Pa., May 31-June 3, 1938.
3. Cover image of the Minutes of the Fifth General Assembly of the Orthodox Presbyterian Church, Meeting at Westminster Theological Seminary, Chestnut Hill, Philadelphia, Pa., February 9, 1939…
All scans prepared by the staff of the PCA Historical Center.
April 27 : WSC Q. 25 – Our High Priest
Christ executes the office of priest
With little of Presbyterian history to interest us on this day of April 27, we turn to one of the three offices which Christ executes for His people. This office is so important to our Christian understanding of our redemption and sanctification. Shorter Catechism number 25 tells us that this priestly office is executed “in his once offering up of himself a sacrifice to satisfy divine justice, and reconciling us to God, and in making continual intercession for us.”
The definition of a priest is one qualified and authorized to act in behalf of man with God. Certainly, Christ was over and over again in the Book of Hebrews identified as such a priest, whether we speak about specific references to Him or typical fulfilments of Him as a priest. Hebrews 6:20 tells us that Jesus has “become a high priest forever after the order of Melchizedek.” (ESV)
The two branches of the priestly work of Christ falls into first, His sacrifice to satisfy divine justice. We need to remember that in this sacrificial work, our Lord was both the priest and the victim, and perfect in each. In comparing the animal sacrifices of the Old Testament, the writer makes the contrast in Hebrews 9:14 by stating “how much more will the blood of Christ, who through the eternal Spirit offered himself without blemish to God, purify our conscience from dead works to serve the living God.” (ESV)
The object, and indeed the effect of this offering, was for the full satisfaction of divine justice. Jesus on the cross endured on our behalf the very punishment our sins deserved. He then reconciled us to God. Paul says it all in Romans 5:9, 10: “Since, therefore, we have now been justified by his blood, much more shall we be saved by him from the wrath of God. For if while we were enemies we were reconciled by God by the death of His Son, much more, now that we are reconciled, shall we be saved by his life.” (ESV) Don’t just read this text without emotion! Rejoice in God through our Lord Jesus Christ, as Romans 5:11 charges the reader.
The second branch of Christ’s priestly work falls into the intercession which He makes daily for us now. He makes, in our Confessional fathers words, “continual intercession for us.” He appears in His glorified humanity at the right hand of God. He declares His will to be applied to believers on earth. He answers all accusations against us by that unholy trinity of the world, the flesh, and the devil. And the solid ground of this intercession is the merit of His perfect obedience and sacrifice during His sinless life and death, burial, and resurrection.
Christian reader, has it really grabbed you that Jesus is praying for you now and every day? Do you go on your way every day with that comforting truth in your head and heart? You can, because Christ is your personal priest.
Words to Live By: As priest, His mediatorship is upward from man to God. As the priest, He meets the problems of your guilt, supplying you with righteousness. Live in the light of this wondrous truth of the office Christ executes as a priest.
Through the Standards: Proof texts of Justification:
“Therefore, having been justified by faith, we have peace with God through our Lord Jesus Christ.” (NAS)
“being justified as a gift by His grace through the redemption which is in Christ Jesus.” (NAS)
“Therefore if any man be in Christ, he is a new creation: old things are passed away; behold all things are become new.” (KJV)
Philippians 1:6 “And I am sure of this, that he who began a good work in you will bring it to completion at the day of Jesus Christ.” (ESV)
Tags: Justification Romans, Lord Jesus Christ, NAS, Scriptures Psalms
April 26 : B.B. Warfield Ordained
26 April, 2012 in April 2012 by davidtmyers | 2 comments
He Being Dead, Yet Speaks
We have a few of the characters in this historical devotional guide who are mentioned in more than one date out of the year. Their birth dates, their death dates, and significant dates during their lives are found here. The reason why that is, is that they, while members now of the triumphant church, were well-known members of the militant church on earth. Such a one like that was Benjamin Breckinridge Warfield.
Born in 1851 in Kentucky from good solid Presbyterian heritage, especially on his mother’s side, Warfield was known and still is known as a great defender of the faith. The books he wrote are still readily available in both hard copy as well as on the web. Yet he had limited experience in the pulpit and pastorate, serving only a few years in that capacity. Further, he was not interested in church politics, either in the presbytery, synod, or general assembly. His place of ministry was always in the classroom in a seminary setting.
