Morgan’s possible drivers/domains description29 | Feasible approaches to improvement | *Barriers to deimplementation | Intervention (strategies) | Strategy description | Level of intervention Influence |
Clinician factors: belief that more is better, poor knowledge of evidence, past experience, cognitive dissonance, fear of litigation | Clinician: education about evidence; education about harms of testing in these patients | Provider lack of knowledge/practice | Education and training | Knowledge 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 prompts | Individual |
Patient–clinician interaction: hypothetical, poor communication secondary to patient condition | Physician-directed tool for communication about the issue | Provider lack of comfort | Decision support/supervision from DRAUP team | Training and supervision: reflect on the implementation effort, share lessons learnt, support learning, and propose changes to be implemented in small cycles of change | Individual and social network |
Clinician factors: belief that more is better, poor knowledge of evidence, past experience, cognitive dissonance, fear of litigation | Clinician: education about evidence; education about harms of testing in these patients | Inertia/reflex | Audit and feedback | Audit feedback: provides clinical supervision via digital assessment, review case implementation, make suggestions, and provide encouragement | Individual and Organisational |
Culture of healthcare: expectation of all clinicians (including attendings, consultants, nursing), organisational competitiveness, liability and cost fears | Culture: broad campaign across the ED | Hospital policy | Organisational 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 EBI | Organisational |
Practice environment: ease of protocol | Practice environment: EMR support | Provider lack of confidence | Algorithm development based on EBI | Fidelity refers to assessment of adherence and competence | Individual |
Patient factors: expectation of frequent testing | Patient: provide information about options for treatment | Inertia | Planned 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 EBI | Individual 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.