Table 1

Implementation strategies informed by Morgan’s Practical framework for conceptualising interventions to reduce medical overuse (source: Morgan et al, 2017)

Morgan’s possible drivers/domains description29Feasible approaches to improvement*Barriers to deimplementationIntervention (strategies)Strategy descriptionLevel of intervention
Influence
Clinician factors: belief that more is better, poor knowledge of evidence, past experience, cognitive dissonance, fear of litigationClinician: education about evidence; education about harms of testing in these patientsProvider lack of knowledge/practiceEducation and trainingKnowledge about the innovation, skills to use the innovation, optimism that the innovation will be effective, and improved ability to access details about how to use the innovation without promptsIndividual
Patient–clinician interaction: hypothetical, poor communication secondary to patient conditionPhysician-directed tool for communication about the issueProvider lack of comfortDecision support/supervision from DRAUP teamTraining and supervision: reflect on the implementation effort, share lessons learnt, support learning, and propose changes to be implemented in small cycles of changeIndividual and social network
Clinician factors: belief that more is better, poor knowledge of evidence, past experience, cognitive dissonance, fear of litigationClinician: education about evidence; education about harms of testing in these patientsInertia/reflexAudit and
feedback
Audit feedback: provides clinical supervision via digital assessment, review case implementation, make suggestions, and provide encouragementIndividual and Organisational
Culture of healthcare: expectation of all clinicians (including attendings, consultants, nursing), organisational competitiveness, liability and cost fearsCulture: broad campaign across the EDHospital policyOrganisational support (policy/procedures)Organisational attributes such as the presence of formalised practice policies, positive organisational culture and climate are associated with more favourable service provider attitudes toward adopting the EBIOrganisational
Practice environment: ease of protocolPractice environment: EMR supportProvider lack of confidenceAlgorithm development based on EBIFidelity refers to assessment of adherence and competenceIndividual
Patient factors: expectation of frequent testingPatient: provide information about options for treatmentInertiaPlanned
adaptation
Data-informed changes (reordering, forestalling, or delaying certain components, adding materials or interventions, language and/or cultural adaptations) approach to maintain intervention fidelity during the implementation of EBIIndividual and organisational
  • *To be refined from qualitative analysis

  • DRAUP, deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol; EBI, evidence-based innovation; ED, emergency department; EMR, electronic medical record.