Influence of context on quality improvement priorities: a qualitative study of three facility types in Lagos State, Nigeria.

Background: Quality improvement (QI) collaboratives are increasingly popular. However, there is a need for an in-depth understanding of the influence of context on its implementation. We explored the influence of context on the change concepts considered by public primary (primary health centres), public secondary (public hospitals) and private (private facilities) collaboratives established to improve maternal and newborn health outcomes in Lagos State, Nigeria.

Methods: Between February 2019 and January 2020, we conducted a qualitative study using meeting reports, key informant interviews and participant observation. Data were analysed using the high-quality health system framework for assessing health system and user experience that distinguished three quality domains: quality impacts, processes of care and health system foundations.

Results: Nineteen change concepts and 158 change ideas were observed across 28 facility QI teams. Change concepts and ideas prioritised were influenced by government and non-governmental leaders but ultimately shaped by facility QI capacity, time allocated for QI activities and availability of local data. Of the three quality domains, process of care, including patient satisfaction, received the most attention across facility types. There was considerable variation in the change concepts considered across domains. For example, more public hospitals focused on complication management because of a relatively high prevalence of and capacity to manage maternal complications; primary health centres focused more on complication referrals, while private facilities prioritised revenue generation. Problems with availability of resources were particularly highlighted in primary health centres which had relatively less financial commitment from stakeholders.

Conclusion: Our findings provide insights into QI collaboratives' mechanism of change in which external stakeholders, including government, drove QI priorities for action but the ultimate decisions depended on local realities of facilities. Our findings underscore the need for strong QI leadership and sufficient resources to enable facility QI teams to prioritise change concepts for greater health impact.