Influence of context on healthcare improvement initiatives

Mechanisms of Improvement

What works, for whom, and in what setting?  A realist review on the influence of contextual factors on healthcare quality improvement initiatives

What we know

Context shapes the effectiveness of knowledge implementation and influences QI efforts.  Addressing contextual barriers and facilitators is crucial to implementing effective improvement, yet the role of context is still poorly understood. This study uses a realist review approach to update the evidence base on the contextual conditions for effective improvement (Coles et al, 2017).  Realist methodology (Pawson, 2006) integrates theoretical understanding and stakeholder input with research findings.

Research aim

The review aims to identify and understand the contextual factors that influence the implementation, effectiveness, sustainability and transferability of QI initiatives in healthcare. 

What this research explored

Undertake a realist review of empirical studies of healthcare QI initiatives 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.

Synthesise current evidence to produce guidance to support the design of effective and sustainable context-sensitive improvement strategies and methods.   Through this synthesis, identify 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 and consider the influence of context on improvement outcomes (provider- and patient-level), spread and sustainability.

What this study adds

Spreading and sustaining quality improvement (QI) initiatives in healthcare is a recognised challenge; this research highlights the influence of contextual factors on these efforts. 

Although the evidence base around context in QI is increasing, there remains limited knowledge and guidance about which contextual factors are most influential. This review explores how, when and for whom context impacts during the improvement journey across healthcare system levels.

This is the first realist review of context in QI. The realist approach incorporates theory, research evidence and practical knowledge to facilitate the exploration of the multi-level, multi-faceted nature of context, within complex healthcare settings and contributes to a deeper understanding of how context influences quality improvement initiatives. 

The principle outputs are evidence-based theoretical models that can be applied to QI implementation in healthcare settings, to illustrate the interactions between contextual factors and system levels (macro, meso, micro) at the various stages of the improvement journey.


Benefits and impact

  • Up-to-date evidence review of contextual factors that influence quality improvement initiatives.
  • The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability.


The project was led by Dr Emma Coles, at the University of Stirling, supported by colleagues from the Nursing, Midwifery and Allied Health Professionals Research Unit and the School of Health Sciences at Dundee University.  This work was co-created with improvement leaders and practitioners from across NHS Scotland.    

For more information please contact SISCC (

Related Publications:

The influence of contextual factors on healthcare quality improvement initiatives: a realist review (2020)

The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting?  Protocol for a realist review (2017)


The Health Foundation: Perspectives on Context – A selection of essays considering the role of context in successful quality improvement 

Healthcare Quality Strategy for NHSScotland

Nuffield Trust: Learning from Scotland’s NHS