Characteristics promoting behaviour change: physician experience with a coalition-led quality improvement initiative to reduce excessive laboratory test ordering

BACKGROUND: Attempts have been made to reduce excessive laboratory test ordering; however, the problem persists and barriers to physician involvement in quality improvement (QI) remain. We sought to understand physician participation experience following a laboratory test overuse initiative supported by a QI coalition. METHODS: As part of a larger mixed-methods study, structured virtual interviews were conducted with 12 physicians. The Theoretical Domains Framework (TDF) and the Behavioural Change Wheel (BCW) were used to identify characteristics that influence physician behaviour change for QI leadership and participation and appropriate blood urea nitrogen (BUN) test ordering. A content analysis of physicians’ statements to the TDF was performed, resulting in overarching themes; relevant TDF domains were mapped to the intervention functions of the BCW. RESULTS: Nine overarching themes emerged from the data. Eight of 14 TDF domains influence QI leadership and participation, and 10 influence appropriate BUN-test ordering behaviours. The characteristics participants described that promoted a change in their QI participation, leadership and appropriate BUN-test ordering were: QI education with hands-on training; physician peer mentorship/support; personnel assistance (QI and analytics) and communication from a trusted/credible physician leader who shares data and insights about the physician role in the initiative, clinical best practice and past project success. Other elements included: a simply designed initiative requiring minimal effort and no clinical workflow disruptions; revised order forms/panels and limiting test-order frequency when laboratory tests are normal. Additionally, various future intervention strategies were identified. For their initial initiative participation, physicians acknowledged coalition leader or member credibility was more important than awareness of the coalition. CONCLUSIONS: Based on physicians’ described perceptions and experiences, coalition characteristics that influenced their QI leadership and participation, and appropriate BUN-test ordering behaviours were revealed; these characteristics aligned to several TDF domains. The findings suggest that these behaviours are multidimensional, requiring a multistrategy approach to change behaviour.