Table 1.

New context factors

New Factor	Description	Representative Quotation(s)
External	The extent to which the team or organisation values and acquires QI&I knowledge from external sources (e.g. publications, other QI&I organisations)	“… then learning from others as well... our institution is always looking at what others are doing, how can we learn from others and, you know, … no one person is doing any of this... we have a whole team looking at evidence and measures, and they’re learning from people.” (P22 (senior QI manager) Org 9 Study B)
External Knowledge (general QI&I)
External	The extent to which the team or organisation values and acquires project related knowledge from external sources (e.g. guidelines, other project teams, other hospitals)	“… with those, the forms that we created and we just kind of modelled that after some of the forms that we saw … we just kind of took things that other institutions were doing to create our own form” (P6 (QI team leader),Org 4, Study A)
External Knowledge (project specific)
Infrastructure	The extent to which an organisation has a system for managing multiple QI&I projects including processes for selecting projects and appropriate QI&I methods to use	“I think we struggle a lot with that balance, and so we… do hold back and really are careful when we decide we do want to test something, because we have multiple improvement projects going on in the same area. So, we need to know which ones overlap…in which ways, how will they then affect the other tests and ultimately the patient, and so we… We have to make a very conscious effort to limit some of our testing.” (P23 (QI specialist) Org 9 Study B)
QI&I Portfolio Management
		“…we basically are following three different sets of guidelines out there [Medicare, state collaborative, Joint Commission]… And it makes it even very hard for our quality management department because we have to remember which one we are reporting for and which set of guidelines we are using for our numerator and denominator definitions.” (P2 (QI team leader),Org 1, Study A)
Infrastructure	The availability, expertise and experience of staff with specialist or high levels of QI&I knowledge and skills	“We did have very specific and trained teams…who had one of three roles – they were either a process person, to help with process improvement, or they were an [electronic health record (EHR)] analyst, to help with the [EHR] changes, or they were a data requirements person, to help with writing and programming all of the measures.” (P22 (senior QI manager), Org 9, Study B)
Specialist QI&I Staff
		“Definitely, [Quality Department staff]… The fact that she was willing to be part of the team, she did a lot of work …pulling everything together.” (P9 (QI team leader), Org 6, Study A)
Microsystem	Microsystem staff’s collective potential for delivering care and executing QI&I projects	“…Simultaneous changes happening at once. It’s really… It’s very challenging to keep track of all that when you’re working and that is happening as well as taking care of large volumes of patients...So it’s not just all of your responsibilities and duties of your day, but then you have to keep in mind of all these other things that you need to do for that day as well….I think sometimes it just gets so incredibly busy that it either gets away from you or you just can’t fit another thing on your plate. I mean, you know, and that’s the reality of it.” (P25(nurse), Org 9, Study B)
Microsystem Capacity (project specific)
		“… The process needs to be something that they can fit into what they do every day. And it can’t be in addition to. You know, if all of a sudden you’re going to say to somebody, I know you’re really, really busy, but I want you to do something else as well… and we do that a lot. So if you could just do this as well. And then it doesn’t happen…” (P45 (service manager), Org 10, Study B)
QI&I Team	Contribution of patients, carers and members of the public to the QI&I team efforts	“And then engaging family partners, that’s been one of our priorities…to have a more intentionality around identifying families who wanted to be, or adult patients, who wanted to be partners in the work, and they’re volunteers, but we do have at least two; some teams have more families that are partners.” (P22(senior QI manager), Org 9, Study B)
Patient Engagement & Involvement