Hello Stephen!

Glad that you appreciated the article. Sorry that we cannot meet in Ghana at the CHEPSAA meeting to discuss more on this subject! But you may find something interesting on the subject also in the articles: 1) Change and learning strategies in large scale change programs: Describing the variation of strategies used in a health promotion program; 2) Challenges in managing a multi-sectoral health promotion program; 3) Organizational coherence in health care organizations: conceptual guidance to facilitate quality improvement and organizational change and 4) Characteristics of health care organizations associated with learning and development: lessons from a pilot study. They all concern aspects to consider when trying to imlement improvements in Health and social care. You can download the papers on my Research Gate page. There are of course so many more important articles than these - but in the reference lists you will probably find some more influential papers that will help answering your question. Kind regards, Monica Nyström

Hi Monica

Indeed its unfortunate we are not meeting in Nigeria to caucus on this issue which is at the heart of my mandate at the moment. But ICT revolution has made matters light for us.

Thanks for sharing these articles. I have already visited your RG page and read the second article which brings out the element of factors outside the providers. This concurs with a quote of one author writing about quality improvement that "the problem is not the individual but the system and processes" And your article brings out the element of behavior, which is quite real. That is why factoring change management is so crucial, but just how do you grow and harvest change agents in contexts where health personnel are overstretched.

We are currently collaborating in an intervention to develop a national quality improvement strategy. For me specifically I have to identify quality improvement ideas around service delivery e.g. prevention of mother to child transmission of HIV (PMTCT), maternal neonatal and child health (MNCH), emergency obstetric care (EOC), HIV counseling and testing (HCT), and design appropriate training strategy and mentorship.

Talking about your article on coordination and conflict, I think that the creation of additional structures, which is of advantage, can also provide a challenge if there is no adequate resource allocation as well as dedicated time

When considering issues like conflicts of interest and change fatigue in quality improvement (QI), it is also helpful to consider the politics of QI. One of my favourite articles on this is "Beyond Evidence: The Micropolitics of Improvement" by Ann Langley & Jean-Louis Denis: http://qualitysafety.bmj.com/content/20/Suppl_1/i43.full. The article draws attention to interests, values and power relationships - and how the costs and benefits of QI are distributed. These issues are likely even more pronounced in low-resource settings.

We identified via literature review, 7 common contextual factors key to implementation of the QI programme Productive Ward http://onlinelibrary.wiley.com/doi/10.1111/jonm.12069/abstract A larger review of Lean Healthcare including PW citations we identified 3 main components cited as common impacts... Leadership, empowerment & engagement http://www.emeraldinsight.com/journals.htm?articleid=17102117 The most indepth study of all is from Mary Dixon-Woods http://qualitysafety.bmj.com/content/early/2012/04/27/bmjqs-2011-000760