Table 2. Individual Internalization.

Respondents revealed that internalization or the “understanding the value, benefits, and importance of a set of practices,” is critical to beta-lactam TDM implementation.³⁰ Factors relevant to this node include evidence synthesis and interpretation, iterative exposure to the concept of beta-lactam TDM, and access to multidisciplinary clinical and methodologic experts in support of implementation (the ‘3E’s’).

Factors	Representative quotes	Strategies
Evidence synthesis and interpretation Efficacy benefit of BL-TDM Adjudication of meaningful clinical endpoints (i.e., PK/PD metrics, resistance, mortality) Relationship between BL-TDM and toxicity unclear Subpopulation data insufficient Applicability to local practice	“Unfortunately, none of the TDM data have demonstrated survival benefits. They do demonstrate the transition to achieving pharmacokinetic benefits.” [ID 19, Bedside nurse (critical care); Center 2-PI] “I think it makes it easier because the research is local, in a way, so people are familiar with the research that you’re doing. If they see a positive result from their research, they are probably more confident that it’s applicable.” [ID 24, Pharmacist (critical care); Center 3-FI]	International network to aggregate real-world evidence at a large scale Evidence repository (clinical trials, systematic reviews) Idea sharing (face-to-face, handouts) Local research
Iterative exposure to the concept of BL-TDM Application in real-world patient examples Education and training over time	“I would say, if you’re thinking about whether that is bringing some TDM practice to your own site prior to doing that, you need to test the waters a little bit, right? The only way to do that is to send out some concentrations…The best way to convince someone else that there is a need for something is to show them how it can be useful in improving antibiotic dosing, right?” [ID 25, Pharmacist (infectious diseases); Center 2-PI] “…Unfortunately, doctors, we are all very stuck in this is how I’ve always done it, and we’re probably the most resistant change population… I think if it’s more part of the undergraduate or graduate education, by the time you start your career, it’s already part of your thought pattern or part of your attitude.” [ID 23, Physician, trainee (infectious diseases); Center 3-FI]	Hands-on experience in anticipation, leveraging send-out laboratory tests Frequent and varied exposure to education
Multidisciplinary expertise Research expertise Clinical expertise	“Then when we all sit around together in the mornings and we talk about, “Well, why’d you pick that one,” and we discuss that with the information…from the pharmacist…we may say, “Well, what do you think about tryin’—and we can measure the levels, and this person weighs 800 pounds, or their GFR’s two, or they have no proteins, they’ve been malnourished for six months,” …I think it’s things like that when we pick it apart during the daylight hours that might make us wanna think about doing drug monitoring that’s more targeted instead of just throwing the spaghetti at the wall and using the standard recipe.” [ID 2, Physician, attending (critical care); Center 1-NI]	Protocols, policies, and guidelines Influential leaders in infectious diseases and pharmacy