Table 2 Potential strategies for strengthening wide-scale CQI projects to enhance clinical performance in different contexts

Mechanism 1: Collective or shared valuing of clinical data for improvement purposes: if health centers expect their clinical audit data to be fit for the purpose of QI, then they will be more motivated to use these data for service improvement as envisaged by the CQI model.

Centralized management style; regional board committed and involved in CQI implementation (C1)

● If centralized management of CQI institutes revision of clinical record keeping systems, participating health centers will develop collective or shared valuing of clinical data for improvement purposes, and will in fact use the data for performance improvement, resulting in improvements in care delivery.

● If this works because of the expectations of the potential for data to support CQI (for example, through social mechanisms such as the ‘self fulfilling prophecy’), then

wide-scale CQI projects could encourage health centers sharing this context to enter CQI processes with optimism, and use processes as a way to motivate for improvements in clinical record keeping even where good quality data on care processes are not consistently available at the outset

Local ownership of CQI; competent managers with interest in chronic disease and clinical and population health data (C2)

● If clinical staff use data in non-core ways to illustrate the applicability of data and importance of record keeping, health centers participating in these initiatives will develop collective or shared valuing of clinical data for improvement purposes, and will in fact use the data for performance improvement, resulting in improvements in care delivery.

● If this works because of the adaptive potential of the project then

wide-scale CQI projects could develop examples of different presentation formats of audit data, and of CQI processes to illustrate adaptive potential more strongly, demonstrating their capacity to resonate with different organizational cultures and vision

Poor management, uncertainty and confusion over role definitions (C3)

● If poor overall management and role confusion detracts from health center staff perceptions of the value of their data, health centers participating in wide scale CQI projects are less likely to develop shared valuing of clinical data for improvement, and will be less likely to use the data for performance improvement, constraining the potential for improvements in care delivery, and discouragement (negative feedback loop).

● If this context is a key constraint on the effectiveness of CQI, then

interventions targeting unfavorable organizational contexts should be developed, prior to, or in parallel with, CQI implementation

Mechanism 2: Collective efficacy - If health center staff have a strong sense of shared belief of achieving improvement through the CQI project, then they will be more motivated to attempt changes to improve service delivery as envisaged by CQI, devote considerable effort to it, and persist in the face of difficulties.

Infrastructure supportive of CQI networking; positive prior history of collaboration (C4)

● If regional/organizational infrastructure is supportive of networking for CQI, and networks are formed, health centers will attempt changes, put effort into changes and show persistence, resulting in improvements in care delivery.

● If this works because of informal social control enacted under conditions of social trust, then

wide-scale CQI projects could encourage greater density of networks between health centers in this context, transparent sharing of information and experiences related to CQI

Organizational culture unsupportive of collaboration (C5)

● If organizational culture is unsupportive of collaboration, inappropriate competitiveness and early fatigue and disillusionment will result. If this ‘works’ because of lack of co-operation with social control, related to lack of social trust, then

wide scale CQI projects could seek to identify health centers sharing this context, and aim to build sufficient trust for collaborative networking to take place

Mechanism 3: Organizational changes towards a population health orientation - If health centers share an understanding of their role as supporting health of their service and community populations, not just those presenting for care, then they will engage in activities outside of the health center, build trust with community members, instituting changes for service improvement that are consistent with community needs, and therefore more likely to be acceptable to the community and lead to greater demand for services, and increased delivery of guideline scheduled services – as long as the guidelines and indicators measured are consistent with community needs.

Pre-existing favorable context of patient and community oriented care, supported by stable effective outreach workers and good regional co-ordination for CQI (C6)

● If organizational culture has a strong external focus, participation in CQI may enable clearer understanding of unmet need/under delivery, helping health centers to galvanize to improve care, and will use these data for performance improvement.

● If this works because of the role of CQI in providing information on population health needs, then

wide-scale CQI projects could be designed as broad integrated models as these will be more likely to trigger change towards a population health orientation than narrow CQI models that focus on a more limited range of clinical targets

Staff who can identify with patients and have the skills to take broad ranging action (C7)

● If key individuals are motivated and empowered to take broad ranging action, and have the support to do so, then they will actively participate in wide-scale CQI projects, and use these as a tool to initiate improved care delivery

● If this works because of the role of individual level enthusiasm in promoting change, then

wide-scale CQI projects could seek to proactively build the skills and development of enthusiastic clinical leaders in promoting overall performance improvement across the scope of clinical care