Abstract
OBJECTIVE: To rethink the nature and roles of context in ways that help improvers implement effective, sustained improvement interventions in healthcare quality and safety. DESIGN: Critical analysis of existing concepts of context; synthesis of those concepts into a framework for the construction of explanatory theories of human environments, including healthcare systems. DATA SOURCES: Published literature in improvement science, as well as in social, organization, and management sciences. Relevant content was sought by iteratively building searches from reference lists in relevant documents. RESULTS: Scientific thought is represented in both causal and explanatory theories. Explanatory theories are multi-variable constructs used to make sense of complex events and situations; they include basic operating principles of explanation, most importantly: transferring new meaning to complex and confusing phenomena; separating out individual components of an event or situation; unifying the components into a coherent construct (model); and adapting that construct to fit its intended uses. Contexts of human activities can be usefully represented as explanatory theories of peoples' environments; they are valuable to the extent they can be translated into practical changes in behaviors. Healthcare systems are among the most complex human environments known. Although no single explanatory theory adequately represents those environments, multiple mature theories of human action, taken together, can usually make sense of them. Current mature theories of context include static models, universal-plus-variable models, activity theory and related models, and the FITT framework (Fit between Individuals, Tasks, and Technologies). Explanatory theories represent contexts most effectively when they include basic explanatory principles. CONCLUSIONS: Healthcare systems can usefully be represented in explanatory theories. Improvement interventions in healthcare quality and safety are most likely to bring about intended and sustained changes when improvers use explanatory theories to align interventions with the host systems into which they are being introduced.