From Theory to Implementation: Adaptations to a Quality Improvement Initiative According to Implementation Context

Abstract

As countries continue to invest in quality improvement (QI) initiatives in health facilities, it is important to acknowledge the role of context in implementation. We conducted a qualitative study between February 2019 and January 2020 to explore how a QI initiative was adapted to enable implementation in three facility types: primary health centres, public hospitals and private facilities in Lagos State, Nigeria. Despite a common theory of change, implementation of the initiative needed to be adapted to accommodate the local needs, priorities and organisational culture of each facility type. Across facility types, inadequate human and capital resources constrained implementation and necessitated an extension of the initiative’s duration. In public facilities, the local governance structure was adapted to facilitate coordination, but similar adaptations to governance were not possible for private facilities. Our findings highlight the importance of anticipating and planning for the local adaptation of QI initiatives according to implementation environment.

Influence of context on quality improvement priorities: a qualitative study of three facility types in Lagos State, Nigeria

“… 3 24 25 These leaders, or sometimes the lack of them, were found to be important in Lagos State where facility teams with least QI capacity prioritised many easy tasks, such as quality of meals, while failing to address problems that could have greater impact on health outcomes. 15 Overall, we observed that the modified collaborative approach of NHQI 15 resulted in considerable differences in the actions taken by facility QI teams, driven to a large extent by diversity of facility problems, priorities and exacerbated where leadership was lacking.…”

“…The initiative entailed establishing collaborative learning sessions, coaching and mentoring, and supporting the facilities to conduct QI team meetings to develop change ideas that are expected to lead to an improvement. 15 26 …”

“…1 14 Seeking to improve maternal and newborn outcomes and patient satisfaction, the Lagos State Ministry of Health, the Primary Health Care Board and managers of private facilities implemented the Nigeria Healthcare Quality Initiative (NHQI), a QI intervention using a modified collaborative learning approach. 15 An initial pilot phase ran from November 2014 to September 2017, followed by a scale-up phase between November 2017 and October 2020. Three facility types were enrolled: public primary healthcare centres (PHCs), public secondary hospitals and private facilities.…”

“Quality teaches you how to use water. It doesn’t provide a water pump”: a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program

“…By design QIC runs for a limited time (6–15 months) [ 4 ] and the current commonly used time frames may be too short for the required changes in organizational culture- even where this is supported. QIC interventions in Nigeria and Rwanda extended their implementation period to reflect that QICs may need a greater time than anticipated to function [ 22 , 28 ]. In some setting QICs have been adapted to be aligned with existing organizational cultures and have adopted top-down hierarchical decision making [ 22 ].…”

“…QIC interventions in Nigeria and Rwanda extended their implementation period to reflect that QICs may need a greater time than anticipated to function [ 22 , 28 ]. In some setting QICs have been adapted to be aligned with existing organizational cultures and have adopted top-down hierarchical decision making [ 22 ]. Whilst QICs need to adapted to the context they also need to maintain the core processes such as collaborative decision making, but may need support to do so.…”