Table 1

Examples of the challenges encountered during the implementation of the Clinical Information Network related to preservice training, hospital norms and national policies

LevelExamples of challenges
Preservice trainingThe training of junior medical staff sometimes conflicts with the apparent restrictions on clinical autonomy encompassed by guidelines and their learning experience in tertiary settings where evidence-based guidelines may be looked down on as ‘too simple’.
Concerns that increasing student numbers is affecting the quality of undergraduate training exemplified by a paediatrician’s comments: ‘The interns we are getting are very poor. What I have seen in the last 5 years, I don’t know what kind of training they get.’
Highly variable graduation dates for clinical cadres within and across institutions challenge planning for orientation of the newly qualified clinicians before their rotation on the wards (and see below).
Postgraduate (consultant) training includes little emphasis on management skills such as how to give effective feedback at group or individual levels and in how to foster teamwork among junior clinicians and nurses.
Each hospital retained the primary data on its admissions but utilisation of local data by the hospital clinicians and management for more local quality improvement cycles or planning and resource allocation was limited. This was related to relatively poor computer and data analytical skills and limited capacity in hospital records departments with reliance on more intuitive management based on historical contingencies.
Hospital contexts and practical normsHospitals often lacked printers/projectors making wide dissemination of feedback reports problematic with a continued reliance on receipt of limited numbers of hard copies.
Challenges in local planning and resource mobilisation in hospitals where access to and control over financial resources is very limited. This can impact the continuous supply of hospital stationery such as structured admission (paediatric admission record (PAR)) and discharge forms as well as undermine efforts to improve practices (eg, testing for hypoglycaemia).
There is very high turnover of the medical and clinical officer interns such that almost the entire junior clinical team may change every 3 months.
Continued role (and in some cases reliance on) of pharmaceutical companies’ support for continued education meetings that may undermine guideline adherence.
Practical norms sometimes conflict with practices being promoted such as:

  1. that there is little value in writing a short summary of events around the time of death and recording the primary and contributory diagnoses;

  2. that ascertaining HIV status should be done by specific HIV counsellors, not clinicians;

  3. that anthropometric measurements should be performed by nutritionists, not clinicians;

  4. unavailability of some essential services at night and weekends, for example, inaccessibility of special feeds for malnutrition undermining guideline adherence.

Epistemic and practical boundaries challenge teamwork. Although audit feedback meetings are intended to be multidisciplinary, they are often cadre-specific undermining efforts at relationship building across cadres and in understanding and tackling system barriers.
Competing priorities—the role of heads of paediatric teams is often not perceived as including quality improvement and are given no dedicated time or training for these activities while they also have multiple competing priorities.
National/county
governments		Historically weak systems for disseminating policies and monitoring their uptake linked to weak systems for promoting and regulating quality of care.
Insufficient capacity for generating and using information as part of decision-making in resource allocation (staff and equipment) to ensure minimum standards of care are achieved.