In that sense, he was, as Paul puts it in Ephesians 4:12, an individual who “equipped the saints.” That word “equip” is used in the gospels accounts to describe the necessary work of the fishermen who later became the apostles of our Lord. It was said that when that divine call came, they were “mending the nets.” In other words, they were getting the nets ready for service. This is what the word “equip” speaks about in Ephesians 4. And that is exactly what Warfield did as a professor at Princeton Theological Seminary with his students. They were equipped as student saints. They were prepared for service in the kingdom of God.
No one did a better job in his time there than Benjamin Breckinridge Warfield. He took over the Chair of Charles Hodge from the son of Charles Hodge, A. A. Hodge. He was therefore a link to the marvelous Hodge dynasty at old Princeton. When he died in 1921, it was said that Old Princeton had passed away. In God’s providence, a mere nine years later Westminster Theological Seminary began, as an effort to preserve and continue something of that tradition of Old Princeton.
And to think all this story was begun officially on April 26, 1879 when Benjamin Breckinridge Warfield was ordained to the ministry. It was a recognition of the spiritual gifts which he possessed in knowledge and wisdom, in teaching, and in discernment. His ordination was a recognition by the Church of the hope and anticipation of how those gifts might be used in coming years, for the glory of God.
Words to Live By: Warfield is in heaven now, but his words live on in the church on earth. It will do you, the reader, much good to spend time in reading his books either in book form or on the web. Those books are not always easy to read, but they are worth the effort, for they still stand ready to equip you for service in Christ’s kingdom.
Through the Standards: Only one way of justification
“The justification of believers under the old testament was, in all these respects, one and the same with the justification of believers under the new testament.”
April 25 : Rev. Edwin Rian returns to PCUSA
This Day in Presbyterian History: The Man Who Looked Back
I was frozen in place that day behind the front desk of the Christian conference center in New Jersey. The distinguished man had walked up to me to ask whether the Director of the Conference was on site. I replied that he was away at the time. Whereupon the man gave me his business card, and walked out of the hotel that summer afternoon in 1965. Looking down, I read the name of “Edwin Rian, Assistant to the President, Princeton Theological Seminary, Princeton, New Jersey.” I wish that I could say to our readers that this young seminarian had then rushed out of the hotel to ask the writer of the historic book The Presbyterian Conflict to stop and talk. I wish that I could say to our readers that I stopped him and discussed with him as to why he left the infant Orthodox Presbyterian Church after such a valiant stand against the apostasy of the Presbyterian Church, USA. I could have asked him whether he remembered my father, who stood with him in the nineteen thirties for the faith, by faith. But I did none of these things. I was frozen in time.
Born in Minneapolis, Minnesota, Edwin Rian came to Princeton Theological Seminary to study Semitics at the prestigious school., as part of the Seminary’s class of 1927. Ordained in 1930 in the Presbyterian Church in the United States of America, he advanced his scholarship by studying as a Princeton Fellow at the Universities of Berlin and Marburg in Germany. Returning to the States, he saw clearly the issues which led his mentor J. Gresham Machen to organize Westminster Theological Seminary. He took his stand on those same issues, and like Machen and a number of other ministers, was censured by the Presbyterian Church, U.S.A. As a founding member of the Presbyterian Church of America (1936), he stayed with that church when the Bible Presbyterians left it in 1938. The former was later renamed the Orthodox Presbyterian Church. (1938). It was in 1940 that Rian crystallized the issues by writing the important book, “The Presbyterian Conflict.” It still can be found in print or online, and is quoted often by those who seek to understand this period in American Presbyterian history.
Something happened to Edwin Rian himself, though, in the latter part of the 1940’s. The fact that he left in 1946 to join the Christian University Association as its General Secretary was not unusual. What was unusual was that on April 25, 1947, he left the Orthodox Presbyterian Church to reenter the Presbyterian Church, U.S.A., from which he had been suspended over ten years before.
Various reasons had been suggested for this, sea change. One theory was that Rian was disappointed that a Christian University had not been started in Reformed circles. And certainly, the rest of his life and ministry was taken up in educational circles. But that reason doesn’t ring true to this contributor. The reasons, however, were never revealed.
