Table 2 Examples of Context Typology Described in Studies A and B

Study aim: Reduce elective delivery of babies before 39 weeks where no medical indication that early delivery is required

Study aim: Improve identification of high risk patients in Emergency Department to ensure treatments are delivered in a timely manner

Use of QI&I approach to support navigate and negotiate change

Type 1 Setting(s) of care in which a project takes place

Analysis of incidents of deliveries before 39 weeks gestation without a clear indication enabled a team to identify systemic operational issues related to ability to schedule deliveries on a weekend:

Developing an intervention to appropriately screen the local patient population required many iterative tests of change to ensure it was working effectively:

“We have a situation where we do not have operational support to do elective induction and delivery and C-sections on the weekends. And we are building a coalition to get the operational support around that...” C2 (coaching call),Org 1, Study A

“So there was a best practice alert [triggering at risk patients on arrival to Emergency Department], and we had it on in the background for two months, just testing it and nobody saw it…We would get data and... we would say these patients triggered, were they really the right patients to trigger? And then we continued to tweak the tool…”P23 (QI specialist), Org 9, Study B

Influence of context on effective use of structured QI&I approach

Type 2 Project specific supporting context

Success in eliminating early elective deliveries necessitates buy-in from the obstetrical physicians; therefore, having the right QI team members to effectively engage with physicians was critical to test changes and learn what challenges were being faced:

Developing an effective screening tool required the QI team to obtain feedback from frontline staff on any problems experienced in practice. Staff knew their concerns would be listened to and this influenced their willingness to engage in test of changes:

“Physician support was really instrumental because I think if it was just coming from nursing or clerically from a secretary, there’s just no way, there would have been no buy-in.” P6 (QI team leader), Org 4, Study A

“Yes, I do think that we [staff] are listened to…Because any time I’ve sent an email, or I’ve said I feel like I’ve had trouble with, like if I’m screening somebody and there’s a problem, I get immediate email back that they’ve looked into it. Which I think is great.” P25 (nurse), Org 9, Study B

Type 3 General QI&I supporting context

The extent to which the organisation and microsystem had a general culture of providing standardised care influenced the ease of introducing the specific 39 week care standard:

In introducing the best practice alert screening system the QI team reflected how general QI capability among staff facilitated tests of change and how this had been influenced by organisational QI leadership:

“We really try hard to standardize everything… we really do try to structure everything and standardize it, make everything as fair as possible… just having a lot of policies and protocols in place, so that we’re always doing the same thing for one patient as we would the next...” P6 (QI team leader), Org 4, Study A

“I’m continually impressed by how much everybody actually knows [about QI methods]… So the barrier in terms of explaining things is not as high…

…the fact that they are familiar with QI methods and run charts…it comes from the CEO on down …. it’s very common language.” P24 (QI specialist), Org 9, Study B

“They don’t believe in it [standardization]. Absolutely. Yes, it is the Achilles heel.” P7 (OB Lead), Org 5, Study A