Table 2.

Specific CMO configurations that might be amenable to simple or complicated interventions

Context	Mechanisms	Outcomes	Interventions suggested to improve*	Exemplar quotations from stakeholder group to support the CMO configurations created	SEIPS mapping of mechanisms (subject-specific examples given in square brackets)
Multiple care providers	Different information technology systems Uncertainty about who to contact for what	Lack of timely access to patient records Decisions made on incomplete information leading to suboptimal care	Technological interfaces to improve access to live patient records in a timely manner need to be developed with a user-centred design approach Single point of access for out-of-hours care	‘Most of the time we’ll get everything that we need from the out-of-hours General Practitioner (GP) but it’s adding that extra time, for both us, for the patient and for the out-of-hours GP you know. If we knew the information in the first place it would be a lot easier.’ (Professional) ‘What do carer’s want? And the answer is a single point of communication… don’t think it matters what the single point is but I do think it’s absolutely essential for a carer to have that phone number they can, they can ring and say help I don’t know the answer to this.’ (Informal carer)	External influences [national policies] Organisation of work Technology and tools
Advance care planning (ACP)	Plans not created Plans not communicated/accessible when needed Unclear who is responsible for completing and updating advance care plans Lack of effective processes and tools for care coordination between hospital and community	Optimal care in line with patient preferences not delivered Deviations from preferred place of care or death Admissions to acute healthcare when patient not going to benefit from escalation in treatment interventions	Interpersonal solutions accounting for socially mediated factors to prompt advance care planning creation Technological interfaces to improve access to live patient records in a timely manner across all services including hospitals	‘We looked at the volume of 999 to care homes pre ACPs and post ACPs and there’s a definite reduction it caused. ACPs are empowering care homes nurses to not make that phone call.’ (Professional) ‘How do you keep that up to date when we’ve got an electronic system that’s–but there’s lots of different electronic systems that we’re supposed to be putting the information on’ (Professional) ‘Because he’s not ambulant he can’t go through the usual turn up to clinic so he has to get brought in by ambulance so he has to go through the medical intake he’s there waiting you know for hours and hours and hours for that, then they do the Deep Vein Thrombosis (DVT) and they admit him through the process check his DVT–no, but then it took 3½ weeks to get him home, discharge planning all he came in for was a DVT to be ruled out and but the fact is he’s now in hospital unsafe discharge, la, la, la, la, la, you know everyone wanted him to be at home, he wanted to be at home, but the minute we ticked this system box of get him in we can’t get him out then.’ (Professional)	Organisation of work Technology and tools Person [including dynamics between people–patient/informal carers/healthcare professionals; and, psychological, social and cognitive factors] Physical environment
Workload pressures due to volume of need in comparison with staff resources	Professionals focusing on crisis management Tendency to leave complex issues to ‘in-hours’ care providers	Further crises due to lack of preventative/prophylactic measures Agency staff used–lack of local knowledge disadvantaging them in providing best care	Population-based needs assessment of resources to deliver agreed standards of care	‘What we do is we normalise a lot of it we just say it’s part of our working day to go around correcting all the mistakes that the system has put in.’ (Professional) ‘How much extra work these mistakes cause us and literally every you know about a third of these is that somebody else has actually caused so yes we’ve had to do the extra paperwork. So, it builds inefficiency into our systems.’ (Professional) ‘Actually, we could chuck in agency staff… absolutely yeah and that’s above their paid rate you know.’ (Professional)	Organisation of work Person [healthcare professionals—physical, cognitive and psychological capabilities]
