Table 8.

Matrix of the TDFI approach

Implementation principles (the 'how’)	Behavior change steps (the 'what’)
	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		Attendance at FGs by staff demonstrated commitment to the improvement of practice	IT members each took responsibility for an element of LSs implementation
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		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)
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
7. A monitoring plan		Audit undertaken; key milestones included post-implementation audit				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				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
10. Incorporation into established structures				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