Table 3

Themes illustrating legitimacy

Case ACase B
Subject positionPeripheralCentral
Structural legitimacy
Executive approval: imprimatur to undertake the work
Multidisciplinary improvement team embedded within hospital P: authority in relation to expertise and understanding of context
Credentialed improvement team: bolstered their authority using ‘diplomacy’, build trust and acceptance
Normative legitimacy
Implementation of established knowledge (evidence and standards: establishes a legitimacy of ‘need’ and ‘moral’ basis for changing practices)
Recognised theory-based implementation approaches: improves adoption and integration into routine practice
In-depth formative assessment about envisaged improvement with target clinicians: builds clinician engagementX
Diminished capacity to sustain engagement due to team members’ redeployment
Patient involvement and engagementX
Indirectly through representatives
Improvement outcomesAchieved positive changesAchieved time limited positive changes