Table 1 Strategies for implementing the interventions of the study

Experimental arm investigators meeting

The medical director and nursing director of all ICUs randomized to the experimental arm are invited to attend a one-day meeting, The objectives of the meeting are to present the rationale for the study interventions and the results of the observational phase (baseline results of ICU characteristics, adherence to healthcare processes, patient outcomes and safety climate), to vote on the items for the checklist and to provide training on the use of the study interventions.

Initiation visit of randomized phase

All sites in the experimental arm are visited by one intensivist from the Steering Committee. In these visits, we present the study design, adherence and clinical results of the observational phase, the checklist and definition of targets for improvement to the multidisciplinary ICU team. We also participate in multidisciplinary rounds to train the teams on the application of the checklist and definition of daily goals.

Audit & feedback

We generate monthly reports regarding the rates of adherence of selected processes of care using data collected on the study electronic case report forms. These reports include goals for each process of care so that we can classify the rate of adherence as “achieve the goal,” “close to the goal” or “do not achieve the goal”. Goals are defined based on compliance rates with the care processes obtained in the observational phase. We send these reports and schedule monthly conferences to discuss them with the ICU nursing and physician directors.

Contacts with ICU medical and nursing directors

The coordination center contacts the ICU medical and nursing directors if the checklist or clinician prompting is not being used regularly.

Study website

A study website is available with articles, study materials, videos and a forum to post questions, share experiences and images such as photos of the rounds.

Active reminders

We send SMS messages one to three times a week in the morning to staff from all experimental group ICUs to remind them of the time of the daily visit with the checklist and in the afternoon to remind them about clinician prompting.

Videos

Videos are presented in the training visits and are available on the study website, accessible only by health professionals working at the experimental arm ICUs. The videos contain material on how to use the checklist, how not to use the checklist and two video testimonials of well-known opinion leaders (Mr Paul O’Neill and Dr Derek Angus) that focus on successful quality improvement experiences, patient safety, leadership and team communication.