title: The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews.
abstract: BACKGROUND
  It is now widely accepted that the mixed effect and success rates of strategies to improve quality and safety in health care are in part due to the different contexts in which the interventions are planned and implemented. The objectives of this study were to (i) describe the reporting of contextual factors in the literature on the effectiveness of quality improvement strategies, (ii) assess the relationship between effectiveness and contextual factors, and (iii) analyse the importance of contextual factors.
  
  
  METHODS
  We conducted an umbrella review of systematic reviews searching the following databases: PubMed, Cochrane Database of Systematic Reviews, Embase and CINAHL. The search focused on quality improvement strategies included in the Cochrane Effective Practice and Organisation of Care Group taxonomy. We extracted data on quality improvement effectiveness and context factors. The latter were categorized according to the Model for Understanding Success in Quality tool.
  
  
  RESULTS
  We included 56 systematic reviews in this study of which only 35 described contextual factors related with the effectiveness of quality improvement interventions. The most frequently reported contextual factors were: quality improvement team (n = 12), quality improvement support and capacity (n = 11), organization (n = 9), micro-system (n = 8), and external environment (n = 4). Overall, context factors were poorly reported. Where they were reported, they seem to explain differences in quality improvement effectiveness; however, publication bias may contribute to the observed differences.
  
  
  CONCLUSIONS
  Contextual factors may influence the effectiveness of quality improvement interventions, in particular at the level of the clinical micro-system. Future research on the implementation and effectiveness of quality improvement interventions should emphasize formative evaluation to elicit information on context factors and report on them in a more systematic way in order to better appreciate their relative importance.
authors.affiliation: Department of Public Health, Academic Medical Center (AMC) - University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands. d.s.kringos@amc.uva.nl.
authors.forename: Dionne S
authors.initials: DS
authors.lastname: Kringos
authors.affiliation: Avedis Donabedian Research Institute, University Autonomous of Barcelona, C/Provenza 293, Pral. 08037, Barcelona, Spain. rsunol@fadq.org.|Avedis Donabedian Research Institute (FAD), Universitat Autonoma de Barcelona, ᅟ, Spain. rsunol@fadq.org.|Red de investigación en servicios de salud en enfermedades crónicas REDISSEC, ᅟ, Spain. rsunol@fadq.org.
authors.forename: Rosa
authors.initials: R
authors.lastname: Sunol
authors.affiliation: NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, The Netherlands. c.wagner@nivel.nl.
authors.forename: Cordula
authors.initials: C
authors.lastname: Wagner
authors.affiliation: Health Services Management Centre, University of Birmingham, Birmingham, B15 2RT, UK. r.mannion@bham.ac.uk.
authors.forename: Russell
authors.initials: R
authors.lastname: Mannion
authors.affiliation: Quality and Safety Department, Lyon University, Hospital Network, Lyon, France. philippe.michel@chu-lyon.fr.
authors.forename: Philippe
authors.initials: P
authors.lastname: Michel
authors.affiliation: Department of Public Health, Academic Medical Center (AMC) - University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, The Netherlands. n.s.klazinga@amc.uva.nl.
authors.forename: Niek S
authors.initials: NS
authors.lastname: Klazinga
authors.affiliation: Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. oliver.groene@lshtm.ac.uk.
authors.forename: Oliver
authors.initials: O
authors.lastname: Groene
mesh_terms: D003695:Delivery of Health Care; D006761:Hospitals / Q000592:standards*; D006801:Humans; D058996:Quality Improvement; D000078202:Systematic Reviews as Topic