Table 3 CMOcs from realist interview findings

CMOc 1: The influence of learning collaboratives on the sustainability of a scaled, multi-component intervention

When an intervention is implemented at scale through a collaborative approach using a provincial learning collaborative that brings working groups, committees, and operational leaders across the province together (C), this break down existing silos (M), facilitates sharing among groups who otherwise may not interact (M), encourages cyclical reinforcement of the intervention (M) and facilitates discussions demonstrating the advantages and benefits of the intervention (O) this drives people to make the intervention a priority (M), encourages continuous learning, increasing the likelihood of intervention sustainability (O).

CMOc 2: The degree of importance of continuous monitoring, audit, and feedback on sustainability of a scaled, multi-component intervention

When an intervention is implemented at scale in a context where monitoring & feedback is done on a continual basis (C), through multiple communication and messaging channels (i.e. quality boards, staff meetings, emails) in a way that makes sense and resonates with different levels of staff (M), where staff can see unit performance, the extent of implementation effectiveness and observable benefits achieved (O), this triggers staff to have a better understanding of the extent of impact of the intervention (M), value unit performance, and motivates them to want to perform well and improve (M); this supports the continuation of the intervention and increases the likelihood of intervention sustainability (O).

CMOc 3: The influence of informal leaders on the sustainability of a scaled, multi-component intervention

When an intervention is implemented at scale in a context where strong and supportive leadership is present including front-line informal leaders (C), that show sustained interest in the intervention over time (M), are “hands on” and use their influence to positively communicate the impact and successes of the intervention (M), this triggers staff to pay more attention to the intervention, feel valued and empowered to use the intervention (Ms), where staff feel they are working in an environment conducive to sustaining gains made with the intervention (M) this supports the continuation of the intervention and increases the likelihood of intervention sustainability (O).

CMOc 4: The influence and impact of patient and family stories on the sustainability of a scaled, multi-component intervention

When an intervention is implemented provincially at scale (C) the use of patient or family stories to demonstrate the impact of the intervention to staff is powerful (M), patient stories trigger staff to understand the importance of the intervention and why it is needed (M) stories demonstrate the impact of the intervention for patient outcomes and improved care (O), this motivates staff to want to continue to do the intervention (M), increasing the likelihood of intervention sustainability (O)