ABC for Patient Safety Toolkit

Following a hugely successful programme of work using behaviour change theory to support the implementation of patient safety guidelines and alerts, the Improvement Academy has taken the lead in spreading this learning throughout the region.

If you have any problems playing the above vides, it is also available on our YouTube channel here.

Using theory of Behaviour Change to implement best practice

The problems with implementing best practice are well recognised and interventions to change practice, such as education, audit and feedback, do not consistently lead to change. 

Two main issues inhibit the success of implementation strategies:

  • a failure to understand barriers and levers to implementation of best practice 
  • a failure to use behaviour change theory to design implementation strategies 

Local expertise in Yorkshire and Humber

The Improvement Academy, through the Yorkshire Quality and Safety Group, is working with internationally-recognised behaviour change experts, based locally in Leeds, Bradford and Hull, to apply psychological insights to implementation problems where behaviour change is required, and where intuitive approaches have so far failed to deliver the desired improvement. 

The new approach to the implementation of best practice involves:

  • Assessing the barriers and levers to ideal practice
  • Tailoring implementation strategies according to these
  • Basing both of the above on behaviour change theory.

Is it difficult?

Behaviour change theory can be inaccessible to both researchers and to health care practitioners alike.  This problem was addressed by a group of psychologists within the British Psychological Society with the development of the Theoretical Domains Framework (TDF). 

This framework has now been used in a number of clinical settings with a range of health care practitioners to either assess the barriers and levers to practice or, in the design of interventions, to address these. 

There is a growing body of literature demonstrating and guiding this process, including an online toolkit produced locally by the Yorkshire Quality and Safety Research Group. 

Some examples

The best way of demonstrating the feasibility and effectiveness of this approach is through example: 

  1. Natalie Taylor and colleagues from Bradford engaged in a series of patient safety projects adopting this approach.  One example used this process to reduce the risk of feeding into misplaced nasogastric tubes.  With the involvement of stakeholders, the barriers and levers to ideal practice were assessed using the TDF. Theoretically based practical interventions designed by local clinicians with support from behaviour change experts resulted in more frequent adoption of the desirable clinical behaviours.
  2. TRiaDs (Translation of evidence into practice in dental settings programme) involves a number of projects whereby Scottish Dental Guidelines are implemented into dental practice.  Questionnaires and interviews (based on the TDF) are used to identify barriers and levers to these key recommendations.  Data are routinely collected to measure compliance with the guidance.  Interventions are designed according to elicited barriers and levers and are theoretically based.  Trials evaluating the effectiveness of this approach are underway.
  3. Dr Judith Dyson compared the use of a theoretical approach (the TDF) in the assessment of barriers and levers to hand hygiene with a non-theoretical approach.  Although there was considerable overlap in the barriers and levers identified in these two approaches there were also significant differences.  The use of theory identified more barriers and levers, some of which, people do not ordinarily report but which may have an important impact on behaviour (e.g. emotion).  An instrument was developed and used by the authors to assess barriers and levers to hand hygiene in a group of junior doctors in an NHS trust in the North of England.  Interventions were designed by the researchers and the doctors according to the TDF and hand hygiene improved following implementation of these.

A worked example of the Behaviour Change Toolkit can be seen in the following report:

People who have been on the Achieving Behaviour Change training are able to download resources here. Please speak to Judith Dyson for details of the next training course or for support.

A full breakdown of each of the steps involved is available below (download the zip files by clicking on the header):

Step 1: Forming implementation teams 

  • Resource 1 - Draft email to potential implementation team members
  • Resource 2 - Proforma for contact details for experts and other champions/interested staff
  • Resource 3 - Agenda examples for meetings
  • Resource 4 - Action notes
  • Resource 5 - Example Gantt chart
  • Resource 6 - Action Plan

Step 2: Identifying the target behaviour(s) 

  • Resource 1 - NG tubes case study of identifying a target behaviour
  • Resource 2 - Medicines reconciliation audit tool, Midazolam and Flumazenil audit tool and Nasogastric tube audit tool
  • Resource 3 - Example email to medical records
  • Resource 4 - Example spreadsheet with NG data
  • Resource 5 - Target behaviour examples
  • Resource 6 - Action plan

Step 3: Understanding barriers to performing the target behaviour 

  • Resource 1 - NG tubes questionnaire
  • Resource 2 - Email to organise questionnaire completion
  • Resource 3 - Questionnaire Template
  • Resource 4 - Questionnaire data entry spreadsheet
  • Resource 5 - Email to organise focus groups
  • Resource 6 - Focus group interview schedule (following questionnaire)
  • Resource 7 - Focus group interview schedule (no questionnaire)
  • Resource 8 - Action plan

Step 4: Devising intervention strategies to address identified barriers 

  • Resource 1 - Summary of Michie et al (2005)
  • Resource 2 - Summary of behaviour change techniques (BCTs)
  • Resource 3 - Summary of BCTs with examples of practical strategies applied for patient safety
  • Resource 4 - Summary of mapping paper including matrix of domains and techniques and how techniques have been used in the context of patient safety for specific barriers
  • Resource 5 - Action plan

Step 5: Intervention implementation 

  • Resource 1 - Example report to senior management
  • Resource 2 - Report template
  • Resource 3 - Example email to senior management 
  • Resource 4 - Example of how implementation team members might work to implement interventions
  • Resource 5 - Log of implementation dates
  • Resource 6 - Action plan

Step 6: Evaluation 

  • Resource 1 - Example email to Medical Records
  • Resource 2 - Example final report
  • Resource 3 - Final report template
  • Resource 4 - Action plan

Please also see Dr Judith Dyson’s BALHHI tool to assess the barriers and levers to hand hygiene.

Behaviour Change

Find out more about Behaviour Change for Patient Safety here

Further Information 

Dr Judith Dyson’s BALHHI tool to assess the barriers and levers to hand hygiene.