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An exploratory analysis of the Model for Understanding Success in Quality

Kaplan, Heather C.; Froehle, Craig M.; Cassedy, Amy; Provost, Lloyd P.; Margolis, Peter A.

doi: 10.1097/HMR.0b013e3182689772

Background: Experience suggests that differences in context produce variability in the effectiveness of quality improvement (QI) interventions. However, little is known about which contextual factors affect success or how they exert influence.

Purpose: Using the Model for Understanding Success in Quality (MUSIQ), we perform exploratory quantitative tests of the role of context in QI success.

Methodology: We used a cross-sectional design to survey individuals participating in QI projects in three settings: a pediatric hospital, hospitals affiliated with a state QI collaborative, and organizations sponsoring participants in an improvement advisor training program. Individuals participating in QI projects completed a questionnaire assessing contextual factors included in MUSIQ and measures of perceived success. Path analysis was used to test the direct, indirect, and total effects of context variables on QI success as hypothesized in MUSIQ.

Findings: In the 74 projects studied, most contextual factors in MUSIQ were found to be significantly related to at least one QI project performance outcome. Contextual factors exhibiting significant effects on two measures of perceived QI success included resource availability, QI team leadership, team QI skills, microsystem motivation, microsystem QI culture, and microsystem QI capability. There was weaker evidence for effects of senior leader project sponsors, organizational QI culture, QI team decision-making, and microsystem QI leadership. These initial tests add to the validity of MUSIQ as a tool for identifying which contextual factors affect improvement success and understanding how they exert influence.

Practice Implications: Using MUSIQ, managers and QI practitioners can begin to identify aspects of context that must be addressed before or during the execution of QI projects and plan strategies to modify context for increased success. Additional work by QI researchers to improve the theory, refine measurement approaches, and validate MUSIQ as a predictive tool in a wider range of QI efforts is necessary.

Heather C. Kaplan, MD, MSCE, is Assistant Professor, Perinatal Institute, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Ohio. E-mail:

Craig M. Froehle, PhD, MBA, is Associate Professor, Carl H. Lindner College of Business, University of Cincinnati; James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Ohio.

Amy Cassedy, PhD, is Research Associate, Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center,Ohio.

Lloyd P. Provost, MS, is Consultant, Associates in Process Improvement, Austin, Texas.

Peter A. Margolis, MD, PhD, is Professor, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical, Ohio.

Support was provided by the Robert Wood Johnson Foundation Grant 65149.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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