Skip to main content

Table 4 Mechanisms

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

Initial programme theory mechanismRefined programme theory mechanismResponse triggered by interventionSystem level influence
Creating the CultureEmpowermentStaff with autonomy to initiate improvement and come up with ideas/solutions; increases their desire to become involved.Organisational structures to support autonomy.
OwnershipOwnership of QI drives improvement activities.Micro level—operational context (ward/clinic) where change takes place.
Macro/meso level—organisational ownership, engaging with national initiatives and being able to translate them to local priorities.
Frontline engagementEngagementEngagement with QI efforts fostered by interest, active involvement and autonomy.Needs micro/meso/macro level commitment.
Informed practitionersQI capability buildingMicro level—empowers frontline staff to lead initiative and increased confidence show/tell other staff.Needs micro/meso/macro level commitment.
QI capacity buildingMicro level—enabling via the provision of resources and support: building skills, knowledge, relationships and the confidence to enact change.Needs micro/meso/macro level commitment.
Strong leadershipPsychological ‘safety’Micro level—freedom to voice concerns; characterised by openness, trust and open communication.Organisational macro/meso structures to facilitate that psychological safety within QI work.
MotivationMicro level—motivation of staff.Macro/meso level support for improvement.