He went on to serve in a variety of administrative posts in colleges and universities like Trinity University in San Antonio, Texas, Beaver College in Jenkintown, Pennsylvania, Jamestown College in Jamestown, North Dakota, Biblical Seminary in New York City, New York, and the American Bible Society in New York City. His last ministry and one in which he came full circle, was the position of Assistant to the President of Princeton Theological Seminary, Dr. James I. McCord, where he served for 15 years until his retirement. He departed this life in 1995 at age 95 in San Diego, California.
Words to Live By: Jesus said in Luke’s Gospel, chapter 6:62, “No one who puts his hand to the plow and looks back is fit for the kingdom of God.” The commentator writes that there are some whose hearts are in the past. They walk forever looking backwards and thinking wistfully of the good old days. The watchword of the Kingdom servants is always “forward,” never “backward.” Let us be not be content with lukewarm service.
Through the Standards: Once justified, always justified
“God does continue to forgive the sins of those that are justified; and, although they can never fall from the state of justification, yet they may, by their sins, fall under God’s fatherly displeasure, and not have the light of His countenance restored unto them, until they humble themselves, confess their sins, beg pardon, and renew their faith and repentance.”
April 24 : Birth of J. A. Alexander
Joseph Addison Alexander was the third son of the Rev. Archibald Alexander and his wife Janetta (Waddel) Alexander. In modern terms, Joseph was home schooled, and he developed an insatiable thirst for knowledge, pursuing one subject after another as it caught his attention. Eventually he grew to become another of that esteemed early faculty of the Princeton Theological Seminary.
His biographer says of J.A. Alexander that
“…in the midst of all his laborious and diversified pursuits he saved time for the most heart-searching exercises in his closet. He gave himself up to daily communion with his God. He might neglect everything else, but he could not neglect his private devotions. In point of fact he neglected nothing. He moved as by clockwork. The cultivation of personal piety, in the light of the inspired word, was now with him the main object that he had in life. The next most prominent goal that he set before himself was the interpretation of the original scriptures; for their own sake, and for the benefit of a rising ministry, as well as for the gratification he took in the work. The Bible was to him the most profoundly interesting book in the world. It was in his eyes not merely the only source of true and undefiled religion, but also the very paragon among all remains of human genius. He knew great portions of it by heart….But more than this, the Bible was the chief object of his personal enthusiasm; he was fond of it; he was proud of it; he exulted in it. It occupied his best thoughts by day and by night. It was his meat and drink. It was his delectable reward. There were times when he might say with the Psalmist, “Mine eyes prevent the night watches that I might meditate in thy word, I have rejoiced in the way of thy precepts more than in great riches.” He succeeded perfectly in communicating this delightful zeal to others. His pupils all concur in saying that “he made the Bible glorious” to them.
Words to Live By: The Bible is the very Word of God—His self-revelation to His people. J.A. Alexander seems to have made Psalm 1 the model and guide for his life. If you have never memorized a portion of Scripture, this Psalm is short and is a great place to start. Setting it to memory, such that you can think on it at various times, will bring real profit.
1 Blessed is the man that walketh not in the counsel of the ungodly, nor standeth in the way of sinners, nor sitteth in the seat of the scornful.
2 But his delight is in the law of the LORD; and in his law doth he meditate day and night.
3 And he shall be like a tree planted by the rivers of water, that bringeth forth his fruit in his season; his leaf also shall not wither; and whatsoever he doeth shall prosper.
4 The ungodly are not so: but are like the chaff which the wind driveth away.
5 Therefore the ungodly shall not stand in the judgment, nor sinners in the congregation of the righteous.
6 For the LORD knoweth the way of the righteous: but the way of the ungodly shall perish.
Additional Notes for this day:
Professor J.G. Machen, lecturer, author and Bible scholar, delivered two addresses on Christianity at the dedication of the new home of the New York Bible Society in East Forty-eighth Street. [The Continent 53.17 (27 April 1922): 529.]
Through the Standards: Act of justification is from the Triune God
“God did, from all eternity, decree to justify all the elect, and Christ did, in the fulness of time, die for their sins, and rise for their justification: nevertheless, they are not justified, until the Holy Spirit does, in due time, actually apply Christ unto them.”
April 23 : Horace Newton Allen
The Earliest Protestant Missionary to Korea
It wasn’t luck. It wasn’t chance. It wasn’t good fortune. It was plainly providential.
