Assessing the applicability of the Model for Understanding Success in Quality (MUSIQ) for primary care: a multi-case mixed methods analysis
Jane Cullen
1 2 * , Nihal Jayamaha 3 , Paul Childerhouse 4 , Lynn McBain 5
1
2
3
4
5
Handling Editor: Tim Stokes
Abstract
Effective quality improvement (QI) is vital to improve healthcare quality and outcomes. The context surrounding QI has a dynamic relationship that impacts QI efforts over time. Developing an understanding of context may provide opportunities to address barriers to success. Most studies into contextual influences have been conducted in secondary care. Primary care is key to improving population health, equity and value. The Model for Understanding Success in Quality (MUSIQ) is a commonly used context assessment tool that was developed in large, mainly secondary care organisations, and questions have been raised as to its applicability in primary care.
This study aims to assess the applicability of the MUSIQ in primary care settings and suggest adaptations for primary care.
A multi-case mixed methods approach was followed with quantitative data from the MUSIQ survey tool, compared with qualitative data from Aotearoa New Zealand primary care interviews. The Consolidated Framework for Implementation Research (CFIR) guided qualitative data collection and analysis.
Scores were duplicated between common microsystem and organisational factors. External motivation created mixed reactions and scores depending on interpretation, but consistent themes of community responsibility and network relationships were identified as strengths. A lack of QI infrastructure and triggering events were consistent findings.
Total MUSIQ scores were impacted by scores given for factors at different MUSIQ levels that are combined in many primary care organisations. A primary care adaptation of MUSIQ is proposed that removes the duplicated levels and adds key primary care contextual factors not included in MUSIQ.
Keywords: barriers and facilitators, context, general practice, implementation science, model for understanding success in quality, MUSIQ, primary care, quality improvement.
References
1 Braithwaite J, Glasziou P, Westbrook J. The three numbers you need to know about healthcare: the 60-30-10 Challenge. BMC Med 2020; 18: 102.
| Crossref | Google Scholar | PubMed |
2 Doty MM, Tikkanen RS, FitzGerald M, et al. Income-related inequality in affordability and access to primary care in eleven high-income countries. Health Aff 2021; 40: 113-120.
| Crossref | Google Scholar | PubMed |
3 Bate P, Robert G, Fulop N, et al. Perspectives on context: A selection of essays considering the role of context in successful quality improvement. London: Health Foundation; 2015. Available at https://www.health.org.uk/publications/perspectives-on-context
4 Kao LS. Implementation science and quality improvement. In Success in Academic Surgery: Health Services Research. Springer; 2014. pp. 85–100. 10.1007/978-1-4471-4718-3_8.
5 Van Kemenade E. Patterns emerging from the TQM paradigm in relation to the 21st century complex context within TQM journal. TQM J 2022; 34(3): 494-514.
| Crossref | Google Scholar |
6 Ovretveit J, Mittman B, Rubenstein L, et al. Using implementation tools to design and conduct quality improvement projects for faster and more effective improvement. Int J Health Care Qual Assur 2017; 30(8): 755-768.
| Crossref | Google Scholar | PubMed |
7 Dewan M, Parsons A, Tegtmeyer K, et al. Contextual factors affecting implementation of in-hospital pediatric CPR quality improvement interventions in a resuscitation collaborative. Pediatr Qual Saf 2021; 6: 455.
| Crossref | Google Scholar | PubMed |
8 Kaplan HC, Froehle CM, Cassedy A, et al. An exploratory analysis of the model for understanding success in quality. Health Care Manage Rev 2013; 38: 325-338.
| Crossref | Google Scholar | PubMed |
9 Ovretveit J, Mittman B, Rubenstein L, et al. Using implementation tools to design and conduct quality improvement projects for faster and more effective improvement. Int J Health Care Qual Assur 2017; 30(8): 755-768.
| Crossref | Google Scholar | PubMed |
10 Reed JE, Kaplan HC, Ismail SA. A new typology for understanding context: qualitative exploration of the model for understanding success in quality (MUSIQ). BMC Health Serv Res 2018; 18: 584.
| Crossref | Google Scholar | PubMed |
11 Coles E, Wells M, Maxwell M, et al. The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting? Protocol for a realist review. Syst Rev 2017; 6: 168.
| Crossref | Google Scholar | PubMed |
12 Douglas LC, Heo M, Azad N, et al. Contextual factors associated with quality improvement success in a multi-site ambulatory setting. J Healthc Qual 2019; 41: 317-328.
