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Table 3 Barriers identified in the QICs mapped to the CFIR domains and constructs

From: The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review

CFIR domain CFIR construct Barriers Refs Reliability of findings based on MMAT
Intervention characteristics Complexity QI processes are difficult to implement in a short period of time due to their associated complexities. [28, 34, 35] Low-medium
Outer setting Patient needs and resources QI in care may not be achievable in all stroke patients. [26, 35, 36] Low-medium
Cosmopolitanism Collaborative action can be undermined by: the effort required, lack of perceived benefit, negative comparisons, lack of contribution and resentment. [28, 34, 39] Low-high
External policy and incentives QIC participation can be hindered by not securing external support and having little to no experience of previous QI initiatives. [34,35,36] Low-medium
Inner setting Structural characteristics Organisational challenges such as staff turnover, changes to stroke service structure and available resources can have a negative impact of implementation, engagement, and motivation. [22, 24, 28, 29, 31, 40] Low-high
Networks and communications Collaboration over the phone may not be effective for providing support and meeting need. [29, 40] High
Culture QIC team members may perceive organisations as slow to change and lacking in innovative culture. [27, 40] High
Implementation climate: Compatibility Scheduling busy team members together for meetings is challenging. [40] High
Implementation climate: Relative priority Organisational priorities often take precedence above collaboration, innovation, and implementation. [24, 27, 28, 33, 39] Low-high
Implementation climate: Organisational incentives and rewards Lack of incentives for career learning and progression can create tension and affect morale. [27, 39] High
Implementation climate: Goals and feedback Lack of autonomy over improvement aims can affect the relevancy of changes and the degree of creativity a team can apply to them. [28] Low
Implementation climate: Learning climate Capacity and willingness to learn can impact the extent to which participants engage with the approaches employed in a QIC. [29, 30, 39] Medium-high
Readiness for implementation: Leadership engagement Unsupportive leadership can prevent teams from participating in the QIC and making improvements. [28, 33, 39] Low-high
Readiness for implementation: Available resources Insufficient staff time and resources allocated to QIC attendance and improvement activities, including data collection, significantly affects participation and success. [24, 27, 28, 31, 33, 35, 37, 39, 40] Low-high
Readiness for implementation: Access to knowledge Limited access to and experience with patient data tools and equipment is challenging. [28, 35, 40] Low-high
Individual characteristics Knowledge and beliefs about the intervention Perception of staff in different professions varies as to the need for intervention and the attitudes towards QICs. [24, 27, 30, 35] Low-high
Other personal attributes Motivation for change is susceptible to factors that are outside of the QICs control. [31, 40] Medium-high
Process Engaging: Opinion leaders Low actual levels or perceived levels of engagement with QI activities, particularly in clinicians, may impede improvement. [24, 27, 31, 35] Low-high
Engaging: Champions Local champions are not necessarily sufficient on their own to overcome some barriers and collaboration between local teams is required. [24] Medium
Executing Inconsistencies and delays in employing the QIC approach can have a negative impact on compliance, motivation, and improvement. [22, 26, 31, 35] Low-high
When QIC support and resources are withdrawn, improvements may not be sustainable. [23, 24, 26, 34, 35] Low-medium