Table 5.

Inter-organisational mechanisms of change

Themes (No. studies)	Evidence synthesis				Quality of Evidence [ref.]
	Description of relationship QIC component–mechanism–outcome			Contextual enablers of mechanism (or barriers)	Quantitative and mixed methods	Qualitative and review
	QIC component	Mechanism of change	Outcome
Shared community of practice (N = 7)	Collaboration with other hospitals	• Sense of community reinforced or created • Increased motivation, by supporting reframing of improvement topic as desirable, urgent and achievable	Health workers motivated and empowered to take action towards common goal	• Settings where a community of practice amongst clinicians exists or can be developed • Barrier: external pressures on hospitals incentivising competition v. collaboration.	Medium [46, 67–69]	Low [17, 50, 63]; medium [67, 69]
Platform for capacity building (N = 5)	Collaboration with other hospitals	• Platform to refine skills for improvement provided • Definition of standard care processes facilitated		• Settings with quality-focused HR systems, e.g. incorporating quality objectives in professional development and performance appraisals • Barrier: high performing hospitals have less to gain from collaboration • Barrier: Collaboration can be undermined by free-riding (not all facilities contribute equally) and social loafing (leaving it to others to support low performing hospitals)	Medium [51, 67–70]	Low [51]; medium [67, 69, 70]
Demonstration role (N = 3)	Collaboration with other hospitals	• Feasibility of improving outcome of focus is demonstrated	Increased engagement in QIC	• Supportive leadership • External support to disseminate success stories • Barrier: Large hospitals may have less to gain from collaboration	Medium [71]	Low [51, 63]
Friendly competition (N = 6)	Collaboration with other hospitals	• Reputational gain from improvement (or conversely risk of non-improvement) at individual and organisational level achieved. • Access to others’ data and benchmarking for internal gains enabled.	Normative pressures to conform (change practice and improve) created.	• Open sharing of data on mutual performance • Alignment with institutional priorities (lack of which contributes to perception that collaboration is stressful and time-consuming) • Geographically dense professional network • Non-hierarchical teams facilitating decentralised decision making • Barrier: competition for financial incentives linked to quality criteria	Medium [47, 66]	Low [17, 63]; medium [69]; high [72]