Agile Stepwise Quality Improvement: Enhancing change and learning in complex and volatile healthcare contexts

Background. Although limitations in improvement efforts are well known, transforming healthcare organisations remains a challenge. Practical use of quality improvement (QI) approaches, including the Plan-Do-Study-Act cycle, have revealed several shortcomings, often hindered by insufficient resources and lack of supportive context. Yet, even in volatile organisational contexts, the need for improvement and high-quality care remains critical. To be effective, QI must develop greater resilience in the face of unfavourable conditions. This study aimed to explore whether, and how, a new, more agile QI approach could strengthen QI efforts and foster learning within an obstetric unit, despite contextual instability. Methods. This case study of a large obstetric unit, with two geographically dispersed labour wards, employed an in-depth longitudinal process approach. It examined contextual factors, the implementation process, perceived impact, and the sustainability of the new approach. Conventional content analysis was used to analyse qualitative data from repeated interviews with key actors, organisational documents, field notes, and a qualitative questionnaire. Results. The implementation spanned nearly two years. Despite occurring during a volatile period with high staff and managerial turnover, the Agile Stepwise QI approach had a positive impact on QI within the unit. It supported change efforts, reduced feelings of failure when progress was difficult, and contributed to a more positive and effective perception of QI work. Testing before implementation became increasingly common. Although scaling tested solutions remained challenging, having team members with decision-making authority facilitated the process. Involving managers and senior staff was difficult due to high turnover, which affected sustainability. Nevertheless, the approach was still in use at one site 3.5 years after its initial implementation. Conclusions . Agile Stepwise QI positively influenced improvement work in the obstetric unit, even under volatile organisational conditions. Key features - open problem analysis, creative idea generation, agile small-scale testing, stepwise scaling, and interprofessional collaboration - proved valuable for driving change. The approach fostered learning at individual, team, and organisational levels, indicating a positive impact on overall improvement and learning capability. However, sustainability depended on the continuity of key staff, including QI team members, support functions and managers. Article classification: Research paper