Table 3

Explanatory factors enabling sustained practice of perinatal audit

Dimensions/question	Main finding	Factors identified*
Capability: implementation depends on its workability and integration into everyday practice. How do people integrate the work into their daily practice? Or how is it not integrated?	People have the capability to implement because activities related to perinatal audit are integrated and embedded into everyday work.	Activities are part of daily workflow. Activities are part of job expectations. Activities are part of formal training for some. Activities are linked to other meetings and QI processes. Activities are part of district support/regional outreach. Related implementation costs are embedded into existing budgets. Activities are integrated with the data system and process (eg, M&E, information unit) (C and D). Activities are part of official job descriptions (A). Activities are part of orientation (A and C).
Contribution: implementation depends on people’s contributions to doing the intervention by investing meaning, commitment, effort and appraisal Why do people contribute to implementation of the intervention? Or, why don’t people contribute?	People contribute to the intervention because they understand perinatal audit, value it, trust it and use it to help build and nurture relationships.	People have a common understanding of the intervention. People value it for improving service delivery, helping them learn skills, enabling them to debrief as a team. People use the review process as an opportunity to navigate professional hierarchies, hold each other accountable, improve communication and build/nurture their relationship with team members. People trust the process because the meetings are well facilitated and occur in an environment conducive to learning in a safe, non-blame environment. People also learn over time that the system works.
Potential: implementation depends on people’s commitment to operationalising the intervention. Why are people committed to operationalising the intervention? Or, why are people not committed?	People are passionate about their work, committed to improving the quality of service delivery and motivate each other to implement activities relating to perinatal audit.	People are passionate about their work. People are committed to providing high quality service delivery. Individual motivation stems from the desire to learn, problem solve and self-improve. Intangible incentives to attend the M&M meetings, that is, learning, debriefing, communicating. There is shared commitment to work together and improve the health system because people are invested in the area (eg, come from community or intend to continue working at the hospital for a long time). Engagement of multiple actors; when some actors are absent from the process, it makes it difficult to implement effectively. There are tangible incentives to attend the M&M meetings, that is, performance reviews (A and C) and CPD points (C and D).
Capacity: implementation depends on people’s capacity to co-operate and co-ordinate their actions. What gives people the capacity to implement the intervention? Or what limits people’s capacity?	People have the capacity to implement because they work in an enabling environment that supports the implementation of perinatal audits.	People work in a well-functioning hospital with sufficient and well managed material and human resources. Low staff turnover. Strong, predictable and open communication system in place between levels and staff. Good management enables a healthy organisational culture conducive to learning, innovation and accountability. Culture of data use for decision making (A, C and D). Strong social network among the staff (B).

*Factors listed means these were identified across all case studies with the exception of where indicated with A, B, C or D linked to case study assignment. Online supplemental file 7 provides a breakdown by case study.
CPD, continuous professional development; M&E, monitoring and evalutation; M&M, morbidity and mortality; QI, quality improvement.