| Crossref | Google Scholar | PubMed |
13 Kaplan HC, Provost LP, Froehle CM, et al. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf 2012; 21: 13-20.
| Crossref | Google Scholar | PubMed |
14 National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press; 2021. 10.17226/25983
15 Auraaen A, Slawomirski L, Klazinga N The Economics of Patient Safety in Primary and Ambulatory Care: Flying Blind. OECD Health Working Papers. OECD; 2018. 10.1787/baf425ad-en
16 Crabtree BF, Nutting PA, Miller WL, et al. Primary care practice transformation is hard work: insights from a 15-year developmental program of research. Med Care 2011; 49: S28-S35.
| Crossref | Google Scholar | PubMed |
17 Fiscella K, McDaniel SH. The complexity, diversity, and science of primary care teams. Am Psychol 2018; 73: 451-467.
| Crossref | Google Scholar | PubMed |
18 Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci 2016; 11: 40.
| Crossref | Google Scholar | PubMed |
19 Birken SA, Rohweder CL, Powell BJ, et al. T-Cast: an implementation Theory Comparison and Selection Tool. Implement Sci 2018; 13: 143.
| Crossref | Google Scholar | PubMed |
20 Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of Health Services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50.
| Crossref | Google Scholar | PubMed |
21 Flottorp SA, Oxman AD, Krause J, et al. A checklist for identifying determinants of practice: a Systematic Review and Synthesis of Frameworks and Taxonomies of Factors that prevent or enable improvements in Healthcare Professional Practice. Implement Sci 2013; 8: 35.
| Crossref | Google Scholar | PubMed |
22 Nilsen P, Birken, SA Handbook on Implementation Science. Edward Elgar Publishing; 2020. 10.4337/9781788975995
23 Stange K, Glasgow R Considering and reporting important contextual factors in research on the patient-centered medical home. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Available at www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/contextual-factors.pdf
24 Tabak RG, Khoong EC, Chambers DA, et al. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med 2012; 43(3): 337-350.
| Crossref | Google Scholar | PubMed |
25 Nilsen P, Bernhardsson S. Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res 2019; 19(1): 189.
| Crossref | Google Scholar | PubMed |
26 Brennan SE, Bosch M, Buchan H, et al. Measuring organizational and individual factors thought to influence the success of quality improvement in Primary Care: a systematic review of instruments. Implement Sci 2012; 7: 121.
| Crossref | Google Scholar | PubMed |
27 Birken SA, Powell BJ, Shea CM, et al. Criteria for selecting Implementation Science Theories and Frameworks: results from an international survey. Implement Sci 2017; 12: 124.
| Crossref | Google Scholar | PubMed |
28 Skolarus TA, Lehmann T, Tabak RG, et al. Assessing citation networks for dissemination and implementation research frameworks. Implement Sci 2017; 12: 97.
| Crossref | Google Scholar |
29 Garbutt JM, Dodd S, Walling E, et al. Barriers and facilitators to HPV vaccination in primary care practices: a mixed methods study using the Consolidated Framework for Implementation Research. BMC Fam Pract 2018; 19: 53.
| Crossref | Google Scholar | PubMed |
30 Ilott I, Gerrish K, Booth A, et al. Testing the Consolidated Framework for Implementation Research on health care innovations from South Yorkshire. J Eval Clin Pract 2013; 19: 915-924.
| Crossref | Google Scholar | PubMed |
31 Keith RE, Crosson JC, O’Malley AS, et al. Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a Rapid-Cycle Evaluation Approach to improving implementation. Implement Sci 2017; 12: 15.
| Crossref | Google Scholar | PubMed |
32 Kowalski CP, Veeser M, Heisler M. Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption. BMC Fam Pract 2018; 19: 109.
| Crossref | Google Scholar | PubMed |
33 McHugh M, Brown T, Liss DT, et al. Practice facilitators’ and leaders’ perspectives on a facilitated quality improvement program. Ann Fam Med 2018; 16: S65-S71.
| Crossref | Google Scholar | PubMed |
34 Meyers D, Miller T, Genevro J, et al. EvidenceNOW: balancing primary care implementation and implementation research. Ann Fam Med 2018; 16: S5-S11.
| Crossref | Google Scholar | PubMed |
35 Oetzel J, Ngawati R, Penetito-Hemara D, et al. Facilitators and barriers for implementation of health programmes with Māori communities. Implement Sci Commun 2024; 5(1): 26.
| Crossref | Google Scholar |
36 Stokes T, Tumilty E, Doolan-Noble F, et al. HealthPathways implementation in a New Zealand health region: a qualitative study using the Consolidated Framework for Implementation Research. BMJ Open 2018; 8: e025094.
| Crossref | Google Scholar | PubMed |
37 Kirk MA, Kelley C, Yankey N, et al. A systematic review of the use of the consolidated framework for implementation research. Implement Sci 2015; 11: 72.
| Crossref | Google Scholar | PubMed |
38 Wilson WJ, Jayamaha N, Frater G. The effect of contextual factors on quality improvement success in a lean-driven New Zealand healthcare environment. Int J Lean Six Sigma 2018; 9(2): 199-220.
