Third order | Second order | First order | Facilitators | Barriers |
National level factors | Leadership and coordination mechanisms | Guidelines and standards | Absence of national case management protocols16 | |
NMCR implementation | Commitment 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 factors | Policies and coordination mechanisms | Standards | Absence of management protocols16 | |
Training | Training of all key staff17 19 21 Obstetricians’ and midwives’ involvement in safe motherhood initiatives21 | Training of single people22 | ||
Leadership and coordination of audit sessions | Good 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 supervision | Political 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 | ||
Incentives | Role 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 availability | Human resources, essentials equipment and supplies | Adequate 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 environment | Culture and practice of quality improvement | Blame-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 relationship | Good 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 patients | Empowered 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 outcomes | Audit impacts | Positive 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 factors | Sustained support | Availability | External body providing technical support and/or required resources21 22 24 |
NMCR, near-miss case review.