The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting? Protocol for a realist review

Abstract

BackgroundContext shapes the effectiveness of knowledge implementation and influences health improvement. Successful healthcare quality improvement (QI) initiatives frequently fail to transfer to different settings, with local contextual factors often cited as the cause. Understanding and overcoming contextual barriers is therefore crucial to implementing effective improvement; yet context is still poorly understood. There is a paucity of information on the mechanisms underlying how and why QI projects succeed or fail in given settings. A realist review of empirical studies of healthcare QI initiatives will be undertaken to examine the influence and impact of contextual factors on quality improvement in healthcare settings and explore whether QI initiatives can work in all contexts.MethodsThe review will explore which contextual factors are important, and how, why, when and for whom they are important, within varied settings. The dynamic nature of context and change over time will be explored by examining which aspects of context impact at key points in the improvement trajectory. The review will also consider the influence of context on improvement outcomes (provider- and patient-level), spread and sustainability. The review process will follow five iterative steps: (1) clarify scope, (2) search for evidence, (3) appraise primary studies and extract data, (4) synthesise evidence and draw conclusions and (5) disseminate findings. The reviewers will consult with experts and stakeholders in the early stages to focus the review and develop a programme theory consisting of explanatory ‘context–mechanism–outcome’ configurations. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. A review advisory group will oversee the review process. Review findings will follow RAMESES guidelines and will be disseminated via a report, presentations and peer-reviewed publications.DiscussionThe review will update and consolidate evidence on the contextual conditions for effective improvement and distil new knowledge to inform the design and development of context-sensitive QI initiatives. This review ties in with the study of improvement programmes as vehicles of change and the development of an evidence base around healthcare improvement by addressing whether QI initiatives can work in all contexts.Systematic review registrationPROSPERO CRD42017062135

The influence of contextual factors on healthcare quality improvement initiatives: a realist review

“…The review was conducted and reported in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance and publication standards [31,32]. No changes were made to the published review protocol [33].…”

Exploring challenges in quality and safety work in nursing homes and home care – a case study as basis for theory development

“…Management, culture and systems for better quality and safety have been the main topics in Norwegian national healthcare policy [1][2][3]. These key challenges have also been highlighted internationally [4][5][6][7]. There is a clear need to ensure leadership, a culture of openness and learning, and a system for developing, embedding and sustaining quality and safety improvements.…”

Beyond barriers and facilitators: the central role of practical knowledge and informal networks in implementing infection prevention interventions

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