| Background: Health care quality improvement interventions (QIIs) are influenced by characteristics of the changes they aim to implement, the context within which they are carried out, and the tactics and strategies of the teams carrying them out. A straightforward understanding of these complex dynamics of success and failure in QIIs has remained elusive.;Methods: This qualitative case study compared 19 more and 19 less successful QIIs across a range of clinical and organizational settings, using a common framework that included project origination, organizational characteristics, intervention design and implementation challenges. Design features were categorized according to six levers for change: setting expectations, setting incentives, monitoring performance, evaluating performance, enforcing incentives and building capacity. Implementation challenges were categorized as structural, political, cultural, educational, emotional and physical. Case information was collected through interviews and other project documents. Cases were compared systematically using each dimension of the framework.;Results: Almost all cases attempted to set the expectations and build the capacity of providers and organizations to improve. These steps were necessary, but generally not sufficient; more successful QIIs tended to additionally monitor and evaluate performance. Almost no cases set or enforced explicit incentives. Nine archetypes emerged, illustrating patterns in how QIIs are driven to success or failure by the relative influences of context, intended changes, intervention design and implementation strategy. Five archetypes of failure emerged, including four of design (The Squelched Idea, The Bad Idea, "The Best and the Brightest", The Tragic Hero) and one of implementation (Couldn't Roll with the Punches). Four archetypes of success emerged, including one of implementation (Pounding the Pavement), one of context (The Lucky Strike), and two of design (The Great Idea, The Complete Package).;Conclusions: This research yielded new perspectives for the planning and implementation of QIIs. QII teams should not only set expectations and build capacity for change, but additionally make explicit plans for monitoring and evaluating performance and for addressing stakeholder incentives. Using archetypes to explain, in a digestible way, the complex processes underlying successes and failures will make QII evaluations far more useful to those seeking to create or replicate improvements in different settings. |
