Table 4. Components of the Implementation Process.

Domain	Theme	Example
Engaging	Staff	I think in all the hospitals that want to implement PEWS; they should involve all the staff possible since the beginning (implementation leader, Cuenca)
		[We presented] the program for all staff including appointed doctors, nursing staff and residents…the program was introduced emphasizing in the role each of us had in the evaluation of the patient (implementation leader, San Luis Potosi)
		The first thing was the information spread on all areas explaining the program. They would give us informational talks, brochures, detailed information about the program, how it was born, how it is implemented...and its goal (nurse director, Xalapa)
	Hospital leaders	We cannot talk with the entire staff, but we can talk about it with the chief pediatrics nursing, chief of pediatrics, chief of residents, chief of emergency department, so that way we can show results and then each chief with their own staff make a revision again, and resolve doubts again, highlight the measures they are taking (implementation leader, San Luis Potosi)
		Motivation was achieved through the socialization of the project because the first presentation to the directors was very important, to count with their support, they give the approval so we can go on (nurse director, San Salvador)
	Champions	They present the project and we try to be a mediator with the authorities from the institute so all the projects can be implemented...the institute committee has had the doors open without obstacles so the PEWS project could develop (research director, Cuenca)
		[The hematologist] convinced the residents working with her saying it was important to detect patients, even though she never got involved in the implementation or in all the processes we did; I think she helped a lot because she convinced the residents that this was something good (implementation leader, San Luis Potosi)
		My role was as a facilitator and communicator of the team boosting the implementation in the oncology service and the link with the authorities so they could give them the necessary tools to develop the program (quality improvement coordinator, San Salvador)
		We even had people...that accepted it so well, they applied it and adapted to it so fast, that even they were the ones motivating their own colleagues saying, look, this helps in this way, if we evaluate the patient this way, if we pay more attention to this, or if we dedicate a little bit more time to this program we will have this benefit (nurse director, Xalapa)
Pilot	Available resources	In the pilot we realized that we didn’t have everything we needed, even though before the pilot we try to have all the equipment, but we always had observations from the assistant staff related to the resources (implementation leader, Lima)
		We learned that we had several weaknesses. One of them was that we needed to…obtain the necessary [vital sign] equipment for the patient’s attention. With the pilot we identified those weaknesses that in certain ways try to solve them (nurse director, San Salvador)
	Adaptation	I learned from the pilot that it’s the right time to arrange everything, it’s the right time to know that for the implementation we must have the nursing sheets ready, the modified sheet, see our algorithm that doesn’t have to change, everything, all our material, our tools. It’s the right time to make any changes we need on PEWS (implementation leader, Lima)
		Also, in the pilot we made certain changes to our nursing sheet that made it difficult for the nurse to compile all the data (implementation leader, Cuenca)
		We discovered the errors we could have, we had to unite the criteria according to the scales we made and were modified according to every institution...we modify them and the final result is the one we are using now (implementation leader, San Luis Potosi)
	Engaging and skill using PEWS	Also, when we trained again the staff, you could know who wasn’t doing things the right way to reinforce their knowledge and explain them better, which was the pilot’s help (implementation leader, Lima)
		Well, we learned a lot of things from the pilot, from improving the techniques of how to take the vital signs, the technique was improved, the speed of the doctor’s response to the patient was improved (research director, Cuenca)
		With the pilot plan we realized that there were too many details we were taking for granted, that we had many errors when it came to direct attention with the patient, from a bad diagnosis to a medical intervention we made. So, it helped us to realize the errors we were making (implementation leader, San Salvador)
	Teamwork	We learned that working in teams was the key for this project’s success (implementation leader, San Salvador)
		I think that’s what the pilot taught us, that we have work in groups, in teams, that we all depend on everyone, that you can’t do it alone, because sometimes at the beginning the leaders wanted to do everything, see the data, see the files, but they realized they couldn’t, that it was a group work (implementation leader, Xalapa)
	Stage of change	We also learned that the project was feasible and it was worth it for the benefit of the patient because we are all benefited, but especially the patient (nurse director, San Salvador)
		We learned not to be so confident, because even a patient who comes in for chemotherapy can deteriorate and reach a yellow PEWS or even red. We learned that we can measure that, that’s something measurable, not subjective, not just say I think he’s not good, I think we won’t make it, to have something objective and measurable that gives me numbers (implementation leader, Xalapa)
	Outcomes	Well, in the pilot what we saw was that the initial mortality rate we had, that I think it was almost 48%, almost 50%, it was a very high mortality, was reduced to more or less 10 points based on the use of the evaluation scale (implementation leader, Lima)
		I think the most important thing is that we made it, that PEWS was recognized as a tool that worked, the pilot showed that it worked and this maybe opened the doors to create the conditions to run it as a quality project from the hospital (physician director, San Salvador)
Evaluation	Evaluation	The fact that the doctor is always checking medical records of critical patients, medical records of patients who died and make an analysis of that information, if there was a detail that could have prevented the outcome, well that was another factor that allow the implementation and the improvement of the service (implementation leader, San Luis Potosi)
		We made surveys among nurses to figure out how they felt regarding the use of PEWS, and we’re very satisfied to have the answers: more than 90% of the nurses felt comfortable with the application of the scale. They feel comfortable with the scale and they recommend the use of the scale for the improvement in attention of all patients (implementation leader, Cuenca)
		The goal when implementing was to measure the errors, to see where we’re failing and make improvements, that is linked with the detection of reds, what was happening with them, what was the evolution of the reds, and what we did right or wrong (implementation leader, Xalapa)
Outside help	Outside help	The hospital in Queretaro helped us; they invited and guided us to work with St Jude...gave us the guidelines to start working; they guided us step by step to start implementing along with St Jude...they gave us tutorial and training (implementation leader, Xalapa)
		But I think that’s been the direct relationship with other institutions, trainings in other institutions, to go and see how the project is working in another institution, all this allowed to strength…especially to be conscious it had applicability (physician director, Lima)
		There were visits from the staff of St Jude, also from the excellence centers, so they could see how the tool was being implemented, mainly to share experiences, to see how we could improve in those things we’re failing (implementation leader, San Salvador)

Abbreviation: PEWS, pediatric early warning systems.