How is practitioner-led quality and safety improvement sustained across a whole hospital? A process evaluation of a practice development programme

Building frontline workforce capability to sustain quality and safety improvement across whole hospitals is a strategic priority for healthcare leadership. The principles are well established; how to enact and sustain them at scale is not. Practice development, a participatory approach to workforce transformation, has not been evaluated at hospital-wide scale.

To develop and refine programme theories explaining how and why a hospital-wide practice development programme for quality and safety produces its effects in different settings, and to identify the conditions under which practice development mechanisms work, and fail to work, at hospital-wide scale.

This study was a qualitative process evaluation at a major Australian tertiary referral hospital where nursing leaders implemented a Quality Safety Culture Framework across all 41 acute-care units over 6 years. Practice development theory provided the sensitising framework; the empirical material was used to challenge rather than confirm its assumptions. Fieldwork comprised 27 interviews with nursing, medical, allied health, and executive staff; 6 half-day workshops with 49 frontline staff; a multidisciplinary focus group; and approximately 20 h of observations. Four tentative programme theories were developed prior to analysis. Abductive analysis foregrounded theoretical surprise through sustained dialogue between fieldwork and existing theory; within-programme variation provided the analytical structure.

The same programme simultaneously produced sustained participatory quality and safety improvement in some settings and directive compliance in others. Five refined programme theories specify the conditions for enactment: how data are used for learning rather than accountability; whether communicative space is sustained as an organisational precondition; what facilitators actually do; whether leadership creates organisational enablement without prescribing what fills it; and how collaborative prioritisation prevents project proliferation from undermining engagement. Implementation drift from participatory towards directive processes was concentrated in the facilitation pipeline, driven by governance logics that systematically favour measurable quality improvement outputs over relational and cultural processes.

Organisational enablement is necessary but insufficient to sustain participatory practice. Even with genuine participatory design intent, governance infrastructure built to reward measurable outputs can systematically displace participatory processes. The five theories specify the conditions required to sustain participatory approaches at scale and offer practical guidance for hospital leadership teams.