It is important not to overburden staff members who join QI teams (61) and to give them positive feedback, including public recognition of the team's accomplishments (113, 204, 383). Sharing information among teams makes them feel less isolated and lets them build on one another's efforts (203, 266). Regular visits by an outside facilitator also can motivate QI teams (383).

Strong support from top managers can help, while lack of support hinders. At MEXFAM some team members became demoralized and stopped participating when managers were reluctant to provide meeting time, measure the performance of their department, or commit more resources (266, 377). In Côte d'Ivoire a facility was reprimanded for reconfiguring a clinic to improve patient flow without first going through channels to get approval (203). In contrast, strong, consistent support from the Ugandan Ministry of Health has been key to the initial success of its quality assurance program (278).

Social norms may pose an obstacle to teamwork. Health personnel with different backgrounds, such as doctors and midwives, may find it hard to work together as equals, especially where open discussion and sharing of work is not usual (23, 35, 280). In Niger the success of QI teams has been attributed partly to the fact that regional health directors and supervisors did not have a strong sense of hierarchy, did not feel threatened by the QI teams, were willing to participate as equals, and did not dominate team activities (272).

For QI team members training and continuing support of basic analytical skills are essential. It can be hard to find people able to train and guide QI teams in quantitative tasks, however (377). Evaluations of quality improvement teams in Indonesia, Mexico, and West Africa found that analytical skills remained weak even after training and a full problem-solving cycle (204, 223, 377). COPE tools are deliberately kept simple in order to keep self-assessment and quality improvement in the hands of site staff and supervisors.

QI teams cannot resolve some problems, especially when their solution requires additional staff, equipment, technical advice, or policy changes (23, 204, 242). Nevertheless, as noted, some QI teams have used their findings to persuade higher authorities to provide needed resources (264).