Table 3.

Aims, processes and challenges of the participatory action research

Aim	Process	Challenges
Engagement of KNH staff	Formation of core group and involving them in implementing the best-practices.	Capacity building missed out organizational issues such as teambuilding, supervision skills, communication skills and negotiation skills.
Development of quality indicators (QIs)	Adoption of ETAT+ based QIs with targets using face to face meetings and consensus conference.	Less success for approaches requiring self-administered questioners with preference of face to face thus increasing cost of the activity.
		No preliminary study to inform performance target. Targets set at 100% correct performance based on the perceived simplicity of the tasks.
Institutionalization of audits and feedback	Re-energizing routine ward audits Facilitation of the ward audits Formation of department audit team, development of an audit tool and conducting audit. Adopting a rapid hospital survey approach to assess both structure and processes of care	Managers had insufficient skills and motivation to introduce change in a system. Minimal consultants’ support. Staff not compelled to know their clinical performance.
		Problem-solving challenged by poor culture for self-directed reading on quality care and by deeply engrained practices that had become the norm, thus difficult in recognizing suboptimal care and to do root cause analysis
		Multidisciplinary feedback that would encourage system-wide problem and solution identification was compromised by limited repertoire of knowledge on basic patients’ care that required discipline specific audit feedback details
		Insufficient structures to support the clinical audits without involvement of the facilitator
Address knowledge gaps.	Initially we held multidisciplinary educational sessions but finally adopted task oriented CMEs analogous to the format for cadre specific pre-service training.	Punctuality problems among all cadres that reflected the norm of the hospital staff. No effective learning culture, no substantive mechanism of holding the management and staff accountable for QoC
		Multi-professional capacity building not achieved due to poor communication and limited of repertoire of basic and procedural knowledge.
		No substantial incentives to attend or facilitate CMEs e.g. accreditation of CMEs