Performance and challenges of success in quality improvement projects of selected public hospitals in Addis Ababa, Ethiopia: A MUSIQ analysis of a perinatal quality improvement collaborative in Ethiopian public hospitals.

Abstract

Quality improvement collaboratives (QICs) are a common strategy to improve healthcare in low-resource settings. However, their success is highly variable. The Model for Understanding Success in Quality (MUSIQ) posits that contextual factors at multiple levels determine outcomes. We used MUSIQ to investigate why a well-supported perinatal QIC in Ethiopia had mixed results, testing the hypothesis that internal organisational factors rather than external support would be the primary differentiator of success. A cross-sectional study was conducted with all quality improvement (QI) team members across six public hospitals in Addis Ababa participating in a perinatal QIC. Contextual factors were assessed using the validated MUSIQ tool. The primary outcome was binary QI success (met/not met a predefined target for reducing perinatal mortality/morbidity). MUSIQ scores were compared between successful and non-successful hospitals using Mann-Whitney U tests. A multivariable logistic regression model was built to identify factors independently associated with success. Sixty-seven QI team members participated (95.7% response rate). The overall mean MUSIQ score was 121.2±15.6, indicating a 'reasonable chance of success'. However, scores were significantly higher in successful hospitals (median 129.9 vs 118.8, p=0.002). While external support scores were uniformly high, successful hospitals demonstrated significantly stronger scores in the organisation (p=0.045) and QI team (p=0.005) domains. Regression analysis confirmed that factors within the QI team (leadership, physician involvement) and organisation (senior leadership engagement) domains were independently associated with success, after accounting for other variables. The success of this QIC was predominantly determined by internal organisational and team factors, not by the strong external support common to many global health initiatives. This highlights a critical implementation gap: top-down QICs often fail to catalyse the necessary internal leadership and team dynamics for success. Future initiatives must invest in building internal organisational context alongside providing external technical support.