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This paper aims to theorise and test a causal model of predominantly lean-driven quality improvement (QI) in the context of health-care clinical microsystems, examining the effects contextual factors in this setting have on improvement activity.

QI practitioners at a New Zealand District Health Board were surveyed on a range of contextual factors hypothesised to influence improvement outcomes. Survey responses were analysed via partial least squares path modelling to test the causal model that was designed to be consistent with the “model for understanding success in quality” (MUSIQ) model (Kaplan et al., 2012) adopted in health-care QI.

Defined variables for teamwork, respect for people, lean actions and negative motivating factors all demonstrated significant effects. These findings support the representation of the microsystem layer within the MUSIQ model. The final model predicted and explained perceived success well (adjusted R² = 0.58).

The sample was a non-probability sample and the sample size was small (n = 105), although power analysis indicated that we exceeded the minimum sample size (97 cases). Even though health-care processes have universality, this study was conducted in only one district in New Zealand.

The results support highly functional teamwork as the critical contextual factor in health-care QI outcomes and suggest lean-driven process improvement can be a valid mediating mechanism. The key recommendation for practitioners is to increase focus on human resource capability when initiating and supporting QI.

The originality is testing the robustness of the MUSIQ model specifically in a lean environment, which provides the context for QI. The paper provides a more detailed specification of contextual factors acting as exogenous variables that moderate the cause (lean actions) and the effect (perceived success).

The purpose of this paper is to investigate the contextual factors contributing to the sustainability of healthcare quality improvement (QI) initiatives.

Themes from semi-structured interviews with international healthcare leaders are compared with Kaplan and Provost et al.’s (2012) model for understanding success in quality (MUSIQ). Critical success factors within these themes are shown in detail.

The interviews provide a rich source of information on critical success factors. The themes largely correspond with MUSIQ, reinforcing its robustness. An important factor emerging from the interviews was the importance of engagement with patients and families in QI, and this needs consideration in seeking to understand context in QI.

Interview participants represent a limited set of western countries and health systems. Their experiences may not hold true in other settings.

The detail on critical success factors provides QI practitioners with guidance on designing and implementing sustainable initiatives.

Including consideration of contextual factors for engagement with patients and families in frameworks for context in QI appears to be an original idea that will add value to such frameworks. Researchers in patient engagement are starting to address contextual factors and connections should be made with this work.

The importance of culture is often emphasized for continuous learning and quality improvement within health care organizations. Limited empirical evidence for cultivating a culture that supports continuous learning and quality improvement in health care settings is currently available.

The purpose of this report is to characterize the evolution of a large division of physical therapists and occupational therapists in a pediatric hospital setting from 2005 to 2018 to identify key facilitators and barriers for cultivating a culture empowered to engage in continuous learning and improvement.

An ethnographic methodology was used including participant observation, document review, and stakeholder interviews to acquire a deep understanding and develop a theoretical model to depict insights gained from the investigation.

A variety of individual, social, and structural enablers and motivators emerged as key influences toward a culture empowered to support continuous learning and improvement. Features of the system that helped create sustainable, positive momentum (e.g., systems thinking, leaders with grit, and mindful design) and factors that hindered momentum (e.g., system uncertainty, staff turnover, slow barrier resolution, and competing priorities) were also identified.

Individual-level, social-level, and structural-level elements all influenced the culture that emerged over a 12-year period. Several cultural catalysts and deterrents emerged as factors that supported and hindered progress and sustainability of the emergent culture.

Cultivating a culture of continuous learning and improvement is possible. Purposeful consideration of the proposed model and identified factors from this report may yield important insights to advance understanding of how to cultivate a culture that facilitates continuous learning and improvement within a health care setting.

Health services continue to face economic and capacity challenges. Quality improvement (QI) methods that can improve clinical care processes are therefore needed. However, the successful use of current QI methods within hospital settings remains a challenge. There is considerable scope for improvement of elective clinical pathways, such as hip and knee replacement, and so the use and study of QI methods in such settings is warranted.

A model to manage variability was adapted for use as a QI method and deployed to improve a hip and knee replacement surgical pathway. A prospective observational study, with a mixed-methods sequential explanatory design (quantitative emphasised) that consisted of two distinct phases, was used to assess its effectiveness.

Following the use of the novel QI method and the subsequent changes to care processes, the length of hospital stay was reduced by 18%. However, the interventions to improve care process highlighted by the QI method were not fully implemented. The qualitative data revealed that staff thought the new QI method (the model to manage variability) was simple, effective, offered advantages over other QI methods and had highlighted the correct changes to make. However, they felt that contextual factors around leadership, staffing and organisational issues had prevented changes being implemented and a greater improvement being made.

The quality of QI reporting in surgery has previously been highlighted as poor and lacking in prospective and comprehensively reported mixed-methods evaluations. This study therefore not only describes and presents the results of using a novel QI method but also provides new insights in regard to important contextual factors that may influence the success of QI methods and efforts.

