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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.

From: Documenting the experiences of health workers expected to implement guidelines during an intervention study in Kenyan hospitals

Level of action Components of the intervention and mechanisms anticipated by the research team through which they might influence practices
  Training, Guidelines & Standards External Supervision Feedback Local Facilitation
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