| Crossref | Google Scholar |
39 Tomoaia-Cotisel A, Scammon DL, Waitzman NJ, et al. Context matters: the experience of 14 research teams in systematically reporting contextual factors important for practice change. Ann Fam Med 2013; 11 Suppl 1(Suppl 1): S115-S123.
| Crossref | Google Scholar | PubMed |
40 Griffin A, McKeown A, Viney R, et al. Revalidation and quality assurance: the application of the MUSIQ framework in independent verification visits to healthcare organisations. BMJ Open 2017; 7: e014121.
| Crossref | Google Scholar | PubMed |
41 Barson S, Doolan-Noble F, Gray J, et al. Healthcare leaders’ views on successful quality improvement initiatives and context. J Health Organ Manag 2017; 31: 54-63.
| Crossref | Google Scholar | PubMed |
42 Kringos DS, Sunol R, Wagner C, et al. The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. BMC Health Serv Res 2015; 15: 277.
| Crossref | Google Scholar | PubMed |
43 Reed J, Ramaswamy R, Parry G, et al. Context matters: adapting the Model for Understanding Success in Quality Improvement (MUSIQ) for low and middle income countries. Implement Sci 2017; 12(48): 23.
| Crossref | Google Scholar |
44 Durie M, Hoskins TK, Jones A. Interview: Kaupapa Maori: shifting the social. N Z J Educ Stud 2012; 47(2): 21.
| Google Scholar |
45 Cullen J, Childerhouse P, McBain L. Contextual antecedents of quality improvement: a comparative case study in rural, urban and Kaupapa Māori general practice. J Prim Health Care 2022; 14: 179-186.
| Crossref | Google Scholar | PubMed |
46 Cullen J, Childerhouse P, Jayamaha N, et al. Developing a model for primary care quality improvement success: a comparative case study in rural, urban and Kaupapa Māori organisations. J Prim Health Care 2023; 15: 333-342.
| Crossref | Google Scholar | PubMed |
47 Lanham HJ, Palmer RF, Leykum LK, et al. Trust and reflection in primary care practice redesign. Health Serv Res 2016; 51: 1489-1514.
| Crossref | Google Scholar | PubMed |
48 Larkins S, Carlisle K, Turner N, et al. At the grass roots level it’s about sitting down and talking’: exploring quality improvement through case studies with high-improving Aboriginal and Torres Strait Islander primary healthcare services. BMJ Open 2019; 9: e027568.
| Crossref | Google Scholar | PubMed |
49 Coombe CM, Chandanabhumma PP, Bhardwaj P, et al. A Participatory, Mixed Methods Approach to define and measure partnership synergy in long-standing equity focused CBPR partnerships. Am J Community Psychol 2020; 66(3–4): 427-438.
| Crossref | Google Scholar | PubMed |
50 Avby G, Kjellström S, Andersson Bäck M. Tending to innovate in Swedish primary health care: a qualitative study. BMC Health Serv Res 2019; 19: 42.
| Crossref | Google Scholar |
51 Middleton L, Dunn P, O’Loughlin C, et al. Taking Stock: Primary care innovation. A report for the New Zealand Productivity Commission. Wellington, New Zealand: Victoria University of Wellington, Health Services Research Centre; 2018. Available at https://www.treasury.govt.nz/sites/default/files/2024-05/pc-inq-ssp-taking-stock-primary-care-innovation-victoria-university-wellington-v2.pdf
52 Damschroder LJ, Reardon CM, Widerquist M, et al. The updated consolidated framework for implementation research based on user feedback. Implement Sci 2022; 17: 75.
| Crossref | Google Scholar | PubMed |
54 Parchman ML, Anderson ML, Coleman K, et al. Assessing quality improvement capacity in primary care practices. BMC Fam Pract 2019; 20: 103.
| Crossref | Google Scholar | PubMed |
55 Leite H, Radnor Z, Bateman N. Meaningful inhibitors of the lean journey: a systematic review and categorisation of over 20 years of literature. Prod Plan Control 2020; 33(5): 403-426.
| Crossref | Google Scholar |
56 Hashim MJ. Principles of family medicine and general practice–defining the five core values of the specialty. J Prim Health Care 2016; 8(4): 283-287.
| Crossref | Google Scholar | PubMed |
57 Lim S, Islam NS. Small Practices, Big (QI) Dreams: customizing Quality Improvement (QI) efforts for under-resourced Primary Care Practices to improve diabetes disparities. JMIR Diabetes 2022; 7: e23844.
| Crossref | Google Scholar | PubMed |
58 Knight AW, Dhillon M, Smith C, et al. A quality improvement collaborative to build improvement capacity in regional primary care support organisations. BMJ Open Qual 2019; 8: e000684.
| Crossref | Google Scholar | PubMed |
