Table 3.

Contextual factors

Category	No. of studies	Evidence synthesis				Quality of evidence (ref.)
		Relationship with outcome		Relationship with mechanism		Quantitative and mixed methods	Qualitative and review
1 Healthcare setting in which a QI intervention is introduced
Facility size	N = 1	No	No evidence that hospital size is associated with improvement in outcome.	-	Not discussed.	Medium [42]
Base line performance	N = 1	Yes	Lower base line performance of hospitals is positively associated with magnitude of outcome improvement.	Yes	Lower base line performance is positively associated with active participation in QIC.	Medium [43]
Voluntary or compulsory participation	N = 1	No	No evidence of differences in outcomes.	-	Not discussed.	High [44]
Factors related to health facility readiness	N = 5	Yes/No	Inconclusive evidence of association between programme pre-conditions (staff, resources, usability of health information system systems, measurement data availability and senior level commitment to target) and outcomes.	Yes	Bottom up leadership style may foster more positive perceptions of organisational readiness for change. Limited clinical skills, poor staff morale and few resources negatively associated with outcomes.	Medium [42, 45, 46]; high [47]	Low [48]
2 Project-specific contextual factors
External support	N = 6	Yes	Quality, appropriateness and intensity of quality improvement support positively associated with perceived improvement in outcomes.	Yes	The number of ideas tested by quality improvement teams partly mediates the association between external support and perceived improvement.	Medium [42, 46]; high [49]	Low [48, 50, 51]
Quality improvement team characteristics	N = 4	Yes	Inclusion of opinion leader, team functionality and previous knowledge or experience of quality improvement is positively associated with outcome.	-	Not discussed	Medium [52, 53]; high [49, 54]
3 Wider organisational context and external environment
Leadership characteristics	N = 5	Yes	Supportive leadership is positively associated with perceived improvement in outcomes.	Yes	Supportive leadership may motivate physicians to implement quality improvement and may enable active testing of ideas by quality improvement teams. Lack of supportive leadership may demotivate and stall quality improvement team efforts.	High [49, 54, 55]	Low [51, 56]
Health system alignment	N = 4	-	Not discussed.	Yes	Alignment with national priorities, national-level quality strategy, and incentives systems is essential to enable leadership support.	Medium [46]	Low [48, 50, 51]