What influences perceptions about the concept of return on investment from healthcare quality improvement programmes? An institutional theory perspective

Purpose This paper aims to highlight the factors influencing the conceptualisation of return on investment (ROI) from healthcare quality improvement (QI) programmes. Design/methodology/approach In their previous work, the authors found that the concept of ROI from QI is broad and includes numerous internal and external benefits for organisations. In this paper, the authors developed a framework outlining the factors that influence this conceptualisation of QI-ROI from an institutional theory perspective. The framework is based on the synthesis of their serial studies on the determinants of the concept of ROI from QI. The research was performed from 2020–2023 and involved a global multidisciplinary systematic literature review ( N = 68), qualitative interviews ( N = 16) and a Delphi study ( N = 23). The qualitative and Delphi studies were based on the publicly-funded mental healthcare in UK. Participants included board members, clinical and service directors, as well as QI leaders. Findings The authors outline a framework of internal and external institutional forces that influence the conceptualisation of ROI from QI programmes in mental healthcare and similar organisations. Based on these factors, the authors state several conjectures. In doing this, the authors highlight the ambiguities and uncertainties surrounding QI-ROI conceptualisation. These challenge leaders to balance various monetary and non-monetary benefits for organisations and health systems. This explains the broadness of the QI-ROI concept. Originality/value The authors developed a framework highlighting the forces underpinning the broad, ambiguous and sometimes uncertain nature of the QI-ROI concept. They raise awareness about dilemmas to be confronted in developing or applying any tool to evaluate the value for money of QI programmes. Specifically, the work highlights the limitations of the ROI methodology as a primary tool in the QI context and the need for a more comprehensive tool.