Cake and tigers – context matters for primary care quality improvement success

1 Nov 2017 | Primary Care
Tagged Primary Care

Tiger tea


If you have children or grand-children you may have read books like Hazel Edwards’ There’s a hippopotamus on our roof eating cake or Judith Kerr’s The tiger who came to tea. The thought of a tiger or hippopotamus doing something so out of context but acting like it’s all normal, business as usual, works really well (for adults and children). So there is something about context (or the polar opposite) that influences success and has ensured these two books have become ‘classics’ compared with thousands of others.

So what has this to do with quality improvement in health care?

Quality improvement initiatives in health have become widespread but, like children’s books, some are successful and some are not. This variability is strongly influenced by differences in context and the setting involved.

Context can relate to: an organisation’s culture and its motivation for change; leadership within teams and from senior management; the quality improvement resources and training available; and the individual skills in an organisation. The setting includes things like the information technology available, current health policy and other environmental factors.

The good news is experts have identified the most important contextual factors that impact on the success of a quality improvement effort and have condensed them into one model – the Model for Understanding Success in Quality (MUSIQ)1.

We’ve been thinking about how the model can best be applied to New Zealand primary care as there may be many interconnected systems involved (eg, pharmacies, general practices, primary health organisations, non-governmental organisations, aged residential care and secondary services).

Box 1 blogUsing the MUSIQ tool for the successful Whakakotahi primary care improvement challenge projects has shown the diversity of the teams and organisations.

Encouraging each project team to score themselves according to contextual factors (see Box 1) before and after their quality improvement initiative will provide important learnings for primary care. It will also help inform how, when and where building quality improvement capability and capacity will be most effective.

Then, hopefully, like cake and tigers, our quality improvement initiatives in New Zealand primary care will become classics.

Author: Dr Susan Wells is a member of the Commission's Primary Care expert advisory group. and the programme's clinical advisor. Sue's contributions offer insights on the context for primary care quality improvement success. Sue works as an Associate Professor of Health Innovation and Quality Improvement at the School of Population Health, University of Auckland, and before becoming a public health medicine specialist was a GP for 10 years.

1. Kaplan HC, Froehle CM, Cassedy A, et al. 2013. An exploratory analysis of the Model for Understanding Success in Quality. Health Care Management Review 38(4): 325–38. URL:

Last updated 16/10/2019