BMJ Qual Saf 20:i18-i23 doi:10.1136/bmjqs.2010.045955
  • The structure of improvement knowledge

Understanding the conditions for improvement: research to discover which context influences affect improvement success

Open Access
  1. John Øvretveit
  1. Health Innovation Implementation and Evaluation, Medical Management Centre, The Karolinska Institutet, Stockholm, Sweden
  1. Correspondence to Dr John Øvretveit, Director of Research, Professor of Health Innovation Implementation and Evaluation, Medical Management Centre, The Karolinska Institutet, Floor 5, Berzelius väg 3, Karolinska Institutet, SE-171 77 Stockholm, Sweden; jovret{at}
  • Accepted 29 October 2010


Context can be defined as all factors that are not part of a quality improvement intervention itself. More research indicates which aspects are ‘conditions for improvement’, which influence improvement success. However, little is known about which conditions are most important, whether these are different for different quality interventions or whether some become less or more important at different times in carrying out an improvement. Knowing more about these conditions could help speed up and spread improvements and develop the science. This paper proposes ways to build knowledge about the conditions needed for different changes, and to create conditional-attribution explanations to provide qualified generalisations. It describes theory-based, non-experimental research designs. It also suggests that ‘practical improvers’ can make their changes more effective by reflecting on and revising their own ‘assumption-theories’ about the conditions which will help and hinder the improvements they aim to implement.


  • Funding The research on which this paper is based draws on studies of total quality management implementation in Norwegian hospitals funded by the Norwegian Medical Association5 43; studies of 12 innovations in Swedish healthcare funded by VINNOVA (Swedish Governmental Agency for Innovation Systems) and The Vårdal Foundation, Sweden31; a study of the Jönköping county improvement programme in Sweden44; studies of 10 Netherlands national quality improvement programmes funded by ZonMw (The Netherlands Organisation for Health Research and Development)45 and a study of the context sensitivity of patient safety practices funded by the Agency for Healthcare Research and Quality7 in which the author participated, as well as experience gained by advising and evaluating different quality improvement projects and programmes in different health systems. The ideas expressed in this paper are the author's personal conclusions from this research and should not be taken to reflect those of the funding organisations of any of these studies or other researchers.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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