Development of a Theory for Understanding Engagement in Quality Improvement in Primary Care

Context: Practice redesign and quality improvement (QI) is essential for primary care practices to achieve high quality health care. Studies in non-primary care fields have identified factors that influence engagement in QI work. Less is known about factors that facilitate and inhibit QI work in primary care. Objective: To expand our theoretical understanding of factors that facilitate or inhibit engagement in QI work in primary care. Design: Cross-project evaluation of qualitative and quantitative data collected from 4 QI studies. Comparative analysis conducted. Setting: Primary care practices participating in one of 4 QI studies. Results: We describe a theoretical model that depicts the interrelationship of factors that influence practice engagement in QI work, where QI engagement is defined as the active participation in QI work through allocation of time and deliberate action. Key factors include: 1) Professional status, which refers to the relative position of individuals within the social hierarchy. In primary care, professional status varies widely, from physicians to individuals with high school degrees. 2) Psychological safety, which refers to the sense of safety individuals have within a group. When present, individuals are more likely to be active participants. 3) Leadership behavior, or the actions of those in charge that influence the involvement of others. And 4) The nature of the quality improvement target, meaning whether a target was clinical or administrative. This factor defines who should be involved in the QI process. Our theoretical model suggests that practices able to manage differences in professional status create psychologically safe environments in which QI engagement is more likely to result. Conclusions: Practice redesign and improvement in primary care is founded on the assumption that primary care practices have the capacity to experiment, innovate and change. We offer initial theoretical insight as to how to foster quality improvement work in primary care