Table 2 Influences upon the implementation of each specified step

 Step 1: To address trust and credibility and prepare for action planning

  The semantic differential scale responses indicated the step may not be understand what the step requires of them, may not agree that it should be part of their work, or ‘buy-in’ to the intervention.

  Narrative responses indicated that triangulation would be seen as different; the method could come from existing report; clinical leads may not have the time/capacity to undertake the work (especially in relation to gathering and reading the minutes) but that job planning may be an opportunity but depends upon clinical director support; clinical governance staff may support the step more than clinical lead; may need to be negotiated/arranged well in advance and this may need data, “to hook them in”.

  Techniques to support implementation: 1.1 Goal setting; 1.2 Problem solving; 1.4 Action planning; 4.1 Instruction on how to perform behaviour^a; 8.7 Graded task^a; 9.1 Credible source

 Step 2: To identify priorities for action from within the hospital feedback

  Responses to the semantic differential scale in the NPT toolkit indicated the step may not be distinguished from current ways of working and key individuals may not drive the step forward.

  Narrative comments included that: There may be different perspectives about what constitutes a priority between the clinical group and the senior leaders; Suggestion to clearly state the aim from prioritising; Suggestion to filter data to short list, rather than review full data set; That those writing the local improvement plan may wish to exclude a target behaviour if they believe they are unable to improve it.

  Techniques to support implementation: 1.1 Goal setting; 1.2 Problem solving; 1.3 Goal setting outcome; 1.4 Action planning; 9.1 Credible source.

 Step 3: To align message about data to organisational priorities

  The semantic differential scale responses indicated that individuals may not understand what the step requires of them, may not agree to it becoming part of their work and may not ‘buy-in’ to the intervention.

  Narrative comments included that: it may be difficult to find documents and time to review minutes; those involved may be aware of regulators’ priorities; clinical governance staff may be happy to help; other stakeholders may not engage but that linking to costs (e.g. via length of stay) may support engagement.

  Techniques to support implementation: 1.1 Goal setting; 1.2 Problem solving; 1.4 Action planning; 4.1 Instruction on how to perform behaviour^a; 5.3 Information about social consequences^a; 6.1 Demonstrate behaviour^a; 9.1 Credible source.

 Step 4: To present prioritised data items in a way that increases motivation to commit organisational resources

  The semantic differential scale responses indicated that individuals may not understand what the step requires of them, may not agree to it becoming part of their work and may not ‘buy-in’ to the intervention.

  Narrative comments included that: Including positive framing may increase support of key individuals; Comparison should be locally defined, for example, against local hospital; Trust may not allow use of loss-framed data.

  Techniques to support implementation: 1.1 Goal setting; 1.2 Problem solving; 1.4 Action planning; 5.3 Information about social consequences^a; 9.1 Credible source.

 Step 5: To seek evidence about barriers and potential actions to address barriers

  The semantic differential scale responses indicated that individuals may not understand what the step requires of them, may not perceive value in it, may not agree to it becoming part of their work and may not ‘buy-in’ to the intervention.

  Narrative responses indicated that: May not be hospital librarian doing evidence summaries, maybe this should be done by the audit provider; clinical governance team may be pleased to do work to identify high- and low-performing teams and data for triangulation; finding staff time to undertake observation of care may be difficult, although the service improvement team might support this work, but could only do for a few priorities; need to give examples of what ‘waste’ might look like.

  Techniques to support implementation: 1.4 Action planning; 4.1 Instruction on how to perform the behaviour; 6.1 Demonstration of the behaviour; 9.1 Credible source; 12.2 Re-structuring of the social environment; 13.2 Framing/re-framing

 Step 6: To model the link between barrier, action and organisational priorities

  The semantic differential scale responses indicated that individuals may not understand what the step requires of them, may not perceive value in it, may not agree to it becoming part of their work and may not continue to support the intervention.

  Narrative responses indicated that: Need to seek agreement from action owners and know what to do if they do not agree.

  Techniques to support implementation: 1.2 Problem solving; 1.4 Action planning; 1.6 Discrepancy between current behaviour and goal^a; 2.5 Monitoring of outcomes of behaviour without feedback4.1 Instruction on how to perform the behaviour; 6.1 Demonstration of the behaviour; 8.1 Behavioural practice^a; 9.1 Credible source; 12.2 Re-structuring of the social environment.

 Step 7: To present to governance group in order to gain approval for the action plan.

  The semantic differential scale responses indicated that individuals may not understand what the step requires of them, may not agree to it becoming part of their work and may not ‘buy-in’ to the intervention.

  Narrative responses indicated that the participant may only be given a couple of minutes to present at the committee.

  Techniques to support implementation: 1.1 Goal setting; 1.2 Problem solving; 1.4 Action planning; 9.1 Credible source.