User-centered design of digital audit and feedback dashboards to support pediatric antimicrobial stewardship

Abstract Background Audit and feedback (A&F) is commonly used to support guideline-concordant care, yet its effectiveness varies widely and is strongly influenced by how feedback is designed and experienced by clinicians. Poorly designed A&F can be perceived as punitive, unclear, or disconnected from clinical workflows, limiting engagement and impact. User-centered design (UCD) approaches offer a promising strategy to optimize A&F interventions prior to large-scale implementation. This study describes the application of UCD combined with rapid assessment procedures (RAP) to iteratively develop audit and feedback dashboards to support pediatric antimicrobial stewardship. Methods We conducted a qualitative, iterative design study within a large urban health system as part of a broader antimicrobial stewardship implementation initiative. Using RAP, we completed four interview waves with clinicians ( N = 16) from pediatrics, family and community medicine, internal medicine, and emergency medicine. Semi-structured interviews explored general attitudes toward performance metrics and detailed feedback on successive departmental and individual A&F dashboard mock-ups. Data were rapidly synthesized using matrix analysis, with team-based debriefs between waves to identify themes and guide iterative dashboard refinements until thematic saturation was achieved. Results Early dashboard versions were described as visually dense, difficult to interpret, and insufficiently transparent regarding metric definitions and calculation methods. Clinician concerns evolved across iterative design cycles, shifting from readability and visual design to credibility of metrics, perceived fairness, psychological safety, and workflow integration. Participants emphasized the importance of actionable feedback, appropriate peer comparators, transparency balanced with simplicity, opportunities for discussion and reflection, and alignment with clinical workflows and decision support tools. By the final interview wave, clinicians generally viewed the dashboards as clear, acceptable, and supportive of reflection, learning, and quality improvement. Conclusions Applying user-centered design and rapid assessment methods prior to implementation can meaningfully improve the readability, acceptability, and perceived credibility of audit and feedback interventions. Findings suggest that effective A&F should be intentionally designed as a collaborative learning tool rather than a compliance mechanism. Early, iterative engagement with clinicians may be critical to fostering trust, engagement, and sustained behavior change in stewardship and other implementation science efforts.