Table 3 Barriers identified in the QICs mapped to the CFIR domains and constructs
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. | Low-medium | |
Outer setting | Patient needs and resources | QI in care may not be achievable in all stroke patients. | Low-medium | |
Cosmopolitanism | Collaborative action can be undermined by: the effort required, lack of perceived benefit, negative comparisons, lack of contribution and resentment. | 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. | 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. | Low-high | |
Networks and communications | Collaboration over the phone may not be effective for providing support and meeting need. | High | ||
Culture | QIC team members may perceive organisations as slow to change and lacking in innovative culture. | 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. | Low-high | ||
Implementation climate: Organisational incentives and rewards | Lack of incentives for career learning and progression can create tension and affect morale. | 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. | Medium-high | ||
Readiness for implementation: Leadership engagement | Unsupportive leadership can prevent teams from participating in the QIC and making improvements. | 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. | Low-high | ||
Readiness for implementation: Access to knowledge | Limited access to and experience with patient data tools and equipment is challenging. | 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. | Low-high | |
Other personal attributes | Motivation for change is susceptible to factors that are outside of the QICs control. | Medium-high | ||
Process | Engaging: Opinion leaders | Low actual levels or perceived levels of engagement with QI activities, particularly in clinicians, may impede improvement. | 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. | Low-high | ||
When QIC support and resources are withdrawn, improvements may not be sustainable. | Low-medium |