Table 1 Illustration of how, at the study design stage, it was considered that the four main elements of the intervention might help foster change in health care practices through effects at three main levels within hospitals.

Organisation

Hospital Administration, Clinical and Departmental Leadership

Clarifying technical goals, essential roles, resources and support systems required to provide best practice care

Adoption and institutional ownership of standards

Evaluation against standards

Encouragement and support for change

Re-affirmation of guidelines and standards

Promoting leadership

Promotion of organizational change

Gauging success against goals

Recognising and valuing positive change

Promoting recognition of the 'owners of success' and local achievement

Identifying continued needs and new goals

Promotion of sense that 'performance matters'

Agent for addressing critical resource needs

Promotion and continuous reminder of needs and goals

Emissary for change

Social groups

'Culture of Practice'

Credible and authoritative new practice guidelines

Creation of a critical mass to support adoption of new practice and, through peer influence, discourage non-compliance

Promotion of teamwork across cadres

Re-training and strengthening skills

Recognition of good performance

Promoting team leadership

Promotion of departmental change

Support for early adopters

Promote challenging of poor performance

Re-training, orientation and strengthening skills

Local recognition of good performance

Promoting team working

Advocate and channel for communication about change

Support for early adopters

Local reminder/prompt

Individual Practice

Provision of knowledge and skills

Availability of prompts and reminders

Reflection on personal contribution