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Table 2 Included studies

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

Author, year, countryClinical area improvement interventions occurredImprovement aimCare or quality gap; deficiency that intervention aims to addressContext description/features
Armstrong et al. 2016, UK [37]Primary care practicesImprove the quality of the chronic kidney disease (CKD), register and implement the CKD bundles and introduce self-management toolsImprove quality of the CKD register.Unique features of primary care setting: prioritisation, lack of mechanisms to mandate engagement, working relationships (locus of power—nurses were implementers but GPs/Practice Managers needed to authorise), alignment with financial (and other) incentives; the degree of fit between the intervention and the context in which it was being implemented as the most influential interrelationship.
Benning et al. 2011, UK [38]Designated clinical areas in 4 UK hospitalsImprove reliability of specific frontline care processes in designated clinical specialities and promotion of organisational and cultural changeImprove reliability of care processes across different clinical sites within hospitals and develop safety culture and good leadership to enable organisational management of problems and risk.Organisational climate. Gap between strategic level and frontline.
Boaz et al. 2016, UK [39]Intensive care units and lung cancer pathwaysImplement improvement priorities identified through a participatory/co-design processIntensive care units prioritised improvements in enhancing basic care, reducing noise and sleep deprivation, communication, patient-doctor communication on ward rounds, transition to the ward: ‘lost in translation’, hallucinations, ventilation and individualised care. Lung cancer pathways prioritised improvements in pillows, personal items, information, privacy, diagnosis-giving, support and information.Patient and carers experience/working alongside staff. This type of engagement focused on ‘smaller scale’ improvement—rather than the current focus of large-scale change and identified the benefits of this approach to the broader cultural challenges around the acceptability of change.
Carney 2011, Republic of Ireland [40]Clinical and non-clinical heads of departments within hospitalsn/a—study was an exploration of the pivotal role of head of department/directorate to healthcare management and its influence on healthcare planning and quality healthcare delivery.n/aOrganisational culture. Leadership.
Curry et al. 2018, USA [41]Hospital-wide leadership and organisational cultureOutcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR).Hospital organisational culture affects patient outcomes including lower risk-standardised mortality rates (RSMRs) for patients with acute myocardial infarction; little is known about whether and how culture can be positively influenced.Organisational culture as a contextual factor that can accelerate learning and improvement; impacts on adoption of EBP.
Darley et al. 2018, UK [42]Maternity servicesn/a—study was an exploration of the utilisation of an improvement capability assessment tool.Variations in service performance and quality improvement.Organisational context; interactions between organisational performance and improvement capability; division of intervention and context is arguably somewhat artificial—the two interact in multiple, complex and dynamic ways.
Dixon-Woods et al. 2013, UK [43]Adult intensive care unitsReducing central line bloodstream infections; improvements in patient safety and reduce 30 day mortality.Decline effect and failure to outperform secular trend seen in replication of QI/PSP initiatives. Healthcare-acquired infections and central line catheter-related blood stream infections—reduce morbidity and mortality associated with these infections.Broad: national to local, influence of inner and outer, context as culture, context as implementation climate. Outer context—national infection control policies—top down and punitive. Local context—experience of QI initiatives, data collection capability, feedback systems, local leaders to develop consensus and coalition. Improved understanding of contexts of implementation may reduce risks of decline effects and add value beyond secular trends.
Dückers et al. 2011, Holland [44]Across hospital organisationsStimulate the development of quality management systems and the spread of methods to improve patient safety and logisticsAddress the lagging development of quality management systems optimisation of healthcare delivery through organisational-wide diffusion and quality improvement programmes.Macro: stimulating physicians to join quality-improvement initiatives but also by adopting the organisational strategy for sustainability and dissemination, national performance measures and policy. Meso: leadership and performance management—align vision and quality, create feedback loops between layers and internal programme structure. Micro: QI training from external experts. System changes affect the context factors in the theory of organisational readiness: organisational culture, policies and procedures, past experience, organisational resources, and organisational structure. These factors are utilised to manage spread and sustainability.
Edward et al. 2017, Australia [45]Operating rooms and recovery/post-surgical care wardsReduce the incidence of inadvertent perioperative hypothermiaSlow process of translating research; need for effective translational research models to ensure patient care quality and safety are not compromised. Strong evidence that mild intraoperative hypothermia quadruples the risk of surgical site infection, doubles the risk of perioperative myocardial events and significantly increases surgical blood loss.Stakeholders. Frontline: clinicians, teams, collaboration. Learning systems.