The purpose of this paper is to investigate how successful lean six sigma (LSS) manifests in the Australasian (Australian and New Zealand) context relative to the context in the USA in terms of LSS project definition, structure and practices.

In-depth investigation through case studies – 12 Australian/New Zealand cases and 4 US cases – on the implementation mechanisms of successful LSS initiatives.

A significant difference was found between Australasian and US definitions of an LSS project. However, firms in both regions followed similar project selection, initiating and execution practices. LSS reporting structures were found to be well-established in US organizations, but none of the Australasian organizations were found to be equipped with such a structure, although the effectiveness of LSS implementation success remained unaffected.

Sufficient uniformity of LSS was found across two regions implying its usefulness/generalizability, but the findings are based only on 12 cases.

The paper provides the groundwork to develop a unique LSS model for Australasian organizations to improve processes in an effective and efficient manner.

Despite hospitals’ efforts to reduce health care-associated infections (HAIs), success rates vary. We studied how leadership practices might impact these efforts.

We conducted eight case studies at hospitals pursuing central line-associated blood stream infection (CLABSI)-prevention initiatives. At each hospital, we interviewed senior leaders, clinical leaders, and line clinicians (n=194) using a semi-structured interview protocol. All interviews were transcribed and iteratively analyzed.

We found that the presence of local clinical champions was perceived across organizations and interviewees as a key factor contributing to HAI-prevention efforts, with champions playing important roles as coordinators, cheerleaders, and advocates for the initiatives. Top-level support was also critical, with elements such as visibility, commitment, and clear expectations valued across interviewees.

Results suggest that leadership plays an important role in the successful implementation of HAI-prevention interventions. Improving our understanding of nonclinical differences across health systems may contribute to efforts to eliminate HAIs.

Globally and particularly in Ireland, reduced expenditure on healthcare along with increasing pressure to increase patient throughput and improved performance against standards, is forcing healthcare providers to adopt tools from the business sector and apply them in the healthcare sector to bring about improved performance. The paper aims to discuss these issues.

This study is interpretivist in nature, specifically focussing on exploring how the balanced scorecard can support improved service delivery within a hospital department. The research will conduct an exploratory case study of a single hospital site within the Irish republic. This research is based on qualitative interviews with corroboration from document review and direct observation. This study provides a snap-shot of the Cath Lab service at a moment in time.

The development of a strategy map and proposed balanced scorecard for an Irish hospital unit.

The development of a balanced scorecard for a healthcare organisation.

This study explores how Lean was deployed in several hospitals in the Apulia region in Italy over 3.5 years.

An exploratory qualitative design was drawn up based on semi-structured interviews.

The drivers of Lean in hospitals were to increase patient satisfaction and improve workplace well-being by eliminating non-value-add waste. The participants highlighted three key elements of the pivotal implementation stages of Lean: introduction, spontaneous and informal dissemination and strategic level implementation and highlighted critical success and failure factors that emerged for each of these stages. During the introduction, training and coaching from an external consultant were among the most impactful factors in the success of pilot projects, while time constraints and the adoption of process analysis tools were the main barriers to implementation. The experiences of the Lean teams strongly influence the process of spontaneous dissemination aided by the celebration of project results and the commitment of the departmental hospital heads.

Lean culture can spread to allow many projects be conducted spontaneously, but the Lean paradigm can struggle to be adopted strategically. Lean in healthcare can fail because of the lack of alignment of Lean with leadership in healthcare and with their strategic vision, a lack of employees' project management skills and crucially the absence of a Lean steering committee.

The absence of managerial expertise and a will to support Lean implementation do not allow for systemic adoption of Lean. This is one of the first and largest long-term case studies on a Lean cross-regional multi-hospital application in healthcare.

The aim of this research is to determine the impact of a learning organisation (LO) on developing quality improvement practices (QIPs) and to propose knowledge-sharing (KS) as a moderator which is anticipated to support the beneficial effect of a LO on QIP. A further objective is to establish whether training provision raises the abilities of healthcare organisations (HCOs) to attain greater standards of QIP via a LO and KS.

A total of 240 responses, obtained from employees working at private HCOs in Jordan, comprised the valid dataset. Structural equation modeling (SEM) was utilised for data analysis. Multigroup analysis (MGA) was performed to compare the impact of workers who had or had not undergone training.

The findings indicated that QIP was significantly enhanced by LO. HCOs with the objective of converting a KS-moderated LO could attain improved QIP standards, but within the surveyed establishments, this effect was only appreciated at modest degrees. By performing MGA, no variations were identified in the impact of workers.

Managers should place more emphasis on training and learning within HCOs. However, respondents did indicate that their establishments had notable degrees of KS, suggesting a potential strength that could be used positively by the managerial hierarchy.

This study encompasses an original contribution to contemporary scholarship in the field of knowledge management and quality through its examination of the moderating effect of KS on LO and QIP.