Sent to Korea as a physician, Horace Newton Allen was in Seoul in 1884 when a royal relative of the governing family was stabbed and left badly injured. A German diplomat called for Dr. Allen to treat the young man with Western style medicine practices with the result that the young member of the royal family recovered in three months. Obviously pleased with the results, the royal family was grateful beyond words and ready to do any thing and everything the physician desired. He promptly went about to establish a hospital which sought to train native Koreans in Western style medicine practices. But Allen also sought to open up the vast land to American evangelists and missionaries, for that was what Dr. Allen was himself.
Born April 23, 1858 in Delaware, Ohio, Horace Newton Allen studied at Ohio Wesleyan University. Graduating from there, he went on to get his medical credentials from Miami Medical School in Ohio. Sent out first by the Presbyterian Board of Foreign Missions to China, he stayed but a year as a result of less than welcome from the Chinese people. So he went to Korea and had the above experience.
This wide and effective door occurred when Korea was still anti-Christian in its attitude and actions toward Christians. A little before this, over 10,000 Koreans who had converted to Christianity had been beheaded. But his example as a Christian doctor enabled the opening of the door to Christians evangelists and missionaries from other lands, including the United States, to enter the land and minister there in complete freedom.
In fact, so much did he identify with the Korean people, that the United States in 1897 appointed him as a diplomatic minister and consul general to that land. He stayed there in this government position until 1905 when President Teddy Roosevelt recalled him. He returned to the United States and died in 1932.
The medical facility which he began was called in Korean, “The House of Extended Grace.” And that is what Dr. Horace Allen brought to Korea as he evangelized the souls of people in that Asian nation and healed the bodies of Korean people.
Words to Live By: When God opens up a wide and effective door, God’s people need to be ready to enter through it for the work of Christ’s kingdom.
Through the Scriptures: Psalm 37 – 39
Through the Standards: Justification is free to us, but not to Christ who paid for it
“Christ, by His obedience and death, did fully discharge the debt of all those that are thus justified, and did make a proper, real, and full satisfaction to His Father’s justice in their behalf. Yet, in as much as He was given by the Father for them; and His obedience and satisfaction accepted in their stead; and both, freely, not for anything in them; their justification is only of free grace; that both the exact justice, and rich grace of God might be glorified in the justification of sinners.”
Tags: Born April, Horace Newton Allen, Korea, United States
April 22 : Jonathan Dickinson
A Man Fit for the Times
Jonathan Dickinson shares a lot of credit in the shaping of the early Presbyterian Church in the American colonies. Born on April 22, 1688 in Hatfield, Massachusetts, he graduated from Yale in 1706. Two years later, he was installed as the pastor of the First Presbyterian Church of Elizabethtown, New Jersey, where he remained for the next forty years.
In 1722, with respect to the issue of creedal subscription, a schism began to develop in the infant Presbyterian church. The question was simple. Should a church officer — elder or deacon — be required to subscribe to everything in the Westminster Standards, or would it be sufficient for that officer to simply subscribe to the more basic truths of historic Christianity, as expressed, for instance, in the Nicene Creed? Dickinson took the latter position and became the chief proponent of it in the infant church. The fact that the same issue was raging in the mother countries among the immigrants from England, Scotland, and Ireland only heightened the controversy in the colonies. Eventually, the approaching storm of schism was stopped by the Adopting Act of 1729. Written by Jonathan Dickinson, it solidly placed the church as believing in the Scriptures of the Old and New Testaments as the only infallible rule of faith and life, while receiving an adoption the Confessional standards of the Westminster Assembly as subordinate standards of the church. Each court of the latter, whether Session, Presbytery, Synod, and General Assembly would decide what exceptions to the latter would be allowed, and which exceptions would not be tolerated to the Westminster Standards.
In addition to his pastoral leadership in the church courts, the fourth college to be established in the colonies was the College of New Jersey in October of 1742. It began in the manse of the first president, namely, Jonathan Dickinson. The handful of students in what later on become Princeton Theological Seminary and Princeton University studied books which were a part of Dickinson’s pastoral library, and ate their meals with his family. He would pass on to glory four months after the beginning of this school.
His last words were symbolic of his place in the history of the Presbyterian church. He said, “Many years passed between God and my soul, in which I have solemnly dedicated myself to Him, and I trust what I have committed unto Him, He is able to keep until that day.”
