What to write
Contextual elements considered important at the outset of introducing the intervention(s)
Explanation
Context is known to affect the process and outcome of interventions to improve the quality of healthcare.1 This section of a report should describe the contextual factors that authors considered important at the outset of the improvement initiative. The goal of including information on context is twofold. First, describing the context in which the initiative took place is necessary to assist readers in understanding whether the intervention is likely to ‘work’ in their local environment, and, more broadly, the generalisability of the finding. Second, it enables the researchers to examine the role of context as a moderator of successful intervention(s). Specific and relevant elements of context thought to optimise the likelihood of success should be addressed in the design of the intervention, and plans should be made a priori to measure these factors and examine how they interact with the success of the intervention.
Describing the context within the methods section orients the reader to where the initiative occurred. In single-centre studies, this description usually includes information about the location, patient population, size, staffing, practice type, teaching status, system affiliation and relevant processes in place at the start of the intervention, as is demonstrated in the first example by Dandoy et al2 reporting a QI effort to reduce monitor alarms. Similar information is also provided in aggregate for multicentre studies. In the second example by Duncan et al,3 a table is used to describe the practice characteristics of the 21 participating paediatric primary care practices, and includes information on practice type, practice setting, practice size, patient characteristics and use of an electronic health record. This information can be used by the reader to assess whether his or her own practice setting is similar enough to the practices included in this report to enable extrapolation of the results. The authors state that they selected practices to achieve diversity in these key contextual factors. This was likely done so that the team could assess the effectiveness of the interventions in a range of settings and increase the generalisability of the findings.
Any contextual factors believed a priori would impact the success of their intervention should be specifically discussed in this section. Although the authors’ rationale is not explicitly stated, the example suggests that they had specific hypotheses about key aspects of a practice’s context that would impact implementation of the interventions. They addressed these contextual factors in the design of their study in order to increase the likelihood that the intervention would be successful. For example, they stated specifically that they selected practices with previous healthcare improvement experience and strong physician leadership. In addition, the authors noted that practices were recruited through an existing research consortium, indicating their belief that project sponsorship by an established external network could impact success of the initiative. They also noted that practices were made aware that American Board of Pediatrics Maintenance of Certification Part 4 credit had been applied for but not assured, implying that the authors believed incentives could impact project success. While addressing context in the design of the intervention may increase the likelihood of success, these choices limit the generalisability of the findings to other similar practices with prior healthcare improvement experience, strong physician leadership and available incentives.
This example could have been strengthened by using a published framework such as the Model for Understanding Success in Quality (MUSIQ),4 Consolidated Framework for Implementation Research (CFIR),1or the Promoting Action on Research Implementation in Health Services (PARiHS) model5 to identify the subset of relevant contextual factors that would be examined.4,6 The use of such frameworks is not a requirement but a helpful option for approaching the issue of context. The relevance of any particular framework can be determined by authors based on the focus of their work—MUSIQ was developed specifically for microsystem or organisational QI efforts, whereas CFIR and PARiHS were developed more broadly to examine implementation of evidence or other innovations.
If elements of context are hypothesised to be important, but are not going to be addressed specifically in the design of the intervention, plans to measure these contextual factors prospectively should be made during the study design phase. In these cases, measurement of contextual factors should be clearly described in the methods section, data about how contextual factors interacted with the interventions should be included in the results section, and the implications of these findings should be explored in the discussion. For example, if the authors of the examples below had chosen this approach, they would have measured participating team’s’ prior healthcare improvement experience and looked for differences in successful implementation based on whether practices had prior experience or not. In cases where context was not addressed prospectively, authors are still encouraged to explore the impact of context on the results of intervention(s) in the discussion section.
Examples
Example 1
CCHMC (Cincinnati Children’s Hospital Medical Center)is a large, urban pediatric medical center and the Bone Marrow Transplant (BMT) team performs 100 to 110 transplants per year. The BMT unit contains 24 beds and 60–70% of the patients on the floor are on cardiac monitors…The clinical providers…include 14 BMT attending physicians, 15 fellows, 7 NPs (nurse practitioners), and 6 hospitalists…The BMT unit employs ∼130 bedside RNs (registered nurses) and 30 PCAs(patient care assistants). Family members take an active role…2
Example 2
Pediatric primary care practices were recruited through the AAP QuIIN (American Academy of Pediatrics Quality Improvement Innovation Network) and the Academic Pediatric Association’s Continuity Research Network. Applicants were told that Maintenance of Certification (MOC) Part 4 had been applied for, but was not assured. Applicant practices provided information on their location, size, practice type, practice setting, patient population and experience with quality improvement (QI) and identified a 3-member physician-led core improvement team. …. Practices were selected to represent diversity in practice types, practice settings, and patient populations. In each selected practice the lead core team physician and in some cases the whole practice had previous QI experience…table 1 summarizes practice characteristics for the 21 project teams.3
Training
The UK EQUATOR Centre runs training on how to write using reporting guidelines.
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