A Practical Guide to Assessing and Addressing Context in Quality Improvement

This article highlights the often underestimated influence of context in improving the quality of inpatient pediatric care. Context includes environmental, social, cultural, and systemic factors that surround and influence health care service delivery and intervention outcomes. Underappreciation for context can be responsible for the lack of intervention success in improving patient outcomes and can lead to differences in outcomes when initiatives are replicated or spread across health care settings. We draw from the field of implementation science (IS) to highlight essential concepts for measuring context, emphasizing the need for a comprehensive, multifaceted approach to address context effectively. Quality improvement (QI) and IS are complementary disciplines that share a common goal of improving health outcomes. They often engage the same stakeholders in similar environments, addressing overlapping challenges. Whereas QI is usually an "inside job" with practitioners deeply embedded in the context they seek to improve, IS seeks to understand how to implement evidence-based practices across varied contexts unfamiliar to those leading the implementation. This lack of familiarity with the context makes measuring and adapting to context a primary focus in IS. Recognizing that context influences how well interventions work, implementation scientists use frameworks to conceptualize, measure, and adapt to diverse contexts effectively. These frameworks help ensure interventions are appropriately tailored to the specific environments to achieve the desired outcomes. In this article, we introduce one such framework, the Practical Robust Implementation and Sustainability Model (PRISM). Organized by PRISM domain, we outline a multifaceted approach for improvers to address context comprehensively, which, at a minimum, includes clinical and community partner engagement, diverse QI team composition, and iterative data-driven adaptations to dynamic contextual factors. Addressing context should improve QI success, patient outcomes, and the replication of initiatives.