Reliance on professionals outside specialist palliative care to deliver frontline services	Inexperience Lack of training Uncertainty about how to gain expert advice/advice not available	Default to admit patients to hospital Missed or delayed diagnosis of palliative care emergencies, for example, bowel obstruction, pathological fractures	Additional specialist palliative care resources for direct patient care and/or training of others in frontline care: population-based needs assessments could guide quantification of this. Robust concurrent evaluations of effectiveness, and value of additional resources and new training interventions	‘We might have breathing difficulties… well breathing difficulties can be so many things so we’ve got to walk in and we’ve got to, we’ve got to determine first of all you know is this a reversible cause, you know is this an asthma, is this a chest infection or is it palliative care you know so…and then once we’ve decided okay perhaps it is palliative care, we don’t know at what stage.’ (Professional) ‘You’ve got the GP who doesn’t know the patient, they turn up its gonna take a lot more time to sort them out locally, it’s easier to get them admitted.’ (Professional)	Organisation of work Person [healthcare professionals: team working, psychological and cognitive factors]
Medication management	Complicated medication regimes Unfamiliarity of frontline staff with palliative care medications Myths and fears about symptom control medications Breakdown of practical systems for prescribing, supplying and administering medications	Delays in symptom control Increased risk of medication errors: wrong doses prescribed, dispensed or administered	End-to-end solutions for medication provision and management, for example, electronic prescribing, clarity about who could prescribe/alter dosing of existing medications/transcribe prescriptions Out-of-hours pharmacy support Increased anticipatory prescribing	‘I saw people going out of hospital with complicated treatments regimes that gave the feeling that I don’t think there’s a chance in a million of those people taking the right drugs at the right time.‘ (Informal carer) ‘Tell me if I’m speaking out of turn, I think in the community out-of-hours GP’s, Primary care, some people are afraid of it and they’ll only prescribe it [oral morphine instant release liquid] every 4 hours whereas we didn’t have a problem in giving them every hour.’ (Professional) ‘And then when there’s artificial barriers put up so when for instance we can’t get the drugs in the community even if you call on-call pharmacy it’s really difficult to get the medicine from say the hospital because it’s a community patient and they want a hospital prescription and it’s always things like that it’s like an artificial barrier that’s put up for accessing the meds.’ (Professional) ‘We used to have dose ranges which were stopped so we would have 2.5–10 mg of midazolam written up but once that’s stopped the GP then writes 2.5 mg 2 hourly, but if that patient then overnight an hour later is in excruciating pain the qualified nurses there can’t give anything, can’t take a verbal, has to wait for out-of-hours then to come which could take X, Y-10 [participant indicating problems of this taking an unknown length of time] you know or however long, so that can be quite frustrating.’ (Professional)	Organisation of work Person [patient, informal carers, healthcare professionals: physical, psychological and cognitive factors]
Implicit reliance on informal carers	Inadequate support	Carer distress and breakdown	Investment in carer support: psychological, emotional and practical Adequate needs-based assessment of patient care	‘I had a patient admitted a week last Friday who was in renal failure end of life, he preferred basically a death at his home we rang out-of-hours at quarter to eleven they arrived at 2am patient was severely agitated with retention of urine potentially they gave a stat that they didn’t catheterise patient an hour later became very, very agitated GP couldn’t go out the wife panicked and then rang 999 he was then admitted and died so… I think if the reassurance that somebody was gonna go back, maybe the GP could visit then she may not have panicked and rung 999. However, she could’ve also rung me back, but she didn’t so it was a very sad situation really, because he was obviously extremely agitated, but he dipped very quickly… People react differently overnight as they might do during the day really don’t they? They often say long hours at night they see things differently, in the day there would’ve been a lot more people around… we see a lot of out-of-hours calls where people panic and ring 999 even though you’ve put everything in place.’ (Professional) ‘I was confused, my wife running a really high temperature with her being tired because I thought they visited on the weekend I didn’t take her temperature quite as often as I should.’ (Informal carer) ‘And I had a promise of support from Marie Curie which was very good for my peace of mind.’ (Informal carer)	Organisation of work Person [patient, informal carers: physical, social, psychological and cognitive factors]

*As demonstrated in figure 1, evidence to support these is variable: we report here the suggestions made during the stakeholder event. Our analysis demonstrated professional belief in these interventions regardless of the level of empirical evidence.

ACP, advance care planning; CMO, context–mechanism–outcome; SEIPS, Systems Engineering Initiative for Patient Safety.