Phase I: toolbar development

This Phase was carried out in three steps, including a systematic review, FGDs with experts and semi-structured interviews with the target group (emergency care providers and recipients), and a panel of experts. The planned duration for this purpose was 13 months, which was from April 2018 to April 2019.

In the first step, a comprehensive search strategy was devised to identify the domains and items related to assessing the preparedness of NHHCs, which provide basic emergency care. This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). The five databases including PubMed, Scopus, Web of Science, Barakat Knowledge Network Systems (BKNS) and Scientific Information Database (SID) were searched. All of the searches were performed in English and/or Persian languages with no time limit until March, 2018. Also, grey literature and manual search were done. Studies were appraised using the Mixed Methods Appraisal Tool (MMAT). Content and data of the included studies were synthesized by means of directed content analysis methods; then, they were classified according to Donabedian model [30]. For more information on the findings of this step, see the published systematic review and protocol articles [28, 29]. The most comprehensive model used for health care assessment is the Donabedian model. It was presented in 1966 and defined three distinct aspects of quality, which include structure, process, and outcome. This model is more accepted due to its simplicity and flexibility, and most evaluation studies also use this model [31].

In the second step of toolbar development, in accordance with the health care delivery system in Iran and based on emergency care (basic life support), a qualitative exploratory study was conducted using Semi-Structured Interviews (SSIs) and Focus Group Discussions (FGDs). Those who fail to participate in the FGDs will have a semi-structured interview. Before starting the interviews, the study and its objectives were presented to the participants and their informed consent was secured. SSIs and FGDs were then performed by two skilled researchers using an interview guide developed through literature review and expert consultation. The interviews continued to saturate the data. Overall, 12 SSI were carried out with providers providing care services at NHHC in Tabriz, northwest of Iran. In addition, 2 FGDs were held with 13 specialists in the conference room of the health service management department. The people participating in the FGD sessions were drawn from various specialists, such as Emergency Medicine (EM), Primary Health Care (PHC), the executives of health centers, with over 5 years of work experience, and Emergency Medical Services (EMS) experts. The mean age of the participants was 40 years an average work experience of 13 years. Refer to the table for more details about the participants in the interviews and focus group discussion sessions (Table 1).

Characteristics of demographic variables of participants in FGD and ISS

Participants were employed using the purposive sampling method because this sampling method ensures that the participants in the interviews have relevant experience and adequate knowledge in the field of research. Snowball sampling was also used to access other physicians with experience in this field. Sampling was continued with maximum variety to achieve greater data transferability of data and saturation [23]. To achieve maximum diversity, informants were selected from different age groups, experiences of dealing with LTEs, and a variety of experiences to provide basic emergency care. All interviews were recorded and transcribed verbatim immediately. As soon as the first interview was performed and transcribed, data analysis was started using the “framework analysis approach”. For more information on the findings of this step, see the published qualitative study and protocol study articles [29, 32].

In the third step, the domains and items of the relevant toolbar, which were explored through using a systematic review, FGDs, and interviews with the target group, were examined by the research team for overlap and repetition. Then, the table of specifications methodology was used to determine the final domains and items [33]. A panel of emergency medicine experts reviewed items in each domain. In practice, the alignment of a group of items in rows with the existing domains in the columns was examined. Qualitatively, it was authored by a panel of experts based on expert feedback on what other items should be added or removed. Finally, the alpha version of the toolbar was designed.