Flynn and Hartfield 2016, Canada [46]Paediatric Intensive Care UnitImprove hand hygiene practice within the paediatric intensive care unitNeed to understand barriers and facilitators around implementing initiatives in complex systems. Many quality issues and adverse events in healthcare are preventable. Poor quality and adverse events are costly to healthcare systems. Infections are preventable harm.Individual, unit and organisational; QMF as a whole system changes mechanism. Leadership—different system levels.Organisational culture—general interest from leading physician in QI and strong working relationships between physicians and nurses. Resources (or lack of)—personnel and QI knowledge. Complex social interventions—a variety of contexts across multiple levels of the healthcare system: patient, healthcare provider, multidisciplinary team, institution and local and national healthcare system levels.
Gagliardi et al. 2014, Canada [47]Colon cancer screening, prostate cancer diagnosis, pancreatic cancer treatment servicesThree areas of clinical priority identified by the cancer agency—increase update of colorectal screening, reduce overuse of prostate cancer screening and reduce mortality associated with pancreatic cancer.Collaboration among researchers (clinician, non-clinician) and decision makers (managers, policy-makers, clinicians), referred to as integrated knowledge translation (IKT), enhances the relevance/use of research, leading to improved decision-making, policies, practice, and health care outcomes. But IKT is not widely practiced due to numerous challenges. Focus was the improvement of clinical areas identified by provincial cancer agency.Culture receptive to change, leadership support, feedback to staff (PARIHS). Organisation: culture, leadership, capacity (infrastructure, political, economic, social). Individual: professional role, involvement, personal characteristics. Contextual factors at the individual (knowledge, beliefs, motivation) and organisational (culture, leadership, capacity) levels.
Gingold et al. 2016, USA [48]Paediatric primary careIncrease the uptake of childhood immunisations.Routine childhood immunisation can prevent morbidity and mortality. Uneven adherence to immunisation guidelines leaves some communities vulnerable to outbreaks of vaccine-preventable diseases.Data infrastructure, management structure, interpersonal interactions, beliefs and behaviours.
Gjestsen et al. 2017, Norway [49]Home-based care servicesNational programme established to develop and implement assistive living technologies is integrated in primary care services by 2020.Assisted living technologies—help monitor and treat degenerative and chronic diseases that follow an ageing society through the use of sensors, alarms and reminders and could be used to prevent hospitalisations by providing early warnings of exacerbation events or deterioration.MUSIQ—microsystem, QI team, healthcare system macro (external, policy), meso (organisation factors), micro. Context factors interdependent and mutually reinforcing. Acknowledges the organisational, social, political and policy context.
Green et al. 2017, UK [50]Acute medical hospital wardsCOPD bundle aims to improve the quality and consistency of the care received by patients, and to reduce variations in care processes and clinical outcomes. Diabetic foot care—improve screening and management of in-patient diabetic foot complications based on current best practice guidelines.Challenge of consistent implementation of clinical guidelines: implementation of care bundles developed from guidelines to deliver evidence-based changes
COPD is associated with significant morbidity and mortality—following hospitalisation, consistency in care during admission, discharge and follow-up care has been shown to reduce readmissions and improve clinical outcomes. Timely identification and management of diabetic foot can prevent significant complications (lower limb amputation) and reduce associated morbidity, improving clinical outcomes.
Organisation and stakeholder/practitioner level. Implementation climate.
Grooms et al. 2016, USA [51]Neonatal Intensive Care UnitsFocus on clinical and value improvement with specific focus on the standardisation of processes and understanding context.Need to systematically address role of context and how to make local context more supportive. Identify gaps and design improvements in QI context to ensure QI initiative is successful. Improve clinical and value outcomes and standardise processes within neonatal units.Organisation; microsystem; data infrastructure.
Hamilton et al. 2014, Canada [52]Surgical units in tertiary and secondary hospitals in SaskatchewanImplement RTC in all surgical units in tertiary and secondary hospitals in Saskatchewan.Consistent approach to QI for nurses is needed to avoid isolated pockets of excellence and ensure projects are aligned and not competing for attention. Enables staff to identify areas for continuous improvement and aims to increase the amount of time nursing staff have to spend with patients.Organising for quality domains: educational, structural, cultural, political, physical, technical. Highlights the importance of understanding existing context when considering QI implementation and the limitations of mandated top-down imposed QI initiatives.
