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.	[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.	[34–36]	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