Words to Live By: Is this your testimony? Paul writes in his last letter to the first century church, “. . . for I know whom I have believed, and am persuaded that He is able to keep that which I have committed unto him against that day.” (KJV – 2 Timothy 1:12)
Through the Standards: Faith alone justifies, but never stands alone
“Faith, thus receiving and resting on Christ and His righteousness, is the alone instrument of justification: yet is it not alone in the person justified, but is ever accompanied with all other saving graces, and is no dead faith, but works by love.”
Tags: Adopting Act of 1729, Jonathan Dickinson, New Jersey, WCF, Westminster Standards
April 21 : Maryland Toleration Law
Maryland Toleration Law Opens up Colony for Reformed Preaching
April 21 was an important date in 1649 for the Reformed faith in the colony of Maryland. Originally, Maryland was a colony established as a refuge for English Catholics. But as more non-Catholics came into the colony, and indeed it became a Protestant colony, the Maryland Assembly on this date established the Maryland Toleration Law, or as it is sometimes known as The Act Concerning Religion.
What it did was to mandate religious tolerance for trinitarian Christians. That adjective “trinitarian” is important. If a citizen of the colony denied the deity of Jesus Christ, for example, then the punishment was seizure of their land, and even death. Thus Unitarians, or Jews, or atheists were threatened by this law. It was meant more so as a protection for the Roman Catholics as it was for the Protestants, and specifically the Reformed faith.
It wouldn’t last long on the books, being repealed in 1654 by Oliver Cromwell’s influence upon the colony, and specifically the Anglican Church. It would be returned to the law books, but then repealed forever in 1692. It is interesting though that a part of it was found in the First Amendment of the U.S. Constitution, which states “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the rights of the people peaceably to assemble, and to petition the Government for a redress of grievances.” The phrase “the free exercise thereof,” comes from the Maryland Act of Toleration.
What interests us in this Act of Toleration is that it allowed “the father of Presbyterianism” in the colonies, Francis Makemie, the freedom to preach in Maryland. Arriving in the Maryland colony in 1683, he didn’t have to seek permission from the governor of the colony to proclaim the richness of free grace. Further, those of the Reformed faith who were driven out from the Virginia Colony’s control by the Anglicans, could come to Maryland to practice their Reformed faith. Makemie went on to establish several Presbyterian churches in Maryland.
Words to Live By: This same Francis Makemie didn’t let state laws prohibit him from preaching the gospel. (See January 21 historical devotional) He was willing to go where the Holy Spirit led him to proclaim the unsearchable riches of God’s grace, regardless of the state law. But when the liberty of the state enabled him to go, he didn’t “let the grass grow under his feet” in sharing the good news of Christ, and Him crucified. Let us not let the fear of man’s face hinder us in sharing what Christ has done for us.
Through the Standards: Justification, according to the catechisms
WLC 70 — “What is justification?
A. Justification is an act of God’s free grace unto sinners, in which he pardons all their sins, accepts and accounts their persons righteous in his sight; not for anything wrought in them, or done by them, but only for the perfect obedience and full satisfaction of Christ, by God imputed to them, and received by faith alone.”
WSC 33 — “What is justification?
A. Justification is an act of God’s free grace, wherein he pardons all our sins, and accepts us as righteous in his sight only for the righteousness of Christ imputed to us, and received by faith alone.”
Tags: English Catholics, Francis Makemie, Maryland Assembly, Oliver Cromwell


NEW MEXICO: A BLEND OF LANDSCAPE, SPORT AND CULTURE | Land Investor
Land Investor FeaturesVolume 1
posted: Thursday, October 01, 2015
The land, color and skies of New Mexico, combined with its outdoor recreation opportunities, culture, people, history and arts attract ranchland investors to this most unique mountain state, long known as The Land of Enchantment.
New Mexico, the fifth largest state, is long on landscapes that range from vast deserts to open mesas to snowcapped mountain peaks, and low on human population, with just above two million residents. In New Mexico, there are still large, intact legacy ranches in a time where increased populations have led to the fragmentation of larger ranches in more populated regions of the mountain states.
Much of Fay Ranches’ work in New Mexico is off-market and under the radar, involving unlisted confidential properties. We have select, large, off-market working cattle and recreational ranches for sale to offer and discuss with genuine legacy buyers. New Mexico is a ‘non-disclosure state,’ meaning terms and parties of real property sales are not of public record.
