Table 2 A summary of major and minor intervention components encompassed within the overall network intervention strategy drawing on a recent typology [12] of specific strategies and organised in line with conceptual domains linked to this typology [20]. A brief description of the form that these intervention components took as the network was implemented is also provided

1) Alter incentive structure^a

Recognition by the coordinating team and peers of good service provision and achievements in improving care by local teams led by the paediatrician while conversely making it a matter of concern if there is poor care in relation to shared professional goals/standards (assessed using agreed indicators) while avoiding embarrassment/humiliation

2) Change record systems and 3) Mandate change^b

Work with partners was conducted to implement standardised components of medical records including admission clinical forms (checklists); network meetings provided a forum to discuss and promote consensus amongst peers in the presence of a small number of senior members of the paediatric community on the need to promote nationally recommended practices in the form of agreed national guidelines

4) Audit and provide feedback, 5) Develop and implement tools for quality monitoring, and 6) Develop and organise quality monitoring system

Building a mechanism for capturing trustworthy data that enables measurement of practice against relevant and agreed indicators supported by the introduction of a standardised admission record form that enables data capture and subsequent analysis based on indicators of adherence to guidelines and regular reporting on these indicators (feedback) to hospitals in the form of performance reports sent to team leaders at the end of every 2–3 months

7) Facilitation (external)

At the network centre is a clinical coordinator who coordinates network meetings and transmits the feedback by email and then discusses it by telephone, providing advice as required while also promoting peer-to-peer support; the clinical coordinator visited each hospital 2 to 3 times in the first 12 months of network activity

8) Build a coalition, 9) Promote network weaving, 10) Develop academic partnerships, 11) Conduct local consensus discussions,

12) Inform local opinion leaders^b, 13) Involve executive boards^b, 14) Recruit, designate, and train for leadership^b, and 15) Capture and share local knowledge

Deliberate effort to create a network (“a grouping that aims to improve clinical care and service delivery using a collegial approach to identify and implement a range of [improvement] strategies” [38]) that spans government, a professional association, senior peers and hospital team leaders; this is linked through meetings, clinical network coordinator to paediatrician contacts and an informal peer-to-peer messaging group offering a forum to share experiences and learning with a focus on promoting local leadership at the middle (clinical) level of management and change efforts to promote guideline adherence and care improvements. The network itself is built on existing relationships across government, the professional association, a university and a research institution, and with paediatricians who often had training in the university or who share professional ties. These groups have also helped create national guidelines for all hospitals (outside the network too).

At the centre of the network are a research institute and a representative of the university who provide the data management and analytic support linked to regular feedback and outreach (as above) to county hospital paediatric teams. As typically there is only one paediatrician and one nurse and information officer leader, the network team had no active role in recruiting or designating team leaders

Early stakeholder meetings with government and hospitals’ management teams, and especially paediatricians, were conducted on a background of longer term sensitization to the problem of quality care and the value of evidence-based clinical guidelines created with the Kenyan paediatric community. In the 4–6 monthly face-to-face network meetings with paediatricians, their responsibility for improving practices was discussed with simple training provided (see below). Through a WhatsApp group, coordinator encouraged sharing of stories on how hospitals have promoted change

16) Create a learning collaborative, 17) Providing ongoing consultation, 18) Conduct educational meetings^b, 19) Make training dynamic^b, 20) Distribute educational materials^b

The network was initiated with a meeting of a paediatrician, a senior nurse and the health records information officer from each participating hospital and the research institute and university partners. At this meeting and at subsequent hospital-specific introductory visits the network was explained and its purpose to promote better generation and use of health information to support better care. Collaboration is supported from the network centre by a clinical coordinator who coordinates network meetings and offers the feedback, discusses it and provides advice as required while also promoting peer-to-peer support. During the 4–6 monthly meetings predominantly with paediatricians specific short sessions (< half a day) were provided that explained leadership of teams, how to give group feedback, on understanding complex systems and on the principles of quality indicators and their use. The training typically used discussion, reflection and individuals’ experiences as well as presentations. Relationships and the educational approach were complemented by visits to hospitals by the clinical coordinator in the first year to explain and discuss the hospital-specific indicators provided in an overall report

National guidelines for care were distributed to network and non-network hospitals as part of a national distribution and some network paediatricians took part in updating these guidelines in 2015

21) Revise professional roles^b, 22) Facilitate relay of clinical data to providers^b

There has been no formal effort to revise or codify the professional role of the paediatrician or influence accreditation processes (Kenyan paediatricians do not undergo regular reaccreditation once registered with the medical board) but the network aims to foster a shift of role norms for paediatricians through social influences. This consultant group is largely trained to be expert diagnosticians and managers of therapeutic care at individual level and developing an expanded role concerned with overall patient service delivery and quality of care with a responsibility for clinical team performance is implicit in the network approach.

There remains no facility for immediate or rapid relay of data to clinicians or their team leaders in the form of decision support or an interface providing on-demand reports but 2 to 3 monthly reports are regularly delivered