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

Abstract

Background: Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare? Methods: A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework. Results: Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings. Conclusions: This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes.

Why do some inter-organisational collaborations in healthcare work when others do not? A realist review

“…It also supports the ndings of other realist reviews in the literature on related topics, e.g. that by Jagosh et al into collaboration in particular (16,84).…”

“…Our review builds on existing realist-based studies of healthcare collaboration (15,16,84). While these contributions draw attention to particular intervention types and contexts, our contribution provides much needed insight into the inter-organisational entities currently being promoted across healthcare settings.…”

“…Some authors have recently explored barriers to collaboration in integrated care (13), and others, the 'success factors' (14). A variety of evidence reviews have also documented different perspectives regarding inter-organisational innovations (15), improvement initiatives of all types (16), as well as collaborations between healthcare services and higher education organisations (17). However, to date, there remains limited understanding of how other inter-organisational entities such as strategic alliances, joint ventures, or buddying collaborations work.…”

Clinician and Patient Factors Influencing Treatment Decisions: Ethnographic Study of Antibiotic Prescribing and Operative Procedures in Out-of-Hours and General Dental Practices

“…Recognizing the influence of context on the success of quality improvement interventions is crucial to designing, implementing and successfully replicating them in new settings [34]. Understanding the context of urgent dental care in OOH and GDP is key to the design and implementation of dental ABS programmes and interventions.…”

Contextual factors favouring success in the accreditation process in Colombian hospitals: a nationwide observational study

“…The model also includes the interrelation with the manager and the team for Q I [11,13]. The MUSIQ model has been used in a number of countries [6], but to our knowledge it has not been adapted and applied neither in the Latin-american environment nor having accreditation as the objective of a quality improvement initiative.…”