Harvey et al. 2018, UK [53]Secondary care settings including specialist children’s services and specialist diabetes clinicIncrease the uptake of IPT to 12% of adults and 33% of children < 12 years old.Accelerating innovative technology uptake in the NHS; facilitation role of national agencies. Insulin pump therapy is a clinically and cost effective treatment of people with Type 1 Diabetes where multiple daily injections have failed.Leadership support; culture; past experience of innovation and change; structure, systems and processes; organisational priorities; policy drivers; incentives and mandates; inter-organisational networks and relationships. Factors related to the organisation and delivery of healthcare: politics and culture at a local level, alongside organisational and system level issues related to funding and commissioning new technologies.
Hovlid and Bukve 2014, Norway [54]Wards and departments involved in the clinical pathways delivering elective surgeryRedesign the clinical pathway for elective surgery to reduce cancellations and sustain system improvementsInfluence of contextual factors on QI processes and outcomes. Cancellation of scheduled surgery is a quality of care problem.Healthcare system; clinical system. Follows Øvretveit view of interactions of contextual factors with each other and with implementation process.
Kaplan et al. 2016, USA [55]Maternity hospitalsAntenatal corticosteroids (ANCS) to reduce preterm birth complications.Preterm birth is a leading cause of neonatal morbidity and mortality—antenatal corticosteroids can reduce the complications of preterm birth but many hospitals do not have the right processes and conditions for reliable implementation of ANCS.Inner and outer settings. High reliability culture, culture and physician leadership. ‘General elements of context, evidence and facilitation are also important in sustaining evidence delivery at high levels’. Contextual influences on the sustainability of improvements.
Krein et al. 2010, USA [56]Intensive care unitsReduce central-line bloodstream infections.Hospital patient safety; infection control. Prevention of central line-associated bloodstream infections (CLABSI).Structure (leadership, culture, resources, co-ordination); people; champions. ‘We also need to better understand when, how or even which practices and implementation strategies might work given the organizational context’. Which organisations might be more receptive to collaboratives and externally-facilitated efforts.
Manley et al. 2017, UK [57]Wide range of inpatient settings within hospitals—maternity departments, A&E, ambulatory care and specialist care wardsImplementation of safety huddles and other QI tools, Teamwork Safety Climate Survey, and action learning for the facilitators supporting frontline teams.Patient safety collaboration to embed a safety culture, grow leadership and quality improvement capability.Culture; interconnections within the organisation between the frontline teams and leadership.
McCullough et al. 2015, USA [58]Pharmacy-run anticoagulation clinicsImplementation of an evidence-based anticoagulation treatment algorithm as part of the regional Anticoagulation Clinical Improvement Initiative; implement processes of care to improve follow-up actions and reduce loss to follow-up.Strength of contextual elements and their effects; interactions between contextual elements. Improve anticoagulation care and reduce rates of patient complications.Dynamic, multivalent and highly variable in organisational life. Contextual elements multidimensional: e.g. evidence, leadership, teamwork, communication. Ranked as strong, moderate or weak in relation to initiative. Interrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others—predictor of uptake of intervention.
Meehan et al. 2015, USA [59]Skilled nursing facilities (SNF) (UK equivalent of nursing homes)Reduce preventable hospital readmissions through improving the identification, evaluation and management of acute changes in the conditions of SNF residents.Decreasing preventable hospital readmissions from SNFs—in 2011 25% of Medicare beneficiaries discharged from hospital to a SNF had at least one readmission within a year.Institution-specific (e.g. culture, leadership); organisations as complex adaptive systems.
NIHR CLAHRC Greater Manchester 2018, UK [60]Hospital-based wardsImprove the identification and management of acute kidney injury.AKI is a preventable clinical syndrome; need to achieve better identification management in hospital care.National, regional, local (organisational context).
Papoutsi et al. 2018, UK [61]Acute Medical Units or equivalentAim to reduce harm and increase assessment reliability for older people admitted acutely to hospital, through the introduction of a checklist to increase completion of key clinical admission assessments and improve communication.Older patients with multiple co-morbidities suffer from disproportionate levels of harm in their care due to insufficient attention to frailty in non-specialist settings.System of pre-existing patterns of working, communication and sharing responsibility.
