The Influence of Context on Quality
Improvement Success—A Novel Framework
Heather Kaplan, MD, MSc
Peter Margolis, MD, PhD
Craig M. Froehle, MBA, PhD
Lloyd P. Provost, MS

• Summative reports of QI initiatives indicate substantial variation in effectiveness
• There is significant heterogeneity in the performance of groups participating in QI initiatives
• Mixed results may be due to differences in
“context”
• Understanding context may improve results of QI

“Theoretical developments are needed to provide frameworks and predictive theories for creating generalizable research”
Institute of Medicine. Advancing Quality Improvement Research: Challenges and Opportunities , 2007

Descriptive Theory
Carlile PR & Christensen CM. Practice and Malpractice in Management Research. January 6, 2005

• Conduct a systematic, theory-driven effort to test and quantify the hypothesis that contextual factors influence QI
• Objectives
1. Refine a preliminary theoretical framework explaining the influence of context on QI success
2. Test preliminary associations between contextual factors and successful improvement based on this framework in QI initiatives

• “Systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of health care in particular settings. While QI uses a wide variety of methods, they all involve deliberate actions to improve care, guided by data reflecting the effects.”
• QI can resemble
– Type of practical problem solving
– Evidence-based management style
– Application of a theory-driven science to bring about system change
Baily, MA, et al. Hastings Cent Rep, 36 (4), S1-40.

• Anything relating to the set of facts or circumstances surrounding an event
• “…characteristics of the organizational setting, of the individual, of his or her role in the organization, and of any other environmental factor that may shape
[quality improvement effectiveness]”
Rousseau DM. Administrative Science Quarterly.
23(4):521, 1978

Systematic
Review of the
Literature
Preliminary
Theoretical
Framework
Expert Panel
Framework
Refinement
Modified Delphi
Method
Revised
Framework
Influence of
Context on QI
Success
Evaluation of Framework in 3 QI settings
Quantitative Tests of Associations
Between Contextual Factors and QI
Success
Phase I
Refinement of Proposed
Theoretical Framework
Phase II
Framework Evaluation

Characteristics of the Organization &
Environment
-Organizational culture
-Organizational commitment to QI
-Structural Characteristics: Hospital Size, system affiliation, ownership type, financial constraints (market competition), organizational turn over, geographic region, volume, staff tenure
-Human Resources Structure- rewards for QI
Successful Data Collection & Management
-Existing data collection structure
-Belief that data feedback is useful, credible, and valid
Characteristics of the Task
-Strategic importance to the organization
-Scope and Complexity (Problem & Interventions)
-Type of task—systems v. clinical change
Cross-functional QI Team
-Team composition: diversity, tenure, size, age, profession
-Prior history of working together
-Effective Team Leadership
-Functional group interactions and general effectiveness
-Involvement of senior managerial leaders
-Strong physician champion
--Team climate for innovation
-Motivation and Self-efficacy
-Prior QI experience
Application of
QI Methods &
Tools
QI Training
-Training in QI techniques & small group problem-solving
Interactions with Clinical Micro-system
-Awareness on clinical unit (Diffusion)
-Staff and Leadership turnover
-”Buy in” in the importance of the problem
Sufficient Resources/Time
-Organizational Support: protected time and support staff
System &
Process
Changes
Outcome
Improvement

• Systematic Review of the Literature including healthcare and business publications
• What relationships between contextual factors and
QI success have been studied? What relationships have been found to exist?
• What questionnaires/instruments have been used to measure contextual factors? How have authors defined/conceptualized the contextual factors?

• Expert Panel framework building
• Recognized experts in QI
– QI Researchers and Leading Thinkers
– Leaders of QI in Business
– Leaders of QI in Healthcare
– QI Consultants
• RAND modified Delphi method

• Study Population (3 unique QI settings)
– Cincinnati Children’s Hospital QI Projects>45 teams focused on different improvement topics
– Ohio Perinatal Quality Collaborative44 obstetric and neonatal teams from 25 hospitals using QI methods to reduce prematurity and improve outcomes of newborns
– IHI Improvement Advisor Program - Program to train and coach “QI advisors from multiple settings. 25 participating IA’s are responsible for a project at his or her own organization.

Descriptive Theory
Carlile PR & Christensen CM. Practice and Malpractice in Management Research. January 6, 2005

• Theoretical Framework
• User’s Guide
– Framework
– Definitions of the contextual factors and attributes
– Measures used to evaluate contextual factors
• Preliminary results of framework testing

• “In many ways, the term ‘theory’ might be better framed as a verb, as much as it is a noun—because the body of understanding is continuously changing as scholars… work to improve it”
Carlile PR & Christensen CM. Practice and Malpractice in Management Research. January 6, 2005