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Table 4 Intra-organisational mechanisms of change

From: How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review

Themes (No. studies)

Evidence synthesis

Quality of Evidence [ref.]

Description of relationship QIC component–mechanism–outcome

Contextual enablers of mechanism (or barriers)

Quantitative and mixed methods

Qualitative and review

QIC component

Mechanism of change

Outcome

Health professionals -knowledge, skills & problem solving (N = 4)

Use of continuous quality improvement approach

• Refreshed knowledge

• Reinforced confidence and skills in improvement topic area

• Facilitated a problem-solving approach

Change in clinical practice enabled

• Quality and appropriateness (mix of clinical and quality improvement expertise) of mentoring

• Leadership and work culture open to bottom up discussion and reflection

• Health workers participating in quality improvement interventions have adequate clinical competences (or a complementary clinical skills training programme is accessible)

Medium [46]

Low [48]; medium [57, 58]

Health professionals engagement, attitude and motivation (N = 8)

Formulating shared goals

Alignment with national priorities and fit with existing practices

Use of run-charts to visualise progress

Dissemination of success stories

Credibility of change package

• Increased motivation, by reframing improvement topic as desirable, urgent and achievable

• Removed resistance to use of data

• Increased Commitment to change

Increased engagement in QIC—may lead to increased success

• Intensity of mentoring to increase data literacy and use for decision-making, particularly in LMICs

• Supportive leadership

• Barrier: competing programmes and initiatives.

Medium [58, 59]; high [49, 57, 60]

Low [17, 51, 61]; high [57]

Organisational climate (N = 4)

General QIC approach

• Facilitated teamwork and multi-professional collaboration within and across departments

• Facilitated bottom up dialogue and discussion

 

• Quality and intensity of mentoring

• Wider use of improvement tools beyond unit of focus

High [60]

Low [61]; medium [62]; high [57]

Leadership (N = 2)

General QIC approach

• Enhanced leadership engagement

• Decentralised/shared leadership promoted through encouraging bottom up problem solving

Staff morale boosted

• Previous success with quality improvement

• Alignment with institutional responsibilities and participatory working culture

 

Low [48, 63]

Organisational structures, processes and systems (N = 5)

Process mapping

• Definition of standard care processes facilitated

New expectations on performance generated

• Previous success with quality improvement

• Alignment with institutional responsibilities and priorities

• Complementary approach (beyond QIC activities) to institutionalise new ways of working e.g. incorporation in induction or staff training; performance management frameworks for accountability at the level of health workers and/or organisation

 

Low [17]; medium [62, 64, 65]; high [66]

Organisational culture (N = 3)

General QIC approach

• Development of habits for improvement facilitated

Normalisation of new practices

• Leadership open to new practices

• Health system enabling decentralised innovation

 

Low [17, 56]; medium [62]