title: A qualitative study of contextual factors' impact on measures to reduce surgery cancellations.
abstract: BACKGROUND
  Contextual factors influence quality improvement outcomes. Understanding this influence is important when adapting and implementing interventions and translating improvements into new settings. To date, there is limited knowledge about how contextual factors influence quality improvement processes. In this study, we explore how contextual factors affected measures to reduce surgery cancellations, which are a persistent problem in healthcare. We discuss the usefulness of the theoretical framework provided by the model for understanding success in quality (MUSIQ) for this kind of research.
  
  
  METHODS
  We performed a qualitative case study at Førde Hospital, Norway, where we had previously demonstrated a reduction in surgery cancellations. We interviewed 20 clinicians and performed content analysis to explore how contextual factors affected measures to reduce cancellations of planned surgeries.
  
  
  RESULTS
  We identified three common themes concerning how contextual factors influenced the change process: 1) identifying a need to change, 2) facilitating system-wide improvement, and 3) leader involvement and support. Input from patients helped identify a need to change and contributed to the consensus that change was necessary. Reducing cancellations required improving the clinical system. This improvement process was based on a strategy that emphasized the involvement of frontline clinicians in detecting and improving system problems. Clinicians shared information about their work by participating in improvement teams to develop a more complete understanding of the clinical system and its interdependencies. This new understanding allowed clinicians to detect system problems and design adequate interventions. Middle managers' participation in the improvement teams and in regular work processes was important for successfully implementing and adapting interventions.
  
  
  CONCLUSIONS
  Contextual factors interacted with one another and with the interventions to facilitate changes in the clinical system, reducing surgery cancellations. The MUSIQ framework is useful for exploring how contextual factors influence the improvement process and how they influence one another. Discussing data in relation to a theoretical framework can promote greater uniformity in reporting findings, facilitating knowledge-building across studies.
authors.affiliation: Sogn og Fjordane University College, Institute of Social Science, Postbox 133, Sogndal 6851, Norway. einar.hovlid@hisf.no.
authors.forename: Einar
authors.initials: E
authors.lastname: Hovlid
authors.forename: Oddbjørn
authors.initials: O
authors.lastname: Bukve
mesh_terms: D001071:Appointments and Schedules; D017598:Efficiency, Organizational; D006780:Hospitals, Rural; D006801:Humans; D008962:Models, Theoretical; D009664:Norway; D009873:Operating Rooms / Q000458:organization & administration; D036301:Qualitative Research; D058996:Quality Improvement; D013503:Surgery Department, Hospital