Phung et al. 2016, UK [62]Emergency care pathways for Ambulance Service care bundles for acute myocardial infarction and strokeIncrease the reliability of delivering the AMI (> 70%) and stroke (> 90%) care bundles.Ambulance services are an important component of care pathways for emergencies and will influence morbidity and mortality outcomes.Organisational culture, clinical leadership, culture of innovation. Leadership and organisational culture also contextual factors for clinical governance.
Power et al. 2016, UK [63]Range of primary and secondary care settingsDevelop a shared national, regional and locally aligned safety focus on 4 harms, establish measurement system to capture harm-free care and deliver improved outcomes.Promote an innovative approach to patient-centred harm-free care to address the challenges of patient safety programmes that focus on single outcomes within well-bounded healthcare settings that obscure individual’s experiences across pathways of care and exposure to multiple adverse events.Broad: political, economic, social. Organisational context. External contextual influences—importance of ‘supportive outer context’ and how it can influence the impact of the collaborative approach.
Reed et al. 2018, UK [64]72 Ohio maternity hospitals; 2 hospitals (Scotland and USA: 4 QI projects within each hospital)Ohio: improve birth registry accuracy and reduce elective deliveries < 39 weeks. Scotland/USA: broad range of 8 QI projects set within two hospitals in Scotland and the USA.Understand the influence of contextual factors in influencing QI & implementation (QI&I) initiatives within a broad range of settings—through the secondary analysis of qualitative data from two studies examining QI collaboratives/projects.Dynamic with multiple, closely linked factors operating at different levels in a system that is constantly changing in response to QI&I initiatives. Three distinct types of context were identified: the setting(s) of care in which QI&I takes place; the context of the team conducting a specific project; the wider context supporting general QI&I.
Rostami et al. 2018, UK [65]Medication safety in primary and secondary careImplementation of a national Medication Safety Thermometer tool.Reduction of medication-related harm is impeded by lack of routine medication safety data and standardised monitoring processes.Organisational readiness, organisational culture, adaptation of intervention.
Rotteau et al. 2015, Canada [66]Emergency departmentsReduce length of stay and improve patient flow.Crowding in emergency departments is associated with poor patient experience, low staff morale and adverse patient outcomes. Examine how Lean can best be implanted in healthcare settings.Structural, political, emotional, cultural.
Rycroft-Malone et al. 2013, UK [67]Hospital wards providing pre/post-op careImplementation of two evidenced-based guidelines about peri-operative fasting and resumption of fluids (3 intervention approaches were tested).Gaps in literature around processes of implementation—using the issue around the variable evidence-base about the effectiveness of peri-operative fasting interventions—three trial implementation interventions were developed and randomly allocated—which included the prospective use of PARIHS .Implementation context: micro (individual), meso (team), macro (hospital).
Schierhout et al. 2013, Australia [68]Community-based health centresSupport best practice in prevention and management of chronic disease in indigenous primary health care services in Australia.Improvement in quality of care for Indigenous Australians.Regional and organisational infrastructure/culture.
Sommerbakk et al. 2016, Norway [69]Two hospitals, one nursing home, two local medical centres (short-term inpatient care)IMPACT (IMplementation of quality indicators in Palliative Care sTudy).To meet the increased demand for palliative care (PC), efficient strategies are necessary to implement and/or improve PC at all levels of health care, not just in specialist settings.Social (e.g. leadership, culture of change, face-to-face contact); organisational (e.g. resources, structures/facilities, expertise); political and economic (e.g. policy, legislation, financial arrangements).
Sutton et al. 2016, UK [70]Transitions of care across care boundaries— between residential care settings and hospitalReduce unplanned readmissions from residential care homes.Suboptimal transitional care between hospitals and residential care settings—addressing continuity and coordination issues.Inter-organisational.
Tomoaia-Cotisel et al. 2013, USA [71]Primary care practicesTransform primary care practices into patient-centred medical homes.Transformation of primary care services to improve outcomes and processes. Translating research into practice often fails due to lack of knowledge around contextual factors and how they modify intervention effects.Practice setting, larger organisation, external environment, implementation pathway, motivation for implementation.