Table 3

TDF domains, domain-specific themes and example quotes

TDF domainsDomain-specific themesExamples of interview quotes
Social influences1.Physician QI mentorship
2.Coalition (SCIC) provides a forum for QI collaboration
3.’Put a physician leader face’ on the LTOO project
4.Coalition physician members spreading and championing the QI project
5.QI recognition
6.QI sharing (social comparison) to encourage QI
7.Urea lab test ordering physician conformity
‘The biggest bang for the buck is mentorship’ (P9)
‘Integrate physicians into the QI frameworks and organization’ (P2)
‘Led by a trusted, high quality physician, who I know is going to lead the project’ (P11)
‘It is nice that it’s from a physician leader perspective, who shares the QI issues and how they solved it’ (P6)
‘Physician-led projects adds value… in the eyes of other physicians’ (P2)
‘I think having a proof of concept showed in the presentation is excellent because…they did this, okay we can do this here’ (P11)
‘Physicians are educating their learners about the urea test change and why’ (P2)
Environmental context and resources8.Hospital culture differs
9.Minimal physician project effort, straightforward intervention with minimal workflow impact
10.Provide continual access to experienced support personnel to assist physician-led QI
11.Physician staffing challenges
12.COVID-19/pandemic reduced physician time to champion any additional tasks such as QI
13.Connect Care-IT system rollout/ implementation is a competing priority that reduces physician time to participate in QI activities
‘Implementation of things that worked in another site may not necessarily work at a different site’ (P7)
‘Change component to the work flow was very minimal, didn’t create a bunch of extra time for physicians’ (P1)
‘It’s the person to assist to get it done, the sharing of abilities and expertise, it’s awesome’ (P10)
‘Chronically understaffed, don’t have physician coverage’ (P7)
‘Expanding the project has been challenging as everyone is extremely tasked with managing patients’ (P3)
‘Now physicians are like, how do I get through my 12-hour shift with a completely new EMR’ (P7)
Knowledge14.Coalition provided QI education and training encourages physician-led QI
15.LTOO project provides a hands-on QI opportunity
16.‘It is a think tank where physicians can discuss QI topics’
17.Coalition presentation improved LTOO awareness (utilisation and cost data)
‘Provided QI workshop with the methodology and the science of improvement that was helpful’ (P3)
‘Just knowing how to be involved with the QI project’ (P8)
‘Bring a problem to the table and brainstorm ways to address’ (P7)
‘Made reasonable sense, seemed logical and well laid out during the presentation’ (P8) and ‘Given numbers to something that we’ve suspected and known’ (P12)
Social professional role and identity18.Shepherd (chaperone) physician QI leadership role and provide opportunity to lead
19.Physician champion does not view themselves as leading the LTOO project
20.LTOO project aligned to health organisation priorities with support from medical and organisational leaders
21.Competing demands—‘Juggling clinical demands’
‘In the past we were asked to participate, today, we are asked to lead’ (P2) and ‘Shepherd physician-led QI projects’ (P10)
‘Knowing somebody else was running it was great’ (P1) and ‘Co-leadership role’ (P10)
‘Project was recognized as a strategic priority provided more credence to the work, it was Choosing Wisely funded also showed that there was professional and organizational priority’ (P5)
‘Physicians don’t have the time to seek the knowledge of QI, also carry out a project when you’re on busy clinical service’ (P2)
Beliefs about capabilities22.QI is a new skillset for physicians which impacts confidence
23.Lab test ordering is a learnt and ingrained practice
24.Simple Intervention increased confidence to lead QI implementation
‘I feel very beginner and newbie in terms of QI, its foreign and isn’t a concept that is well ingrained’ (P1)
‘It’s an ingrained [learnt), auto practice; the more physicians are in practice and develop a routine and almost a habit’ (P1)
‘It wasn’t taxing for me, supported my participation’ (P12) and ‘Time commitment for me was little’ (P1)
Beliefs about consequences25.Anticipated positive intervention implementation effect (reduced urea ordering)
26.Perceived threat to physician choice and freedom—‘being told what to do’”
27.Physician-led QI was competed out
‘Pretty clean; everyone sees it as a pretty good idea’ (P10)
‘Creates that ivory tower sort of feeling, when you’re just being told what to do …don’t want things imposed on them’ (P7)
‘There is not an appetite for [QI] right now’ (P7)
Behavioural regulation28.Transition from reflexive/ habitual ordering to mindful (evidence-based, patient required) ordering
29.Sustain physician order behaviour change through data reflection and integration in medical learner curriculum
30.ConnectCare (IT system) standardises the lab order sets and the urea blood test has been removed
‘I now think about it instead of automatically just running down the list’ (P1)
‘Support ongoing reflection and data collection’ (P1) and ‘Education will need to become integrated into learner curriculum’ (P2)
‘The most effective thing is really just changing the form’ (P3) and ‘Removing choice (urea blood test) from paper and IT order forms’ (P1)
Emotion31.QI project experience was positive, targeted a grassroots annoying problem, with minimal physician QI effort, motivating physician participation
32.Physicians emotional well-being is impacting their ability to engage in QI
 ‘This has been a positive experience’ (P1) and ‘The thoughts and feeling with the project were more that it was grassroots on the ward’ (P6)
 ‘Trying to provide knowledge or practice change to a group of people who are sort of overworked, trying to sort of balance and survive in their existence’ (P7)
Goals33.Project goals and benefits were clear and that lab ordering is a patient safety and financial issue‘Anyone can understand the goals and for that reason, I think that helped this QI project get traction’ (P11), and ‘Seeing how much we spend in urea blood testing is alarming’ (P6)
Skills34.Past hands-on QI training and involvement encourages future physician QI involvement‘I think having had some formal knowledge of QI processes [helped)’ (P3)
Intentions35.Meet physicians where they are at with a change idea/concept, share the why to motivate grassroots physicians to improve order behaviour‘I think the most importantly, was having a really strong evidence of the ‘Why’.’ (P1)
Optimism36.Pessimistic—‘Tough to change physician behaviour’‘Have to drag along the rest of the group’ (P10) and ‘I think the barrier would be in general physician behaviour’ (P8)
Reinforcement37.No incentives for physician QI involvement (funding/grants and remuneration)‘You’re never going to get anyone to do anything if they are not remunerated’ (P7)
‘We don’t get paid any extra income for doing QI’ (P12)
  • LTOO, Laboratory Test Ordering Overuse; QI, quality improvement; SCIC, Strategic Clinical Improvement Committee; TDF, Theoretical Domains Framework.