Sportsmen yearning for a “real hunt” look to New Mexico. Fewer people combined with favorable habitat and wildlife management have led to impressive Boone & Crockett rankings for elk, mule deer and pronghorn entries.
The southwest New Mexico mountains, known as “the Gila,” are renowned for populations of some of the largest elk in North America. For the mule deer enthusiast, the focus changes to highlight the Rio Arriba and San Juan counties in northwest New Mexico, near the four corners where New Mexico, Arizona, Colorado and Utah meet. Some of the top mule deer taken in North America have been in Rio Arriba County. The habitat here at the base of the Rocky Mountains soars over 14,000 feet and boasts three large river systems.
For wingshooters, it is still possible to see large, wild coveys and bag three species of desert quail in one day. Fly-fishermen enjoy the fisheries flowing from the Sangre de Cristos (Blood of Christ) in northern New Mexico, which flanks the east side of the Rio Grande. Much of this region of the state is heavily forested wilderness. The Sangres, which are further south towards Santa Fe, also produce the Pecos River and harbor a unique Pecos strain of Rio Grande trout found only in this stretch.
Skiers at Angel Fire Resort, Taos Ski Valley and Ski Santa Fe can enjoy some great snow and wintry mountain terrain while the rest of the family is an hour away at a lower elevation in Taos or Santa Fe enjoying outdoor dining in a temperate clime. Only in New Mexico.
In addition to the sportsman’s scene, New Mexico is an international draw for its unique history, culture, cuisine and architecture. New Mexico was partially settled similar to other western states, by way of east-to-west migration. In the case of New Mexico, the east-to-west migration was by way of the Santa Fe Trail during the 1820s through the 1850s. It was also settled with migration from the south over 300 years earlier by way of the famous trade route, El Camino Real, originating in what is now Mexico City and Veracruz, Mexico. Many families in the state are direct descendants of these settlers who came from the south over 400 years ago.
The result is a completely different and unique cultural mix as seen in the art, cuisine and architecture, which is as much of a part of the Enchantment of New Mexico as the land itself. History buffs can see ancestral Pueblo architecture, Spanish influence, Territorial architecture and southwest revival influences, which provide a glimpse into different periods of New Mexico’s unique history and set the stage for New Mexico’s unique art scene centered in Santa Fe.
Overall, New Mexico is a gem of culture, history and wide-open spaces, and it is unlike any other region in the country
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Dubai's International Humanitarian City to Triple in Size
International Humanitarian City Dubai
DUBAI, UAE, Jan. 19, 2017
Decision made in response to sharp rise in demand for emergency aid
IHC to expand a further 300,000 square feet of space for aid provisions
/CNW/ - HH Sheikh Mohammed bin Rashid Al Maktoum, Vice-President and Prime Minister of the UAE, and Ruler of Dubai, has commissioned work to triple the size of his International City of Aid (IHC) to streamline and strengthen operations to support aid agencies. Upon completion, the IHC will now stretch for a further 300,000 square feet, totalling 404,000 square feet.
(Photo: http://mma.prnewswire.com/media/459342/IHC_1.jpg )
Intensifying conflicts in Syria, Yemen, Afghanistan, Nigeria and other trouble spots have led to mass displacement of over 65 million people and a sharp rise in the need for emergency aid in the form of food, shelter, and medicine. Demand for such aid is now at its highest level worldwide since World War II and aid agencies need additional warehousing and logistics support to cope.
The expansion has been approved in order to meet the urgent demands of leading UN and NGO agencies trying to cope with this rising demand, most notably the Red Crescent, UNHCR, ICRC, and the World Food Programme. Specifically, the new space will help IHC members better pre-position stocks in the event of new pandemics, natural disasters and more armed conflicts and conduct more training of aid workers.
Founded in 2003, the International Humanitarian City is already the world's largest humanitarian logistics hub and has nine United Nations agencies as members plus nearly 50 NGOs and businesses working in the aid sector. When it moved to its current location in Dubai Industrial City near Jebel Ali Port and Al Maktoum Airport in 2011 it tripled in size, but demand for more space has continued to climb rapidly.
The IHC has played a pivotal role in first responses to crises in places as far away as Haiti and Vanuatu, but is especially critical in moving goods to trouble spots in the MENA region and East Africa.
SOURCE International Humanitarian City Dubai