Exploring the barriers and facilitators of continuous quality improvement for health promotion within healthcare food environments

Continuous quality improvement (CQI) has become a widely accepted approach to optimize health services while lowering healthcare costs (Quintuple Aim) and has expanded from clinical interventions to health promotion. Retail food environments (e.g. hospital cafeterias, cafes) are of interest given the increased adoption of healthy eating policies and interventions to influence diet (e.g. price, promotion, placement and product). However, there is a lack of understanding of what organizational and policy processes are necessary to implement CQI for health promotion in healthcare. This research uses a qualitative multiple exploratory case study design to explore the barriers and facilitators of CQI for health promotion in healthcare retail food environments. This research occurred in a healthcare setting with an organizational Healthy Eating Policy applicable to staff, patients and visitors. We collected semi-structured interview data with 12 healthcare staff working in Nutrition & Food Services in a Canadian provincial health authority from January to June 2023. We used directed content analysis to analyze the data. We used the Inside out model to interpret cross-cutting organizational barriers and facilitators. Four cases of quality improvement interventions (Plan-Do-Study-Act (PDSA) cycles) were identified. Barriers included expertise to interpret nutrient criteria, lack of data, conflicting benchmarks (e.g. finance and health), third-party vendors, past negative experiences, and a lack of time to monitor and evaluate. Facilitators included an organizational Healthy Eating Policy, understanding community context, local knowledge, partnerships with researchers and leadership. This study revealed how overarching policies, accompanied by organizational support, facilitated quality improvement and engagement in CQI but also created barriers to routine practice and sustainability of health-promoting interventions.