Table 3 Evidence for fidelity of enactment and acceptability

Fidelity of enactment

Review performance and prioritise

“And so we were into this [the gaps in care] and link performance to priorities. We talked about that, that there is now a high priority on getting dementia.”

Select comparator

[Interviewer prompted about the use of comparators] “Yes, yes, now I remember. Exactly. So currently we do not feel we are in a position to compare ourselves to a top 10% because some of the numbers are really low.”

Review existing workstreams

“we’ve looked at the audit and we’ve identified gaps in our strategy and we’ve since added those things into our strategy…So some of the gaps were identification of delirium, so we are now going to have 4AT score done on all over 65s who are coming into hospital, whether they’re coming for a medical or a surgical reason, and that will then be rolled out to other admission areas like medical admission area and surgical admission area and other areas. But initially, our focus is towards emergency department.”

Identify influences upon performance

“One of the other aspects of strategy, when we looked at the dementia audit, was that we had a training issue. Staff were not trained on dementia, Tier 1 training.”

Select strategy aligned to influence

“Staff were not trained on dementia, Tier 1 training. And now we have that as a mandatory field in the electronic service record. So everybody from a cleaner, porter to the chief executive officer will have to be trained.”

Acceptability

Affective attitude, coherence and opportunity cost

“Maybe I’m not reading my emails completely and trying to understand it, but I went into the meeting with some scepticism. What am I going to learn here? But obviously, to my mind, it linked to quality improvement straight away rather than auditing and how this- And so I found it a useful challenge to how we were thinking.”

“And it’s basically educating QI process into the audit. So why the audit is done and what should you do with the audit and planning another cycle? What needs to be changed? Yes, those two hours or four hours, were well spent.”

Perceived effectiveness

“I think the workshop, in a way, for us gave us a nutshell of how we did in the audit overall. You picked up the domains of where we did well and where we didn’t do well. You gave an overview like this of how to go on about it. So, it was a… Each aspect was looked at in depth, in a way. So, you made us think about the local challenges … to take the next step forward. Even though you didn’t say the right way forward, you made us [see] the right things which would be useful for the trust in a way with the right action plan. So, I think overall it was very useful.

Interviewer: Should I have said the things you should be doing?

Interviewee: I don’t think you should. So, I think the way you phrased it or led it is- Because obviously each trust is different and unique.”

Burden

“The workshops, as I said, maybe half a day. So, just the time could’ve been cut short. Telephone calls, maybe give a bit more time.” And later expanded on this to add, “it’s a national project with the reputation of the trust at stake, but if you’re given such a responsibility there should be a dedicated time.”

The same participant later said that the time commitment would be acceptable if there was recognised, and suggested that this could be in the job plan agreed with their manager, “it’s not the time. So, as with anything… It’s the recognition. Exactly. Again, you can see it’s the frustration of not being recognised for so many other things and this comes on the top of one more”.