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
Highlights
Context shapes the effectiveness of knowledge implementation and influences health improvement
This evidence-into-practice or implementation gap is often attributed to the ‘problem’ of context, i.e. the variations in a wide range of contextual conditions and factors across different settings that can impact on the improvement process, influencing the implementation, effectiveness, spread and sustainability of quality improvement (QI) initiatives [4, 6–9]
In updating the evidence base to incorporate the more recent advances in the context and QI literature—a rapidly developing field—this review offers potential to take forward one of the conclusions of the recent Health Foundation review of the evidence for context which states: ‘The evidence base for intervening to modify contextual factors in order to positively impact on the outcomes of quality improvement interventions is currently very weak.’ [17]
Summary
The review will follow the fundamentals of realist inquiry, a theory-driven interpretive approach that seeks to explain the root causes of programme outcomes and diverse patterns of impacts and effects, by evaluating evidence from a range of sources [39]. In contrast to the traditional review process, during this stage, the project team will revisit and if necessary revise the focus of the review based on emerging findings This may require further refinement of the inclusion/exclusion criteria and further purposive searches in response to any revisions of the programme theory, followed by the integration of any additional evidence. Completion of the realist synthesis will allow the reviewers to modify or refine the identified CMO configurations, and use these to explain (a) how and why QI initiatives cause change and generate outcomes within particular contexts and (b) which contextual factors matter, and how, when and for whom they matter, in terms of their influence on the QI process It is at this point that overall conclusions are drawn and a set of tentative recommendations produced. Improvement; RAMESES: Realist and meta-narrative evidence syntheses—evolving standards
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
