| Summary: | <p>Quality circles and similarly structured small groups are commonly used in primary health care in Europe to reflect on and improve standard practice over time. They are a complex social intervention in the fast-changing system of primary health care. Many controlled trials and reviews have documented their positive effects on behaviour change. As effect sizes vary, I sought to understand how and why quality circles achieved their results by using a realist approach.</p>
<p>I conducted a co-inquiry with stakeholders to determine their interests and preferences concerning the direction of my research, and their mental model of quality circles, which I used as a framework for my realist review. After identifying relevant papers and selecting and extracting appropriate data, I labelled and analysed configurations of context and mechanism that shaped the outcomes of quality circle work. From these, I built propositions to develop a programme theory underlying quality circles, then refined and consolidated this in sequential interviews with participants, facilitators and managers of quality circles.</p>
<p>The programme theory suggests that government trust in GPs’ ability to achieve quality improvement, with appropriate professional and administrative support, will motivate them to participate in quality circle work. Professional support includes training in relevant techniques, access to educational materials and personal performance data. Administrative support includes protected time, an appropriate venue and financial resources for meetings. Group dynamics are at the core of the process. Facilitators help participants to build social bonds and mutual trust so that the group becomes a safe environment where participants link insights to everyday practice to develop their professional role. They reflect on their personal experiences, add information from evidence-based or personal performance data and thus create new concepts for improving their practice. With repetition, they gain confidence in their quality improvement skills and can put their innovations into practice.</p>
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