Table 8 Matrix of the TDFI approach
From: The demonstration of a theory-based approach to the design of localized patient safety interventions
Implementation principles (the 'how’) | Behavior change steps (the 'what’) | |||||
|---|---|---|---|---|---|---|
| Â | Step 1: Form implementation team (IT) | Step 2: Identifying the target behavior | Step 3: Identifying local barriers (LB) | Step 4: Identifying local strategies (LS) | Step 5: Implementing local strategies | Step 6: Evaluation |
1. The need for management approval and ongoing support | Medical Directors liaised with risk management, quality improvement, frontline staff to determine focus area/gave full support | Management authorized audit to determine target behavior | Management asked to encourage completion of IPSBQ by staff groups involved in target behavior | Management asked to encourage staff to participate in focus groups (FGs) | Management sent LSs by staff in project report and asked for authorization for implementation | Management authorized for post-intervention audit to be undertaken |
2. The need for commitment among members of the target group | Recruited IT lead and multi-disciplinary group of staff; expectations clarified to ensure IT members were able to commit to fulfilling their role | IT members encouraged to lead audit to identify target behavior; this involved gaining support/assistance from wards/ departments | Â | Attendance at FGs by staff demonstrated commitment to the improvement of practice | IT members each took responsibility for an element of LSs implementation | Â |
3. Use of boundary spanners | HIEC team acted as boundary spanners by filtering external information into the organizations and linking organizational structure to environmental elements | Fed IT ward staff perceptions about potential target behaviors; IT fed this information both 'up’ and 'down’ their own communication channels; facilitated group to specify exact target behavior | Encouraged IT to distribute IPSBQs to colleagues and encourage completion; fed back findings to IT, clinical governance, junior doctor training, etc. | Facilitated IT to arrange/recruit for FGs; fed information within/between Trusts FGs to gauge LS feasibility; initiated links with Trust areas (e.g., IT; radiology, medical illustrations) for LS implementation | Generated/ facilitated links within/between clinical /non-clinical staff so they could co-produce materials/ resources/ systems for implementation of the LSs; interim report sent to senior management | Will feed results of intervention, experiences, and recommendations for sustainability to IT and senior management in final report |
4. Mapping of guidelines onto local problems | Â | Enhanced credibility of guidelines by encouraging IT to audit current practice, and so relating them to local safety issues/ values | Worked with the IT to link key barriers from the IPSBQ to current practice and context (based on audit and discussion) | Â | Â | Â |
5. Adopting the perspective of the target group | Emphasized this not 'performance management’ but aimed to use a 'bottom-up’ approach | Audit data and anecdotal information led IT to make final decision about specific target behavior | Assessing perceived barriers summarized the front-line perspective about the target behavior | Front-line staff generated ideas for LSs, therefore increasing likelihood of adoption | IT members/ward staff were instrumental in the design of SLSs, and/or consulted at key development stages |  |
6. Acknowledging the complexity of the changing behavior in practice | HIEC team listened to IT members to build a picture about the challenges associated with complying with the alert guidelines | Continuous assessment of audit data/staff discussion to determine main concerns about what was negatively affecting compliance | FGs enabled further understanding about barriers and thus the complexity of the procedure | FGs discussed complex matters; LSs based on experience and understanding of pertinent issues; BCTs addressed deep rooted complexities of LBs | Carefully co-designed and implemented LSs with IT so as not to undermine current staff effort and to highlight justification behind change in practice | Â |
7. A monitoring plan | Â | Audit undertaken; key milestones included post-implementation audit | Â | Â | Â | Post implementation audit /exit interviews underway |
8. A flexible approach that is driven by local context | Explained approach aimed to understand/ address perspectives from the 'sharp end of patient care’ | Audit strategy based on understanding of wards /departments; target behavior chosen based on Trust resources (e.g., H3 set pH level at 5) | Different methods for IPSBQ data collection (e.g., on-line, paper copy); took into account IT capacity/ other forums to facilitate completion | Timing of FGs arranged to encompass competing priorities for attendees; LSs accounted for existing systems, equipment, resources, staff, etc. | Implementation of LSs aligned with 1) current Trust activities (e.g., clinician rotations, organized training, compliance deadlines, etc.), and 2) capacity of IT to design/implement |  |
9. Co-production and design to combine theoretical and contextual expertise | Â | Â | Â | Co-developing LSs with multi-disciplinary staff ensured intervention realistic, feasible, simple, and informed by behavior change theory | Co-implementing the SLSs with multi-disciplinary staff meant the intervention was pragmatic, relevant, and theory-based by the operational stage | Â |
10. Incorporation into established structures | Â | Â | Â | SLSs aligned existing equipment, resources, systems; broadcasted practice change via range of mechanisms | Existing Trust services (e.g., medical illustrations, IT) were used to implement LSs | Â |