Table 4

Results of the thematic analysis

Third orderSecond orderFirst orderFacilitatorsBarriers
National level factorsLeadership and coordination mechanismsGuidelines and standardsAbsence of national case management protocols16
NMCR implementationCommitment of health authorities20
Effective task allocation17
Effective coordination24
Standard form for reporting17 21
Effective monitoring and quality assessment17 21
Commitment to training20
Integrating audits into the curricula of medical and midwifery schools21
Absence of directives from the health authority22
Pressures of competing programme activities21
Clashing interests of health authorities compared with those of health providers22
Facility level factorsPolicies and coordination mechanismsStandardsAbsence of management protocols16
TrainingTraining of all key staff17 19 21
Obstetricians’ and midwives’ involvement in safe motherhood initiatives21
Training of single people22
Leadership and coordination of audit sessionsGood leadership17 21
Managerial support19 21
Written management policy17 21
Convincing explanations on the importance of audits17
Introduction of new clinical guidelines together with audits17 23
Dedicated and permanent chairperson20
Involvement of a variety of staff and managers19 20
Presence at the session of the health workers involved in the case20
Case discussion conducted openly, fairly and with decent manners19 20
Focusing also on positive aspects of care20
Cases discussed in an anonymous way23
Balance between the expectations and engagement from both providers and administrators22
Poor understanding, management and participations from leaders17 19 21 22
Managers failing to show that the aim of audit is not finding the guilty party21 22
Lack of task allocation16
Lack of inclusion of all staff19 21
Case selection bias23
The audit highlighted only the negative aspects of case management23
Blaming and/or use of harsh language, threatening, repressive attitude19–23
Loss of confidentiality and/or pointing out explicitly who made a mistake20 23
Underestimation of resources needed21
Delay of release of funds16
Managers’ reluctance in attending meetings24
Centralised decision-making23
Monitoring and supervisionPolitical and/or institutional commitment and active coordination17 22
Standardised forms for reporting17
Structured action plans with transparent information to all staff19 20 24
Constant monitoring and periodic quality assessment17
Lack of follow-up on recommendations16 19 20 23
Lack of transparent results diffusions and provision of feedback16 19 20
IncentivesRole and recognition22 24
Economic incentives21 24
Purchase of necessary essential equipment21
No reward nor economic incentive, in settings with low salaries21–23
Low resources available to implement recommendations24
Resource availabilityHuman resources, essentials equipment and suppliesAdequate human and material resources19 22
Proper documentation19
High patient workload, shortage of staff16 17 19–22 24
Staff absenteeism19 20 and/or high staff turnover21
Shortage of equipment and supplies, including stationery16 19 23
Insufficient record-keeping17 19
Underestimation of resources needed21
Low morale among staff desiring to leave work16
Sociocultural environmentCulture and practice of quality improvementBlame-free environment19
Attitude towards self-criticism22
Positive attitude towards audit and feedback20
Being a teaching hospital associated with research17
Health staff willingness to improve quality of care23
Good case notes perceived as helpful in protecting staff in a legal context22
Culture of blaming, fear and individual punishment16 19–22
Lack of knowledge on principles and methods of audits17 22
Audit not perceived as part of duties17 21
Audits perceived as a way of controlling staff23
Lack of knowledge and/or interest in quality improvement17
Inadequate knowledge of evidenced-based medicine17 19 22
Difficulty from staff to feel questioned about own work17 19 23
Attitude in finding excuses and not revealing the truth19 21
Hierarchy, cultural norms among health staff and interpersonal relationshipGood practices of communication and cooperation between staff19 22
Possibility to challenge staff of higher grade19
Hierarchical differences16
Nurses, midwives and doctors working separately16
Doctors behaving as superior16 22
Lack of assertiveness among mid-level staff17 19 20
Personnel not being used to speak in public, fear of people higher in rank17 19
Disrespectable manners towards lower level staff20
Previously existing conflicts at interpersonal level22
Lack of external support to facilitate dynamics22
Attitude towards patientsEmpowered patients16
Health staff passion and an attitude of caring for patients16 17
Difficulty of accepting professional responsibility22
Poor attention low priority given to some conditions (eg, obstructed labour)16
Low commitment to serve/work16
Outputs and outcomesAudit impactsPositive impact of audits on quality of care21
Positive impact of audits on health staff20–22 24
Lack of evidence or clarity about what the audit is and on its effectiveness19 22
External factorsSustained supportAvailabilityExternal body providing technical support and/or required resources21 22 24
  • NMCR, near-miss case review.