Shortfalls in the quality of health care delivery are widely recognized, despite abundant scientific evidence on the right forms of care to provide.1 Providing the right care in the right circumstances to the right individual has proven difficult, however. While reasons for these significant and persisting quality shortfalls are numerous,2,3 there is growing recognition that adoption and implementation of high-quality, evidence-based care rely heavily on the "implementation context," or the setting in which interventions to improve quality are deployed.4-6 In this issue of QMHC, several groups explore the role of context in quality management, from a number of perspectives, and offer measurement strategies that enable future study.

Two articles in this issue present examples of the ways in which context shapes implementation of an intervention to improve the quality of health-related services. In her article on the application of the breakthrough collaborative method in a nonclinical health care setting, Lindgren investigates the influence of professional context. Guided by an organizing framework of factors associated with success, Lindgren describes how participants in a large project adapted traditional breakthrough collaborative techniques to achieve more effective and coordinated delivery of social services to children in Sweden. Similarly, Howe and colleagues describe ways in which the practice of medicine must conform to the needs and preferences of the homeless, as well as the physical, social, and economic contexts in which they live. Howe et al use their findings to propose best practices that address the contextual factors encountered and further suggest 2 possible context-tailored outcomes measures that could be utilized in further development of quality management practices in the field.

In her study on feed forward systems, Hvitfeldt and colleagues take a slightly different approach by comparing factors that facilitate or impede the implementation of a quality tool for decision support and information management in 2 distinctly different health care systems. Using a mixed-methods analysis, we learn that both patients and providers at specialty clinics in the United States and Sweden value many of the same elements of the feed forward system, while expressing comparatively few criticisms. That context seems to have little bearing on the success of the intervention under study may relate to the broad appeal of the system's overarching objective among health care professionals and health care consumers-the promotion of patient-centeredness in health care delivery. Like Hvitfeldt et al, Peterson compares influences on perceived health care quality among rural and urban residents. Despite substantial differences in opportunities and structure, ones that can potentially influence the outcomes of health care delivery, he finds similarities across settings in consumers' overall perception of health care quality.

Two complementary articles in the current issue propose assessment strategies for a feature of primary care practices that appears to drive successful quality improvement--organizational capacity for change. Ruhe et al explain that this contextual characteristic reflects the aggregate willingness and ability of individuals within an organization to modify existing processes or adopt new ones. Based upon previous conceptual work and empirical studies conducted in large health care settings, the study by Ruhe et al focuses on primary care settings, describing qualitative techniques that reveal contextual influences on the capacity for change at "the front lines of health care delivery." They propose that the resulting qualitative data have value in developing context-tailored interventions to promote the delivery of high-quality services. A second article by Bobiak et al describes efforts to develop a quantitative instrument that assesses capacity for change in diverse primary care settings. It is worth noting that the work reported in both articles highlights the importance of initial efforts to understand the organization and function of a setting in which an intervention will be introduced, prior to its implementation. Although this approach is deeply rooted in Deming's original work on the cycle of quality improvement, the articles by Ruhe et al and Bobiak et al are among the first to describe tools that characterize the implementation context of primary care practices.

Similarly, Nystrom applies a broad theoretical perspective to identify organizational characteristics associated with health care units' ability to learn and manage change. As demonstrated by her systematic literature review of the fields of quality improvement, strategic organizational development, change management, organizational learning, and microsystems, the drive to understand contextual influences on adoption and diffusion of change and innovation is clearly not limited to the health care setting. Furthermore, learning can occur not only when we reflect on why something is not working but also when we reflect on our successes, as illustrated in her qualitative study of Swedish health care units, which have received accolades for delivering exceptional care. Change is also the focus of the article by Umar et al, in which influences on the sustainability of quality improvement initiatives in developing countries are considered. Following a search of published reports on projects conducted at the national and regional levels, the authors use qualitative methods to identify emergent themes related to program sustainability across diverse settings. They highlight, for example, the tendency of stakeholders to seek the provision of more care, rather than better care; a pattern of applying quality improvement models first generated and tested in developed countries; and a focus on realizing immediate, high-impact change, rather than on change efforts consistent with local preferences and resource availability.

Finally, Baumgart et al explore the impact of change in an outpatient surgery center's layout on behavioral patterns of work, employing social network analysis of staff interactions to identify improvements and unintended consequences with potential influence on the quality of care delivered. As described, "where handovers are executed influences how handovers are executed." The need for evidence-based facility design, as an often-overlooked contextual element, is illustrated through a mixed methods approach utilized to create a rich understanding of the study setting.

Although all of the contributions to this special issue of QMHC address the topic of "Context and Quality Management," they do so in ways that are as diverse as they are similar. As described, contextual features arise at the country and health system (eg, Germany, Sweden, United States, and others), regional (eg, rural and urban), specialty/professional (eg, health and social care), facility (eg, outpatient surgery unit), and practice/group (eg, primary care practices) levels. As a result, defining a given context is complex-with elements including the physical environment, as well as the culture, climate, structures, systems, and resources available. To better understand contextual influences on the quality of health care delivery and quality management practice, and further to find ways of acknowledging and effectively addressing the diversity encountered, requires greater reflection, study, and dialogue than can be presented in a single journal issue. We hope that the approaches and results described by various groups working in different contexts on distinctive issues will prompt readers to continue a dialogue leading to greater awareness and a deeper understanding of this important theme in quality management.

-David Litaker, MD, PhD

-Mats Brommels, MD, PhD

-Darcey Terris, PhD

Issue Editors

QMHC Editor's Note: In another contextual report, Broyles, Chou, Mattachione, Wild, and Al-Assaf present a study of the relationship between adverse medical events and hospital charges. The 5 patient safety indicators they used in their tests were decubitus ulcer, iatrogenic pneumothorax, postoperative hematoma or hemorrhage, postoperative pulmonary embolism, and postoperative sepsis.

In the context of a multisite radiology department, Nickel and Schmidt explore the effects of changes in such activities as staff scheduling, appointment planning, and transport planning on the promptness and efficiency with which patients were seen and treated.

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