What is context and why does it matter?

Too often, promising quality improvement initiatives are shown not to work, or if they do they don’t spread. Why not? Could it be that their design was good, the implementation and evaluation sound, but the context in which they were supposed to operate was too hostile to allow any progress?

The message is simple: alongside the importance of what you do (intervention) and how you do it (implementation), the environment or context that you do it in also matters. It is the interaction between these three elements that makes for success.

Understand the role of context and we grow nearer to understanding how to speed up and spread quality improvement in patient care.

Introducing perspectives on context

In this month’s newsletter we share some of our knowledge and learning about context. Our latest webinar discusses the importance of context and how to manage it, a blog from our Chief Executive Dr Jennifer Dixon presents thoughts on how problems created by context can be overcome, and an interview with our Improvement Science Fellow Tim Draycott explores how gaining a deeper understanding of context could improve how we successfully implement training across the NHS.

This newsletter also introduces our new publication on context. We invited leading academics to define and explore the critical ingredients of ‘context’ and the result is Perspectives on contexts, featuring essays from professors Paul Bate, Glenn Robert, Naomi Fulop, John Ovretveit and Mary Dixon-Woods.

Defining a slippery topic

So, what is ‘context’? Well, if an intervention is a ‘seed’ then the context is the ‘soil’. Some types of intervention are fairly robust in a variety of environments, while others are very sensitive to the type of local soil.

There are many considerations to take into account when defining what type of soil you are dealing with. Understanding context means understanding both the external and internal influences on a healthcare provider or organisation.

External influences on an organisation could be many, but include:

• health policy and national frameworks
• resources
• markets and competition
• service differentiation
• supply and demand
• the role of professions
• social and ideological movements and campaigns
• the availability of therapies, equipment and technology.

And when looking at internal influences on an organisation, these might be, for example:

• its culture and leadership
• its size and scope
• the nature of its ownership
• stability and finances
• care standards and patient satisfaction
• staff skills
• personalities and group psychology.

An awareness of factors such as these is vital, as ignoring context risks wasting resources, money and effort.

So what helps to manage context?

In Perspectives on context, Mary Dixon-Woods suggests we need to harness special types of local knowledge held by key individuals when dealing with context. She refers to this as ‘practical wisdom’ gained by experience, and conjectural knowledge, the kind of ad hoc reasoning required when we need to ‘feel’ the way forward amid uncertainties.

This knowledge is complex, tacit and hard to share, but we need to be able to identify the people who have it, so that the right people are involved in taking an improvement forward.

People have tended to concentrate on developing technical improvement skills within organisations, however the softer skills needed to manage and adapt to your local, organisational and national context are just as important when trying to improve care.

Our new report Skilled for improvement? suggests that there are three sets of skills that are vital for organisations wishing to improve quality: technical skills, soft skills and learning skills.

Andrée le May, one of the report’s authors, said during our recent webinar that to improve care, people need ‘to work out how to persuade other people, how to negotiate, how to weave their way through the political quagmire and context within which they are working’. She identifies negotiation, communication, assertiveness and also influential leadership as some of the key soft skills for successful improvement.

Understand and work with context

As John Ovretveit writes in Perspectives on context, to manage context there are often two broad choices: you can adapt your intervention to context, or adapt context to intervention. However, as our interview with Tim Draycott illustrates, the real trick is to interactively adapt both the intervention, the implementation and context over time. 

His PROMPT training course for maternity units takes current guidance and adapts it to meet the specific context. As it has spread, engagement of all staff has emerged as an important factor – so incentivising staff to attend training can adapt the context and may improve outcomes. In turn, the intervention itself has been adapted and refined year on year to meet changes in context.

By gaining a really deep understanding of context you can put in place strategies which will make quality improvement projects easier to implement.

The way forward

As the NHS reacts to the pressures ahead, we know that the best leaders will be those who can manage dynamic and complex environments with many unknowns, to steer a course towards progress. We also know that there needs to be much more permissive trialling of innovations and improvement projects over the next five years, prioritising those that are likely to have the biggest impact.

We need qualitative and quantitative investigation, with insights on context and impact fed back to frontline service improvers. If our policy-makers can really harness the power that an understanding of ‘context’ can bring, then we can really move forward in improving healthcare.