Where there is no gold standard: Mixed method research in a cluster randomized trial of a tool for safe prioritizing of patients by medical receptionists

Medical receptionists have been shown to play a key role in general practice as the first point of contact for patients. They frequently undertake decisions around appointment making which prioritise access to care, but may have limited tools or structures to assist them with this. We report the methods of a study evaluating a customisable tool (POPGUNS - Prioritisation of Patients: A Guide for Non-Clinicians) to support safe prioritisation of patients. This paper reports methodological challenges in a study of this nature where contamination of the study population is an early complication, no current gold standard exists to define safe triaging, contextual differences between practices lead to inter-practice variation, and proxy outcomes (improvement in receptionist response to written scenarios of varying urgency) are used. We have attempted to respond to these challenges by: observing the determinants of inter-practice variation; developing a multi-member panel to constitute appropriate standards for practices; and monitoring self-reported prioritization decisions by practice receptionists through the use of simulated patients.